It’s ironic that as demand grows for psychiatry services, the supply of providers is at a critical low, according to a new report from the National Council for Behavioral Health. The organization’s Medical Directors Institute notes the pool of psychiatrists declined by 10% from 2003 to 2013.
“The average psychiatrist’s age is mid-50s,” says Joe Parks, MD, medical director for the National Council.
Parks says more providers are aging out of the profession without a robust pipeline of new providers to care for the backlog of patients. What also adds to the strain is the fact that psychiatrists are unevenly distributed geographically, creating pockets of serious shortages in most states.
Meanwhile, 40% of practicing psychiatrists limit their work to cash-only patients, further skewing the scarcity of providers in public programs. Medicaid funds 25% of mental health services and 21% of addiction services, according to the organization.
The report emphasizes that narrow, isolated solutions won’t drive the systemic improvements that will be required to address the scale of the problem. Psychiatrist shortages instead must be addressed in collaboration with a wide range of stakeholders and strategies.
New payment solutions
Among the solutions offered, the institute recommends enhanced reimbursement for psychiatry and further implementation of telepsychiatry services.
In some cases, psychiatry is reimbursed at a rate that is lower than the cost of delivering care, resulting in shuttered behavioral health programs. Even in the outpatient setting, rates don’t compare to other specialties, says Saul M. Levin, MD, MPA, CEO and medical director of the American Psychiatric Assn.
“The most glaring example is an evaluation and management code for primary care doctors versus psychiatrists,” Levin says. “Depending on the code, the psychiatrist could get $20 less than what the primary care doctors get.”
Payment rates aren’t just a matter of the price the market will bear, however. Skimping on reimbursement also becomes a parity issue when it translates to reduced access for patients, according parity laws.
“If you pay so little that no one signs up to be on the panel, whether it’s Medicaid or a managed care organization, then that is a restriction of access,” Parks says. “If you pay only enough to cover 75% of the actual cost, then any general hospital or multidisciplinary practice or behavioral health organization has an intrinsic incentive to keep psychiatry to a bare minimum.”
Additionally, the emerging Certified Community Behavioral Health Clinics (CCBHCs)—now rolling out as a federal demonstration project in eight states—will aim to design a new prospective payment system this year that will essentially allow the provider to allocate reimbursement dollars holistically for optimal care rather than with discrete payments rendered code-by-code. Parks says CCBHCs will be a step forward because the payment system will allow flexibility to deliver psychiatry services without financial loss.
“It takes away the business incentive to do your care mix based on whether you make a profit margin on that line of care or not,” he says. “It leaves it up to the agency to deliver the care mix that is optimal.”
Telepsychiatry services are poised for growth, but burdensome regulations and reimbursement stand in the way, experts say. For example, a professional would have to be licensed in multiple states to use the digital technology to deliver care across state lines. The barrier prevents psychiatrists from gaining the efficiency of video visits in their practices and prevents available providers from serving areas of severe shortages.
“Telepsychiatry is truly one of the vehicles to get more access across the country, and we’d like to see more of it,” Levin says. “We’d like to see the payment system actually pay for it.”
Levin says as the technology matures and regulations allow providers to reach patients out of state, uptake will improve.
Patrick Runnels, medical director of the Center for Families and Children in Ohio, says brick-and-mortar practices can realize the value of telepsychiatry because it offers them a chance to leverage providers across multiple sites, which helps ease the staffing burden. With more flexibility, providers can work from home when it makes sense, he says.
“It’s not that there’s actually resistance from providers for telepsychiatry, but that it takes a different level of infrastructure and support to implement it,” Runnels says.
And the experts agree that the younger generation of patients will increasingly expect the on-demand, digital services that telepsychiatry can offer.
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