Report Details Psychiatric Services “Crisis” in U.S.

Psychiatric services are in a state of crisis in the United States, and stakeholders in the health care industry have roles to play in fixing the problem, according to a report from the National Council for Behavioral Health (NCBH). The report was prepared by the nonprofit group’s Medical Director Institute and a 27-member expert panel consisting of providers, payers, government agencies, and psychiatric organizations.

“The coverage of, and increasing demand for, psychiatric services is occurring at the same time as a growing shortage of outpatient and inpatient programs,” the report states. “The lack of access has created a crisis throughout the U.S. health care system that is harmful and frustrating for patients, their families, and other health care providers, and is becoming increasingly expensive for payers and society at large.”

The panel identified six areas requiring reforms:

• Expanding the workforce providing psychiatric services
• Increasing the efficiency of delivery of psychiatric services, including reforming and revising existing regulations that constrain well-coordinated care and access to valuable clinical information
• Implementing innovative models of integrated delivery of primary care and psychiatric care in more settings that have the potential to impact the total cost of care for high-cost/high-risk patient populations with co-occurring medical and behavioral health conditions
• Training psychiatric residents and the existing psychiatric workforce in delivering new models of care
• Adopting effective payment structures in conjunction with matching models that adequately reimburse psychiatric providers for improved outcomes of care
• Reducing the portion of psychiatric providers who engage in exclusive, private, cash-only practices

The pool of psychiatrists working with public-sector and insured populations declined by 10% from 2003 to 2013, the report notes. Aging of the current workforce; low rates of reimbursement; burnout; burdensome documentation requirements; and restrictive regulations regarding the sharing of clinical information necessary to coordinate care were cited as some of the reasons for the decline.

Moreover, the report says, the psychiatric workforce is unevenly distributed geographically across the U.S. Seventy-seven percent of counties are underserved, and 55% of states have a “serious shortage” of child and adolescent psychiatrists. Even in urban and suburban geographic areas with adequate ratios of psychiatrists, the supply of psychiatrists who work in inpatient and outpatient psychiatric facilities has been reduced by those who practice exclusively in cash-only private practices. These practitioners now account for 40% of the workforce, the second highest among medical specialties after dermatologists.

In view of the reduced psychiatric workforce, the panel members offered several recommendations for improving the delivery of psychiatric services:

• Reducing no-shows in outpatient psychiatric programs by setting up “open access” models of scheduling
• Expanding telepsychiatry by reducing regulatory barriers and by ensuring that payers reimburse adequately
• Adding adequate support for prescribers
• Reducing the administrative burdens associated with information sharing and documentation requirements

With regard to inpatient psychiatry, the report notes that, historically, rates of reimbursement for inpatient psychiatric programs have not been sufficient to underwrite their cost in general hospitals. With low margins, inpatient units are reluctant to admit potentially violent clients who pose a risk of property damage, injuring staff or other patients, or requiring additional staff for security. Patients who present with complex biopsychosocial problems––such as homelessness, dementia, the lack of family support, or a criminal history––that don’t lead to a clear discharge plan may also have difficulty accessing inpatient and follow-up care.

Because of these patterns of reimbursement, it is not surprising that salaries for psychiatrists as a specialty profession are the lowest among other specialties, including neurology, the report states.

Sources: NCMDI; March 28, 2017; and HealthLeaders Media; March 30, 2017.