Mental health care shortage is being addressed with outdated ratios

It’s hard to read the news these days without hearing that many people in need of mental health care aren’t getting it. Suicide scrutiny skyrocketed during pandemic; opioid-related deaths soared 30%; the Surgeon General has warned of a mental health crisis among young people.

“I talk to two to five member agency CEOs every week, and I start by saying ‘what’s your biggest concern? “, said Charles Ingoglia, president of the National Council for Mental Wellness, a non-profit organization. The answer is the shortage, in the mental health workforce, for “all levels of staff, independent clinicians, supervisors, medical staff, all levels of the organization”.

One statistic captures this shortage and determines the nation’s response: Whether they know it or not, more than 150 million Americans live in a mental health professional shortage zone, according to the Health Resources and Services Administration, which is part of the US Department of Health and Human Services.

This statistic is extremely influential. For more than a century, public health officials have used it or variations to assess whether a geographic area has enough providers. But it may also be outdated, as it does not reflect the rapid shift from in-person mental health counseling to telehealth.

Right now for many programs “it’s all based on geography” so we’re “sending tons of money to train people to work in geographies with fewer providers, regardless of the conditions that need to be addressed,” Kyle Grazier said. , professor of psychiatry and public health at the University of Michigan and director of its Behavioral Health Workforce Research Center.

“Our way of thinking about supporting the workforce, training people, might be a little behind the times,” she said.

Dr. Grazier is among researchers who have documented the extraordinarily rapid rise of telehealth, paving the way for a future in which geography matters far less.

Primary care doctors often need to see you in person and shine that otoscope in your ears. In 2021, after a year of the pandemic, just 5% of most doctor visits were through telehealth, compared to 40% of mental health visits, according to data from the Kaiser Family Foundation and Epic Research, which has of an electronic health database. recordings.

For mental health professionals, a shortage is declared if the person-to-psychiatrist ratio exceeds 30,000 for a specific geographic area. These ratios feed into a range of federal mental health programs, such as loan forgiveness and National Health Service Corps grants for providers in shortage areas. The J-1 visa waiver program allows international medical graduates to stay in the country if they work in shortage areas. Medicare reimburses an additional 10% for covered services in shortage areas.

Geographic ratios originated from a now infamous 1910 Carnegie Foundation report by Abraham Flexner, an American educator who visited more than 150 medical schools and argued that the poor standards of those schools had led to “a century of reckless overproduction of cheap doctors” USA with horrible health care.

He underlined the ratios to make his point. The United States had one doctor for every 568 people, which Flexner found absurd. Some towns, he wrote, “now have four or more doctors for every one they really need—something worse than waste, because the superfluous doctor is usually a bad doctor.”

Across the country, schools were closed on his recommendation. The report is now considered disgraceful because Flexner advanced racist ideas, including that black doctors should only serve black patients. As a result, five of the country’s seven black medical schools were among Flexner’s closings.

By 1965, it was clear that the medical system was overcorrecting, leading to a shortage of doctors. A 1965 law defined a shortage as an area with more than 1,500 people per doctor, about three times the ratio documented by Flexner.

In 1970, an equally influential Carnegie follow-up report stated that “the United States today faces only one serious shortage of manpower, and that is health care personnel.” Some have observed with regret that Carnegie’s previous efforts had created the shortage.

The regulations were first developed by the Department of Health, Education and Welfare and then replaced by the Department of Health and Human Services.

Here’s how the physician shortage ratios were originally calculated. The United States had the equivalent of about 26,000 psychiatrists and about 240 million people in 1987. That’s about 10,000 people for every psychiatrist. So HHS proposed, quite arbitrarily, that a geographic area with three times the national ratio would have a shortage, or 30,000. There you go.

But these ratios may overstate shortages when many patients access practitioners in other regions via telehealth, and understate shortages where they don’t.

Despite this now well-established shortcoming, there is no easy way to change metrics without upsetting the funding of many programs and institutions, which are required by Congress to rely on it.

Many efforts are underway to arrive at higher measures of shortages. Before the pandemic and the rise of telehealth, HHS launched a program to modernize ratios. Working on a grant from HHS, George Washington University launched a Behavioral Health Workforce Tracker that measures how primary care physicians can facilitate mental health services in counties that lack providers.

Shortages will always matter, as telehealth can also experience critical shortages. For example, the Wall Street Journal reported this week that one in six calls to the National Suicide Prevention Lifeline (launched this weekend with a new three-digit number, 9-8-8) were dropped. before receiving a response, as the call centers were understaffed and overwhelmed.

This is a real and crucial shortage; you just wouldn’t see it from the geographic ratios.

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