Oregon Confronts Shortage of Psychiatrists

BEND, Ore. — Mental health parity laws passed in 2008 require insurance companies to treat mental illness the same way they treat medical conditions. But a dwindling supply of psychiatrists — both nationwide and in Oregon —-is leaving many patients with complex mental health issues without timely access to psychiatric care.

Last month in the journal Health Affairs, researchers from Weill Cornell Medical College and Columbia University published an analysis of the current supply of psychiatrists in the U.S. They found that from 2003 to 2013, there was a 0.2 percent decline in the number of practicing psychiatrists in the U.S. In contrast, there was a 14 percent increase in the total number of doctors, a 10 percent increase in primary care physicians and a 36 percent increase in the numbers of neurologists.

Factoring in population growth, the supply of psychiatrists dropped by 10 percent.
“There’s a particular concern about access to psychiatrists, particularly in rural areas and for people who live in poorer areas,” said Dr. Harold Pincus, a professor of psychiatry at Columbia University and a co-author of the study. “There really does seem to be an access crisis in some parts of the country.”

The Health Resources and Services Administration designates any area with less than one psychiatrist per 30,000 people a mental health professional shortage area. In Oregon, that includes nearly the entire state outside of Portland and Eugene.
“We’re hurting there in terms of the availability of psychiatric time,” said Dr. Magnus Lakovics, a psychiatrist working under a contract with St. Charles Bend. “There’s no question about it.”

Central Oregon has one office-based psychiatric practice with five psychiatrists, then a handful of solo practitioners scattered throughout the region. Deschutes County Mental Health employs several psychiatrists, but they serve primarily patients on the Oregon Health Plan. And the hospital employs and contracts with several more.

“Family doctors take care of the bulk of mental health issues,” Lakovics said. “Usually we get referred patients who are not doing as well in family practice.”

One quarter of U.S. adults report a mental health issue at any given time, and about half will incur a mental illness at some point in their lives. Most of those conditions are treated by primary care physicians, who can prescribe an increasing number of psychiatric medications to treat basic behavioral health conditions.

But 4 percent of the U.S. population will incur a serious mental health issue, and in one survey, two-thirds of primary care physicians reported difficulty in referring patients to mental health specialists. That number was double the rate for any other specialty.

The analysis did not consider the supply of other types of behavioral health providers, such as psychologists, psychiatric nurse practitioners, behavioral health counselors and social workers. In most parts of the country, those practitioners provide the vast majority of mental health care but don’t have the training to deal with the most complex cases and not all can prescribe medications.

The undersupply means patients often face long waiting times for appointments, which, Lakovics said, can allow their condition to worsen until they reach a crisis situation and need a costly hospital stay.

“What oftentimes happens is the hospital serves as the final resource,” he said. “We admit a lot of patients to the hospital that had they seen a psychiatrist earlier and had adequate treatment, wouldn’t have to be admitted.”

Pincus said the undersupply of psychiatrists could be due to a number of factors. For one, psychiatry is one of the lower paying physician specialties. According to the American Association of Medical Colleges, the starting salary for a general psychiatrist is $185,300. Neurologists started out at $250,000 and neurosurgeons topped the list at $475,000.

That’s in part because the health care system tends to reward doctors for doing procedures, like surgeries, rather than spending time talking to a patient.

“It’s an issue that affects primary care providers and pediatricians as well,” he said. “And there’s been a push toward people seeking specialties where there is going to be a much higher level of compensation.”

Low payment rates from health plans has many psychiatrists abandoning insurance altogether, taking only cash payments from patients. Only 55 percent of office-based psychiatrists still accept health insurance. That creates a financial barrier for patients as well, Pincus said.

Psychiatrists have advocated for increasing payment rates to attract more doctors into the field, and some states have offered loan repayment programs to encourage medical students to choose psychiatry.

But those moves could take a while to make a dent. According to the American Association of Medical College most recent report, in 2013, there were 1,461 residents entering general psychiatry and another 413 specializing in child and adolescent psychiatry. Those numbers have increased only 1 to 2 percent from 2008.

Meanwhile, psychiatry ranks among one of the oldest specialties, with 59 percent of psychiatrists over age 55.
“There’s no question there’s a shortage and that’s not going to get better,” Lakovics said.

Pincus and his co-authors advocate a shift toward coordinated care models that rely on a team of behavioral health specialists, with psychiatrist oversight. Others have called for the use of telemedicine to extend the reach of psychiatrists from areas of greater supply to rural areas where there are shortages.

Lakovics said some of that has been tried in Oregon, but it’s not a viable solution.

“Portland can’t serve all of Oregon with telemedicine,” he said. “There aren’t enough psychiatrists in Portland.”

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