THE SHORTAGE OF CHILD PSYCHIATRISTS IN THE U.S.: CAUSES AND SOLUTIONS Gregory K. Fritz, MD Bradley Hospital; Hasbro Children’s Hospital Brown Medical School.

THE SHORTAGE OF CHILD PSYCHIATRISTS IN THE U.S.:

CAUSES AND SOLUTIONS

Gregory K. Fritz, MDBradley Hospital; Hasbro Children’s Hospital

Brown Medical School

NY STEPS Roundtable

September 10, 2007

SHORTAGE OF CHILD PSYCHIATRISTS

Disclosure: I chair the AACAP Steering Committee on Workforce Issues, so not impartial

This Presentation:1) What is the scope of the problem?

2) Why does it exist?

3) What can we do about it?

GENERAL RECOGNITION THAT A PROBLEM EXISTS

“There is a dearth of child psychiatrists …

Furthermore, many barriers remain that prevent children, teenagers, and their parents from seeking help from the small number of specially trained professionals…This places a burden on pediatricians, family physicians, and other gatekeepers to identify children for referral and treatment decisions.”

(Mental Health:A report of the U.S. Surgeon General, 1999)

SCOPE OF THE THE PROBLEM:Psychiatric Epidemiology

Among U.S. children and adolescents ages 9 – 17:

• 20% (15 million) have diagnosable psychiatric disorders

• 9% - 13% (7-10 million) have “serious emotional disturbances”

• 5% - 9% (4-7 million) have “extreme functional impairment”

(MECA 1996: Surgeon General, 1999)

SCOPE OF THE PROBLEM

• Only about 20% of children and adolescents with psychiatric disorder in the U.S. receive any kind of mental health services

• Only small fraction of those getting service get evaluation and/or treatment by C.A.P.

PROJECTION OF DEMAND

• U.S. Population under age 18 will increase by 40% in 50 years

• 70 million in 2000

• >100 million in 2050

• Demand for C.A.P. service in U.S. will increase by 100% from 1995 to 2020

• Demand for general psychiatrists will increase by 19%

(DHHS,2000)

SUPPLY OF CHILD AND ADOLESCENT PSYCHIATRISTS

• Shortage and growing demand has been long recognized

1980 GEMENAC Report: C.A.P.s to 8,000 – 10,000 by 1990

1990 COGME Report: C.A.P.s to 30,000 by 2000

• Currently, about 7,000 C.A.P.s are practicing in U.S.

• If recruitment remains stable, 8,300 C.A.P.s projected for 2020

SUPPLY OF CHILD AND ADOLESCENT PSYCHIATRISTS

• Maldistribution in U.S. is also a problem:

Massachusetts: 17.5 C.A.P.s/100,000 youth

West Virginia: 1.3 C.A.P.s/100,000 youth

U.S. Average: 7.5 C.A.P.s/100,000 youth

(Kim et al, 2003)

NUMBERS AND TRENDS MAY OVERESTIMATE SUPPLY

• RI Survey revealed many listed C.A.P.s are retired, see mostly adults, or don’t practice

• C.A.P.s are aging – baby boomers will retire soon

• Older C.A.P.s work less (by 15%) than younger and see more adults/fewer kids

• C.A.P.s are increasingly female – work less (by 25%) because of family responsibilities

WHY DOES THE PROBLEM EXIST?

• Number of C.A.P. residents in U.S. has remained flat: 712 in 1990, 669 in 2000, 720 in 2005

• Number of C.A.P. training programs in U.S. has decreased by 5 to 115, 1990-2005

• Approximately 20% of U.S. medical schools don’t have C.A.P. training

• IMGs were 43% of C.A.P. trainees in 2001 vs.. 20% in 1990. However immigration/visa rules will IMGs

WHY IS RECRUITMENT A PROBLEM?

Choice of medical field is highly influenced by:

1) Perceived career opportunities

2) Income potential

3) Perceived job satisfaction

4) Professional status

5) Having a respected mentor in the field

C.A.P. INCOME POTENTIAL

• 83% of U.S. medical school graduates have educational debt– Public medical school grads : $100,000 median– Private medical school grads: $135,000 median

• C.A.P. is a low paying specialty in U.S. given the long training time required:

• Among 28 medical specialties, C.A.P. is #20 in median starting income.

continued…

C.A.P. INCOME POTENTIAL

• Longer training and longer time required for rx of a child vs. adult do not lead to better hourly reimbursement

Example:

90801 Medicare reimbursement (2001): $149.58

90801 Medicaid states’ average (2001): $85.19

WHY IS RECRUITMENT A PROBLEM?

• Stigma of mental illness extends to those who treat it. Lack of parity in U.S. is symbolic.

• Perception of psychiatry as “soft science”.

• Practitioners demoralized by managed care.

• Some medical students who want to work with children choose Pediatrics over C.A.P. because they don’t want 3 years of adult psychiatry.

WHY IS RECRUITMENT A PROBLEM?

• Few C.A.P. mentors perpetuates the problem.

• General psychiatry residents who plan on C.A.P. get interested in aspects of adult psychiatry and don’t continue to C.A.P.

INSTITUTIONAL DISINCENTIVES TO RECRUITING MORE C.A.P. RESIDENTS

• 1997 Balanced Budget Act capped a hospital’s total number of residents eligible for GME reimbursement

• Thus, new positions (in any specialty) come from 1) shrinking another residency or 2) operations income

• To discourage sub specialization, programs leading to a second board eligibility (e.g. C.a.P.) are reimbursed only 50%.

SOLUTION STRATEGY #1:ATTRACTION

• Data Acquisition

• ListServ/Website Improvement

• Mentoring/teaching

ATTRACTION: BASIC DATA LACKING

• Which U.S. medical schools put > 5% of graduates into psychiatry? Why?

• Why do we lose ¾ of general residents who plan C.A.P. careers.

• Which general psychiatry programs have a high (or low) % of residents going into C.A.P.? Why?

• Where are unfilled C.A.P. positions? Why?

• Do U.S. minority recruitment programs work?

ATTRACTION: MENTORING/TEACHING

• Harvard/Macy program to identify master teachers

• Summer electives, meeting sponsorships, etc

• Early medical school exposure to C.A.P.

SOLUTION STRATEGY #2CHANGE TRAINING OPPORTUNITIES

• Increase the number of existing programs and slots (categorical and triple board)

• Integrated training

• Accelerated training

CHANGE TRAINING OPPORTUNITIES

Increase the number of existing programs and slots• Target medical schools without C.A.P. training• Revive defunct programs• Harness state support – refer to poor local access• Increase class size in successful programs

(ex: MGH)• Develop Triple Board infrastructure to facilitate

TBP growth.

CHANGE TRAINING OPPORTUNTIES:PREMISES

• Enhanced attraction to existing training models can only go so far

• Multiple “portals of entry” into C.A.P. are required for major increase in C.A.P. numbers

• A number of practicing pediatricians would like to do C.A.P.

• A group of medical students who are potential C.A.P.s do not want to treat adults

• Startup monies are needed for new programs

INTEGRATED ADULT & CHILD TRAINING

• Attracts residents who want to work with children from the start

• Prevents C.A.P. drop off during adult only training– Greater satisfaction– Not board eligible in either until both

completed

• Integrated research training now thriving• Innovative curriculum reform; goal is 4 yrs

PEDIATRIC PSYCHIATRY PILOT PROGRAM

• 3 year residency in Psychiatry and C.A.P. for – Senior pediatric residents– Board eligible or certified pediatricians

• Modeled on TBP: 10 sites, 2 residents/yr/site

• AACAP, APA, RRC, ABPN, have all approved

• “Camel’s nose under the tent” for accelerated training?

C.A.P. ONLY TRAINING?

• Currently neither pediatricians nor child clinical psychologists need full adult training.

• Lack of general psychiatry certification would reduce C.A.P. hours lost to seeing adults

• Politically impossible at present

SOLUTION STRATEGY #3IMPROVE INCENTIVES

• Remove GME barriers

• Federal training incentives

• Improve clinical reimbursement

IMPROVING INCENTIVES:

“CHILD HEALTHCARE CRISIS RELIEF ACT”HR.1106 (Kennedy, Ros-Lehtinen)S. 537 (Bingaman, Collins)

• Remove C.A.P. from hospitals’ GME ceiling• Full GME reimbursement for all years of CAP

training• Scholarship and loan forgiveness for child

mental health professionals

House: 72 bipartisan co-sponsors; Senate: 22

IMPROVE CLINICAL REIMBURSEMENTS

• Recognize that child mental health services take longer to provide than

comparable adult services

• Higher rates for all codes when patient

is <18

• Utilize interactive codes for child services

• Slow-but real- progress in this area.