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New Workforce Data Heighten the Need for a Care Access Strategy
It is time to pursue a national strategy for improving access to behavioral healthcare. A new study funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and published in Health Affairs gives the most accurate picture yet of the size of our workforce, both regionally and nationally. It should spur us to grow our resources, but we must first decide which resources to scale and the magnitude of our goal.
The authors of the study paint “a stark picture,” starting with a surprising admission: “There is simply no comprehensive database on the existing behavioral health workforce.” They reviewed every state licensure database and had to clean and standardize files to generate their findings. National totals are broken down by licensure category:
- Psychiatrists – 51,614
- Psychologists – 102,004
- Licensed marriage and family therapists – 64,592
- Licensed professional counselors – 172,446
- Licensed clinical social workers – 221,791
- Total behavioral health specialists – 612,447
The study also tallies prescribers of psychotropic medications, including primary care physicians (PCPs), nurse practitioners (NPs), physician assistants (PAs), and other MDs with evidence of prescribing these medications. Two findings are of note:
- Prescribers nearly equal behavioral health specialists with a total of 574,745 clinicians.
- There are only about 15,000 fewer advance practice providers (NPs and PAs) than PCPs.
A Complicated Issue Needing Debate
Our workforce inadequacy is widely acknowledged, and recent efforts to expand both the supply and diversity of our professional workforce are welcome. Growth may be essential, but what types of providers are needed? Less expensive solutions are always desirable. Does this include focusing on lower cost providers? Myriad issues make care access a complicated goal that needs urgent debate.
Training new clinicians is probably only part of a multifaceted solution, but our target is not immediately clear. We must estimate the unmet need for services to know our goal. Let us use broad estimates for the sake of argument. If 5% of a population seeks access to specialty services today, we must then add consumers with unmet and unrecognized needs to determine the maximum goal.
Who comprises this group? PCPs might include those with chronic conditions needing to change health behaviors. We must surely add those impacted by stigma, cost, inconvenience, insufficient network diversity, and a lack of psychological awareness. Does this mean 10% of a population needs care access? Could it be more? We can only estimate, but the need is substantial whatever the real number.
Access will require multiple channels for services. Relocating part of our therapy workforce to primary care could establish a more routine, non-stigmatized type of behavioral care. However, 50-minute sessions do not scale well. Visits of 20 minutes or less with a therapist would expand access. This could be supplemented quarterly, and traditional therapy would still have a role. Can hearts and minds be won for such a strategy?
Tech innovation is also needed, perhaps automating key processes like data collection and need stratification. Yet where do digital and virtual solutions fit into the overall scheme? They could serve as an entry point to care (i.e., digital- or virtual-first), but many will oppose this due to a fear of missing clinical risks. We should not improve care access at the cost of reducing clinical quality.
Workforce Expansion Could Become Contentious
Yet the most controversial solution likely to gain traction is not technology-based. It is funding a new tier of providers. There are vast numbers of life coaches, peer counselors, and other types of non-professional healers waiting to gain access to healthcare funding. If funded, many more will surely choose such a career. This is not an unfamiliar story in healthcare.
Advanced practice professionals were once controversial as new, lower skilled clinicians. NPs are now breaking free of MD supervision, and their ranks are swelling. PCPs welcomed these professionals into healthcare decades ago, and now their growth is one factor in the existential crisis facing PCPs today.
A new workforce tier might well become a scalable solution in behavioral health. Certificates are quickly available for non-professional coaches and counselors. A master’s degree has long been the minimum educational requirement for therapists. Yet many without advanced education have natural therapeutic qualities and could deliver positive outcomes. Research will likely validate this.
Does this warrant reconfiguring our delivery system in the name of better access? Turf struggles with licensed therapists are sure to develop as lower-cost tiers typically push for comparable pay over time. Licensed therapists might well have their future compensation, not just their turf, impacted.
Growing business consolidation in the healthcare industry could be an opportunity for pay parity—therapists could finally get paid at levels comparable with professionals like NPs. Equitable pay is less likely if funding is directed to a new tier of caregivers.
Can our field fulfill its mission and provide ready access to care? Can we also ensure jobs for care providers with appropriate pay? Market forces will resolve these questions one way or another. No argument is without merit, and so debate might become heated. Some disappointment is likely.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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