Further Shortage of Psychiatrists in Future

[prominence]

http://m.huffpost.com/us/entry/ther...chiatrists-in-the-us_55eef13ce4b093be51bc128f

There's alot of conversation regarding how we currently do not have enough psychiatrists to address our nation's mental health needs. This fact will be exacerbated by the fact that 60% of our psychiatrists are age 55 or older.

Is it logical to project that once these older psychiatrists retire, psychiatrists' salaries should significantly increase in the next 10 to 15 years given the worsening shortage of psychiatrists at that point?

Will it simply be a case of the limited supply of overall psychiatrists in the U.S. at that point being relatively in a position of great demand?

I would greatly appreciate any thoughts or opinions regarding this key matter facing the future of our specialty.

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[F0nzie]

The 4 gatekeepers:

1. Rates set by Medicare and Insurance.
2. Funding of mental health clinics at the federal and state level.
3. The amount that people can pay for out of pocket.
4. Nurse practitioners.

 

[dl2dp2]

http://m.huffpost.com/us/entry/ther...chiatrists-in-the-us_55eef13ce4b093be51bc128f

There's alot of conversation regarding how we current do not have enough psychiatrists to address our nation's mental health needs. This fact will be exacerbated by the fact that 60% of our psychiatrists are age 55 or older.

Is it logical to project that once these older psychiatrists retire, psychiatrists' salaries should significantly increase in the next 10 to 15 years given the worsening shortage of psychiatrists at that point?

Will it simply be a case of the limited relative supply of overall psychiatrists at that point being in great demand?

Any thoughts or opinions?

Healthcare is not a very elastic economy and doesn't follow clear supply-demand rules. The pricing of services are fixed and negotiations occur at an institutional, rather than individual level. Given billing codes are one and the same no matter what demands there are, I would say that salaries for jobs funded by 3rd party payers will be very similar to what it has always been.

However, ~50% of psychiatrists in private practice don't take insurance, and this number will increase. I suspect fees for private practice will further escalate when supply diminishes. Inpatient units will have a very hard time to retain staff, and many will shut down. This will result in increasing utilization of service venues for indigent populations (i.e. CMHCs, public psych hospitals) and they will need to be increasingly supplemented by block grants from either federal or state govt. In the very long term (i.e. > 20 years), institutional based psychiatry will see a salary rise through this indirect pathway.

In my experience, out-of-network benefits are starting to reimburse only a fraction of psychiatrist fees, so people who want/need the service will start to pay more and more out of pocket. IMHO, dramatic rise in salary in private practice has already happened (and this is related to the disproportionate income growth in the top 5-10%, which is the main target patient base for a PP psychiatrist, and this effect will increase once the supply decreases). On the other hand, this is very market and niche specific, and not everybody has access to this pathway.

Edit: ha, Fonz basically just said the same things I said but much shorter!

 

[sunlioness]

Yeah. And CMHC work is grueling and doesn't pay. They're going to have to fix that or no one will work there.


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[WingedOx]

Yeah. And CMHC work is grueling and doesn't pay. They're going to have to fix that or no one will work there.


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and given our current political climate for funding mental health programs... good luck with that.

 

[sunlioness]

It's a world of hurt out there that's only getting worse . . .

And on that cheerful note, happy New Year!!

*throws confetti*


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[Blitz2006]

Stupid question time,

If there is such a shortage of psychiatrists (as there has been for many years now), why aren't more residency programs sprouting up like they did for radiology 10 years ago?

I'm not saying its a good idea to expand psych residency, as we have witnessed the crash of rads, but just curious as to why it hasn't grown that much (or has it?)

 

[Dharma]

Shortage doesn't necessarily mean it will result in a better financial environment for the typical psychiatrist. If anything, the answer from the 'powers-that-be' will be cheaper, more readily available (albeit not necessarily as skilled and competent) alternatives, i.e. midlevels. Maybe I'm just pessimistic but I don't see the financial future as being so bright for physicians, regardless of so-called shortages and need, psychiatry included.

 

[Blitz2006]

Shortage doesn't necessarily mean it will result in a better financial environment for the typical psychiatrist. If anything, the answer from the 'powers-that-be' will be cheaper, more readily available (albeit not necessarily as skilled and competent) alternatives, i.e. midlevels. Maybe I'm just pessimistic but I don't see the financial future as being so bright for physicians, regardless of so-called shortages and need, psychiatry included.

I agree with you, except in the larger markets like L.A/NYC. With a shortage of Psychiatrists in these cities, cash only practice will only continue to boom, due to simple law of supply and demand. But yes, the people with mental illnesses on Medicid/Medicare I worry about....But hopefully the increase in patients requiring mental health services will prompt insurances to boost reimbursements, but that is more than likely wishful thinking

 

[Blitz2006]

there have been quite a few psychiatry residencies sprouting up and programs increasing the number of residents they take. but through the 1990s the number of residencies and spots in psych shrunk because there aren't enough people who are interested and even many of the IMGs were unappointable. So we won't see a return to the level of psych residency slots available in the early 1990s anytime soon for simply that reason - we don't have good applicants.

Fair enough. But perhaps we should now consider expanding again, as this year we have over 1600 US MD applicants for roughly 1400 spots. I mean, 60% of psychiatrists are above 55. There is already such a shortage, what is going to happen in 2030?

 

[Doctor Bagel]

Yeah. And CMHC work is grueling and doesn't pay. They're going to have to fix that or no one will work there.


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Maybe I live in a lucky place because community mental health here pays better than the VA and the local academic program. Benefits are worse, though. 40 hours a week at a community mental health agency would pay at base around $210k. Grueling, though, yes. Also I think psychiatrists are generally marginalized in community mental health programs (NPs, too) even if pay is good. It feels like you're very much put in the "prescriber" role primarily because their contracts say they need a "prescriber."

 

[so721]

Maybe I live in a lucky place because community mental health here pays better than the VA and the local academic program. Benefits are worse, though. 40 hours a week at a community mental health agency would pay at base around $210k. Grueling, though, yes. Also I think psychiatrists are generally marginalized in community mental health programs (NPs, too) even if pay is good. It feels like you're very much put in the "prescriber" role primarily because their contracts say they need a "prescriber."

Can you explain the grueling part? 40 hours a week seems like cake to me (I'm an intern right now though). Is the work very demanding in terms of paper work etc?

 

[Doctor Bagel]

Can you explain the grueling part? 40 hours a week seems like cake to me (I'm an intern right now though). Is the work very demanding in terms of paper work etc?

Mainly it's just the patients are really sick, and you inherit them on a lot of weird medication regimens. And yeah, documentation isn't included in that 40 hours. If you're lucky you get a lot of no shows, though. I didn't stick around long enough to see how that works out -- the place I worked had a push for productivity, but you can't really control the no shows in that setting.

 

[Mad Jack]

Shortage doesn't necessarily mean it will result in a better financial environment for the typical psychiatrist. If anything, the answer from the 'powers-that-be' will be cheaper, more readily available (albeit not necessarily as skilled and competent) alternatives, i.e. midlevels. Maybe I'm just pessimistic but I don't see the financial future as being so bright for physicians, regardless of so-called shortages and need, psychiatry included.

Given the large number of cash-only psychiatrists out there, I don't think that the powers that be have as much control over psychiatry as they do over other professions. People are willing to pay for psychiatric services, at least to the extent that nearly half of psychiatrists accept no insurance whatsoever.

 

[sunlioness]

Can you explain the grueling part? 40 hours a week seems like cake to me (I'm an intern right now though). Is the work very demanding in terms of paper work etc?

I tried to edit my post and deleted it by accident.

But basically, CMH . . .

You have 40 clinical hours per week. This does not include paperwork. That's patient time. Everything else is on top of that. You haven't evaluated most of the patients you see. You're given a chart and 15 minutes with them to figure it all out. During this 15 minutes, you need to write a decent note. You need to have the patient sign in. You need to make sure their treatment plan is up to date. If it isn't, they need to see their case manager. Write the meds on the script. Document having written the meds on the log. These patients are chronically ill. They are poor. They are often medically ill. Many will ask you for "something for focus" or tell you that their anxiety is out of control and SSRIs don't work for them. Some might present with forms from their disability lawyers. You have 15 minutes with someone you've never met before and you're asked to sign a form saying they can't work. You say you can't and they get mad. 4 patients/hour. 30+ patients per day. 5 days per week. And while you're seeing these patients, your phone is ringing. Case managers are in and out asking questions. "So-and-s0 lost her adderall script. What do you want to do?" Your schedule is constantly changing. Someone cancels and another is scheduled in their place. You have no control over this. You don't know about it until they show up and then you need to figure out where their chart is. They're waiting while you hunt for the chart. You fall behind. People start getting mad.

Total walk in the park.

 

[splik]

Given the large number of cash-only psychiatrists out there, I don't think that the powers that be have as much control over psychiatry as they do over other professions. People are willing to pay for psychiatric services, at least to the extent that nearly half of psychiatrists accept no insurance whatsoever.

well this is office-based psychiatrists - it doesn't include psychiatrists working at HMOs like kaiser, or for the VA, or state hospitals, corrections, academics, private hospitals, community mental health centers. So really, nearly half of office-based private practice psychiatrists don't take insurance, and most of those are in the South and NE (where most psychiatrists are). In the mid-west and west (except for larger cities like LA and SF) most people expect to use their insurance and it would much more difficult to sustain such a practice. Also, cash only practices are done as much for lifestyle than for reimbursements - it would be hard for many/most of these psychiatrists to do full-time cash only private practice, particularly early on in their careers, and even then only in some parts of the country.

 

[eli20]

and given our current political climate for funding mental health programs... good luck with that.

Actually the national conversation on gun violence has many states/fed gov discussing increases in mental health funding (this is of course despite the fact that their is a nebulous/tenuous connection not really backed up by the data and obviously nothing is really set in stone yet), but I'd argue we may actually see increases in funding in the next few years.

 

[OldPsychDoc]

It's an interesting dilemma--the demographics in our region are exactly as prominence mentions, and the production of local residency programs will not even keep up with current demand. (Basically, we can expect about half of our psychiatrists to reach retirement age in the next decade--a few hundred--and the sum production of residents by all of our regional psychiatry residency programs will fill fewer than 2/3 of these positions in the next 10 years--assuming everyone who trained here stayed here!)
Keep in mind also that Medicare, which funds more than 80% of GME positions, has essentially capped the total number of positions since 1997 (https://www.aamc.org/advocacy/gme/71178/gme_gme0012.html). Also, you might find it interesting to know that the ACGME, which governs residency programs, will not accredit new residency positions, even in existing programs with good records, unless there is an "educational rationale" (Believe me, I have NO idea what that means...) for expansion--explicitly forbidding a "workforce rationale". I can understand that they don't want hospitals expanding their programs for the sake of filling workforce needs cheaply with residents--e.g. "we need to cover xx beds and 2 emergency departments 24/7, so we want 8 residents a year instead of 4"--but it seems insane to me, totally disconnected with reality, that they don't look at long-term clinical workforce projections and encourage us to adjust the overall number of trainees accordingly.

 

[Shikima]

It's an interesting dilemma--the demographics in our region are exactly as prominence mentions, and the production of local residency programs will not even keep up with current demand. (Basically, we can expect about half of our psychiatrists to reach retirement age in the next decade--a few hundred--and the sum production of residents by all of our regional psychiatry residency programs will fill fewer than 2/3 of these positions in the next 10 years--assuming everyone who trained here stayed here!)
Keep in mind also that Medicare, which funds more than 80% of GME positions, has essentially capped the total number of positions since 1997 (https://www.aamc.org/advocacy/gme/71178/gme_gme0012.html). Also, you might find it interesting to know that the ACGME, which governs residency programs, will not accredit new residency positions, even in existing programs with good records, unless there is an "educational rationale" (Believe me, I have NO idea what that means...) for expansion--explicitly forbidding a "workforce rationale". I can understand that they don't want hospitals expanding their programs for the sake of filling workforce needs cheaply with residents--e.g. "we need to cover xx beds and 2 emergency departments 24/7, so we want 8 residents a year instead of 4"--but it seems insane to me, totally disconnected with reality, that they don't look at long-term clinical workforce projections and encourage us to adjust the overall number of trainees accordingly.

How does one work one's way into such positions to effect change?

 

[smalltownpsych]

Can you explain the grueling part? 40 hours a week seems like cake to me (I'm an intern right now though). Is the work very demanding in terms of paper work etc?

I work 40 hours and I am exhausted by the end of it. Paperwork for me is minimal, but the cognitive and emotional demands are extremely high. Our work is in the interpersonal realm and it is not quite as simple as "you have schizophrenia, take two risperdal a day and call me next month". Every single case is complex and compliance with treatment and the psychosocial issues are usually more important than finding the right medication. In fact, the patient (and auxiliary staff) need to be continually educated that there is no right medication. Also, it can get quite frustrating dealing with the continual flow of substance abusers who are not really mentally ill. As an intern, I assume you are in an inpatient setting which the substance abusers without serious mental illness are better at avoiding. They reconstitute really quickly the next morning and are on their way.

 

[notdeadyet]

How does one work one's way into such positions to effect change?

Get into national leadership roles.

Unfortunately, that typically involves things like the APA, which folks tend to have a distaste for. Effecting change at a national level like that involves politics and politics is often about unpalatable compromises, which most physician-types have very little patience for.