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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. NY STEPS Roundtable September 10, 2007. SHORTAGE OF CHILD PSYCHIATRISTS.

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ny steps roundtable september 10 2007

THE SHORTAGE OF CHILD PSYCHIATRISTS IN THE U.S.:CAUSES AND SOLUTIONSGregory K. Fritz, MDBradley Hospital; Hasbro Children’s HospitalBrown Medical School

NY STEPS Roundtable

September 10, 2007

shortage of child psychiatrists
SHORTAGE OF CHILD PSYCHIATRISTS

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

This Presentation:

  • What is the scope of the problem?
  • Why does it exist?
  • What can we do about it?
general recognition that a problem exists
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
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
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
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
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 psychiatrists1
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
NUMBERS AND TRENDS MAYOVERESTIMATE 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
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
WHY IS RECRUITMENT A PROBLEM?

Choice of medical field is highly influenced by:

  • Perceived career opportunities
  • Income potential
  • Perceived job satisfaction
  • Professional status
  • Having a respected mentor in the field
c a p income potential
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 potential1
C.A.P. INCOME POTENTIAL
  • Longer training and longer time required for rx of a child vs. adult do notlead to better hourly reimbursement

Example:

90801 Medicare reimbursement (2001): $149.58

90801 Medicaid states’ average (2001): $85.19

why is recruitment a problem1
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 problem2
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
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
SOLUTION STRATEGY #1:ATTRACTION
  • Data Acquisition
  • ListServ/Website Improvement
  • Mentoring/teaching
attraction basic data lacking
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
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 2 change training opportunities
SOLUTION STRATEGY #2CHANGE TRAINING OPPORTUNITIES
  • Increase the number of existing programs and slots (categorical and triple board)
  • Integrated training
  • Accelerated training
change training opportunities
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
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
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
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
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 3 improve incentives
SOLUTION STRATEGY #3IMPROVE INCENTIVES
  • Remove GME barriers
  • Federal training incentives
  • Improve clinical reimbursement
improving incentives
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
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.