1 / 28

NY STEPS Roundtable September 10, 2007

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.

derica
Download Presentation

NY STEPS Roundtable September 10, 2007

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. 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

  2. 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?

  3. 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)

  4. 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)

  5. 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.

  6. 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)

  7. 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

  8. 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)

  9. 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

  10. 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

  11. 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

  12. 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…

  13. 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

  14. 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.

  15. 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.

  16. 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%.

  17. SOLUTION STRATEGY #1:ATTRACTION • Data Acquisition • ListServ/Website Improvement • Mentoring/teaching

  18. 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?

  19. ATTRACTION: MENTORING/TEACHING • Harvard/Macy program to identify master teachers • Summer electives, meeting sponsorships, etc • Early medical school exposure to C.A.P.

  20. SOLUTION STRATEGY #2CHANGE TRAINING OPPORTUNITIES • Increase the number of existing programs and slots (categorical and triple board) • Integrated training • Accelerated training

  21. 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.

  22. 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

  23. 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

  24. 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?

  25. 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

  26. SOLUTION STRATEGY #3IMPROVE INCENTIVES • Remove GME barriers • Federal training incentives • Improve clinical reimbursement

  27. 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

  28. 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.

More Related