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 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 “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 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? • 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: • Perceived career opportunities • Income potential • Perceived job satisfaction • Professional status • 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 notlead 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.

NY STEPS Roundtable September 10, 2007