The COVID-19 pandemic has exacerbated stressors, causing more people to seek behavioral health services from an already over-taxed workforce. According to the Kaiser Family Foundation, about 4 in 10 adults in the U.S. have reported symptoms of anxiety or depressive disorder during the COVID-19 pandemic. CDC data indicate that U.S. drug overdose deaths surged to a record high of 93,331 in 2020, a nearly 30 percent increase from the year before and the largest single-year uptick ever recorded. Yet many people in need of mental health and/or substance use disorder (SUD) treatment do not receive care, partly because of access issues resulting from behavioral health workforce shortages.
Numerous Third Horizon Strategies (THS) clients – from federally qualified health centers to community mental health centers to stand-alone SUD treatment providers – report workforce recruitment and retention as key issues. There is a myriad of reasons for this. Behavioral health providers frequently are reimbursed less than physical health providers and have limited participation in value-based payment arrangements. They also face excessive administrative burden such as lengthy intake and psycho-social assessment requirements, and prior authorization requirements from insurance carriers. Further, providers in many states must navigate complex regulation by multiple agencies. In my home state of Colorado, for example, one agency oversees facility licensing, while a second manages Medicaid contracting and a third manages SAMHSA block grant and state general funds for mental health and substance use prevention and treatment. Consequently, many licensed clinicians choose to go into private practice and accept self-pay, rather than pursuing insurance empanelment.
Compounding workforce shortages is a lack of persons of color entering the behavioral health workforce. For example, according to the American Psychological Association, an estimated 86 percent of psychologists in the U.S. are Caucasian/white in 2018 and about 15 percent are from other racial and ethnic groups, compared to 62 percent versus 38 percent of the general population. There are few targeted efforts to create recruitment, training, and advancement opportunities for clinicians of color. This limits access to culturally responsive care –which can have a profound impact on behavioral health outcomes.
While the shortage of behavioral health professionals is well documented, there is a dearth of evidence-backed solutions and the U.S. lacks a comprehensive, coordinated, national plan to expand the workforce pipeline. Nonetheless we are seeing some promising efforts I believe could be brought to scale. These include:
- HRSA recently expanded the National Health Services Corps (NHSC) loan repayment program to SUD treatment providers. The program seeks to expand access to SUD treatment and prevent overdose deaths by supporting the recruitment and retention of health professionals needed in underserved areas. NHSC should continue to grow and the potential of loan repayment for non-licensed clinicians should be explored.
- Certified Community Behavioral Health Clinics (CCBHCs), an evaluation of the CCBHC demonstration program, has shown that CCBHCs have offered more competitive salaries to address workforce shortages, and hire a range of new staff types, such as peer specialists/recovery coaches and family support workers. The CCBHC demonstration should be expanded beyond the current 10 states.
- The expansion of tele- behavioral health over the last two years has helped extend services into communities that otherwise lack providers and increase productivity since clinicians do not have to travel to provide care in different locations. However, community-based treatment providers caution that some conditions and populations will have better outcomes through in-person services. Therefore, telehealth should be considered as one tool in the clinical toolbox.
- Alternative payment models such as The Addiction Recovery Medical Home Alternative payment model (ARMH-APM) offer providers more flexible, value-driven payment which may support workforce recruitment and retention. Behavioral health providers should be eligible for more APMs across all payer types.
- According to the American Association of Nurse Practitioners (NPs), 22 states along with the District of Columbia grant NPs full-practice authority. This means Psychiatric-focused NPs have full prescribing ability and can augment Psychiatrists. NPs should be able to practice to the top of their licensure nationwide, without regulatory barriers.
- Peer specialists/peer recovery specialists, patient navigators, and community health workers are non-licensed provider types that play a vital role in promoting health and well-being and can extend the work of licensed clinicians. State Medicaid programs across the country can learn from innovators, such as Medi-Cal, who are poised to establish new reimbursement strategies and expand these non-licensed provider types.
- Some providers such as Southeast Health Group have developed “grow your own” programs, in which administrative staff who are interested in career development are offered first-hand, supervised experience and reimbursement for certified addiction counselor training programs. Behavioral health providers should gain resources to pilot and build on successful models.