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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. - PowerPoint PPT Presentation
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THE SHORTAGE OF CHILD PSYCHIATRISTS IN THE U.S.:
CAUSES AND SOLUTIONS
Gregory K. Fritz, MDBradley Hospital; Hasbro Children’s Hospital
Brown 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:1) What is the scope of the problem?
2) Why does it exist?
3) 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 MAY OVERESTIMATE 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:
1) Perceived career opportunities
2) Income potential
3) Perceived job satisfaction
4) Professional status
5) 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 not lead 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.
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