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The Dayton Daily News Path Forward team digs into the most pressing issues facing our community as identified by our readers, including the Miami Valley’s mental health. In investigating the barriers to mental health treatment for the area’s youth, we learned that the shortage of psychiatrists is a challenge facing local providers. This story looks at what Wright State’s Boonshoft School of Medicine, Wright-Patterson Air Force Base and local hospital systems are doing to address the problem.
Almost 20 percent of Americans have some type of mental health issue, according to Dr. Julie Gentile, professor and chairwoman of Wright State University’s Department of Psychiatry. Only about a third of them get treatment.
“I’ve talked to people who have waited months on end to get in to see a psychiatrist,” Gentile said. “(Untreated anxiety and depression) affects their relationships, it affects their occupational functioning, it affects every aspect of their lives.”
The nonprofit Mental Health America ranked Ohio 34th for mental health workforce availability, with a ratio of 560 individuals to 1 health care provider. The Kaiser Family Foundation estimates that Ohio is only meeting about 53 percent of the state’s behavioral health need.
Adult patients wait an average of 25 days for the first available appointment with a psychiatrist while children wait nearly 43 days on average to see a child psychiatrist, according to a series of studies in several cities across the country by the Cambridge Health Alliance.
In hospital emergency rooms, lack of access to psychiatric services often have longer wait times than all other medical diagnoses, according to the National Council for Behavioral Health. The group found wait times for some psychiatric services averaged 23 hours.
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Teens at Daybreak youth homeless shelter in Dayton, many of whom have insurance through Medicaid, have had to wait 90 to 120 days to see a psychiatrist and get a prescription, said Jill Bucaro, associate clinical director at Daybreak. The center often serves youth with not only anxiety, depression and substance abuse issues, but with psychotic symptoms that require medication.
Daybreak now contracts with Wright State to bring in two providers for three hours a week to serve their clients, but it’s not enough to meet the demand, Bucaro said.
“They can’t care for themselves, they are unable to keep themselves safe,” she said. “In that time they get kicked out of their shelter, they get in trouble and go to jail.”
Training the next generation
Lower pay and burnout have been cited in some national studies as possible reasons for the shrinking psychiatric workforce. But local experts said they simply can’t train enough psychiatrists fast enough to fill the growing need.
The current workforce is retiring, with 60 percent of active psychiatrists age 55 or older and 46 percent age 65 or older. Workforce projections show an estimated shortage of at least 21,000 psychiatrists nationwide by 2030, with Ohio among the five states with the biggest gaps.
The good news is the number of medical school students pursuing psychiatry is up.
After a post-Vietnam War spike, interest in psychiatry bottomed out in the mid-1990s, with about 3 percent of medical school graduates choosing the specialty nationwide, according to the American Psychiatric Association. Interest has grown again in the past decade, and that number was up to 5.2 percent in 2018.
It’s even more popular at Wright State, with about 10 percent of graduates pursuing psychiatry. That’s due to faculty committed to mentoring, a strong partnership with the Air Force and a unique focus on psychotherapy training, Gentile said.
Dr. Racheal Johnson, D.O., chief resident of Wright State University Psychiatry, left, talks with Dr. Allison Cowan, M.D., medical director, Wright State Psychiatry residency psychotherapy clinic at Elizabeth Place. The clinic offers low-cost appointments with psychiatry residents to help them train and alleviate a shortage of psychiatrists in the Miami Valley. TY GREENLEES / STAFF
Once a student graduates medical school, they spend at least three years as a resident, working in a teaching hospital and supervised by experienced doctors to master their specialty.
Between the base and Wright State, which partner on medical training, there are 10, four-year psychiatry residency spots in Dayton each year — five civilian and five military — for a total of 40 psychiatrists in training at any one time.
All 40 local psychiatry residents are employed by Miami Valley Hospital and do rotations at Kettering Health Network hospitals, the base, the VA and clinics like Samaritan Behavioral Health.
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Wright-Patt is increasing its annual cohort to seven, starting in 2020, according to Lt. Col. Joseph Coles, a psychiatrist and associate program director for psychiatry at Wright-Patterson Medical Center. The Air Force suffers from the same shortage as the general population, Coles said, and agreed to increase funding to train more psychiatrists here because Wright State had the willingness and enough faculty to do so.
Military residents do about 25 percent of their training on base, and the rest is in the community. So Dayton’s hospitals and clinics benefit as they get more doctors-in-training to serve patients. But once their training is done, those psychiatrists usually go on to military assignments in other locations.
Wright State received more than 800 applications for its five civilian residency spots in 2019, Gentile said. The school would like to increase its civilian cohort to six or seven by 2021, but adding spots is complicated by the federal government’s funding model for graduate medical education.
Wright State is working with all of its funding partners to figure out if that is feasible, Gentile said.
Paying to train new doctors
The average price tag — including salary, benefits and training — for each local psychiatry resident is $88,000 per year. Residency lasts four years, plus a fifth for child psychiatry.
The federal government pays for a portion of that cost through Medicare. Up until 1997, teaching hospitals would tell the federal government how many residents they were training each year and Medicare would pay a set amount per resident based on a formula. The only restriction on how many residency positions could be created was the supply of doctors willing to serve as teachers.
In 1997, Medicare capped the number of residents it would fund at each hospital at whatever number was reported in 1996. And the cap has not been raised since, except for some rural hospitals and those creating new programs.
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How much money each hospital receives depends on how many residents it is allotted; a hospital-specific, per-resident amount that was determined in the 1980s; and the percentage of the hospital’s inpatients that are on Medicare.
That means even a hospital that stays under its resident cap will spend some of its own money to train new doctors.
“Funding for residencies has not increased. And actually, even with the cap, (Centers for Medicare and Medicaid Services) has incrementally decreased the amount of money they are paying,” said Al Painter, an associate dean and psychologist at Wright State. “The magic wand is just not there to say we’re going to add two more and two more over four years of training.”
Even if more federal money was available, it wouldn’t mean psychiatry would get prioritized.
“There are other programs, too, that would be raising their hands at the same time,” Painter said. “I’m sure the surgery program would love to have more residents.”
Teaching hospitals across the country subsidize more than 12,000 residency positions without Medicare support. Miami Valley Hospital pays for 50 more residents across all specialties than its cap allows. The hospital’s parent company, Premier Health, spends about $1.2 million per year to train psychiatrists.
Kettering Health Network did not provide how many residents it pays for itself or how much it spends.
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Subsidizing residencies has become more and more of a burden on hospitals as their other costs rise, Painter said.
“With uninsured care, with technology that is more expensive, with drugs that are more expensive … the costs have gone up enormously,” he said.
“You have to figure out what your priorities are,” said Dr. Teresa Zryd, vice president of academic affairs for Premier Health.
Although it costs more to run a residency program , Painter said being a teaching-hospital comes with benefits.
“Teaching hospitals are where you’re going to get the most up-to-date care and latest studies, latest technologies,” he said.
Dayton Children’s Hospital does not treat Medicare patients. So it gets funding for residents through the U.S. Health Resources and Services Administration. Dayton Children’s got $1.75 million for fiscal year 2019 to train 50 residents across all specialties. It has three child pyschiatry residents right now.
• U.S. Rep. Mike Turner, R-Dayton, has co-sponsored a House version of a bipartisan bill to raise the number of residency positions available nationwide across all specialties.
The Residence Physician Shortage Reduction Act of 2019 would increase the number of residency slots by 15,000 by 2025.
“The nationwide physician and psychiatrist shortage is a serious problem,” Turner said in a statement. “Medical students need the opportunity to learn in order to provide appropriate patient care.”
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Ohio’s senators, Republican Rob Portman and Democrat Sherrod Brown, both said they are concerned about the psychiatrist shortage.
Brown supports increasing funding for graduate medical education and lifting the cap on residency spots, including psychiatry, a spokesman said.
"I am concerned by the shortage of psychiatrists in America," Portman said in a statement. "I'm committed to examining all options to ensure that we have a robust psychiatry workforce for today and the future."
• Another challenge is keeping doctors in the Miami Valley after their training is done.
Those finishing residency have a lot of options of where to practice, sometimes getting as many as 20 to 25 job offers per day from recruiters, according to Gentile. That’s why local employers start their recruitment efforts early, hiring residents to moonlight and integrating them into local teams of providers so they’ll want to stay.
“We don’t have mountains and we don’t have oceans,” Gentile said. What Dayton does have is a culture of mentoring and a culture of education, she said. Plus, an Air Force base and large VA hospital. “Our military affiliation puts us on the map.”
Doctors interested in aerospace, military psychiatry or treating veterans are attracted to working in Dayton, she said.
Many of the Air Force residents who trained here and then served assignments elsewhere will return to retire in the region and start civilian medical careers, Coles said.
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• Other solutions include other types of mental health care providers.
Providers need to get more creative with integrated care models, experts said, where one psychiatrist can help multiple primary care physicians address the mental health of a larger number of patients. Nurse practitioners also can help prescribe medications.
A 2017 National Council for Behavioral Health study recommended that teaching programs should include those integrated care models. Wright State is looking at ways to train medical students alongside nurse practitioner and social work students.
“When you train together, you tend to stay together,” she said.
• Patients also should be aware that not every mental health condition requires a visit to a psychiatrist. Mental health counselors, psychologists and social workers can help with many issues. People are needed to fill some of those jobs, but the shortages aren’t as dire.
The National Center for Health Workforce Analysis predicts a surplus of psychiatric nurse practitioners, social workers and school counselors in Ohio by 2030 but a shortage of psychiatric physicians assistants, psychologists, and addiction and mental health counselors.
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• Telemedicine has eased the shortage of providers, especially in rural areas. Wright State serves 1,500 patients around the state through its telepsych program, but right now a grant that pays for it only covers patients with both an intellectual disability and a mental health condition.
New Medicaid rules that went into effect July 4 expands the types of patients that the state insurance will cover for telepsychiatry and lifted a restriction making those within 5-miles of a provider ineligible.
ABOUT THE PATH FORWARD
Our team of investigative reporters digs into what you identified as pressing issues facing our community. The Path Forward project seeks solutions to these problems by investigating the Miami’s Valley mental health. Follow our work at DaytonDailyNews.com/PathForward.
The Path Forward team has examined youth mental health in the Miami Valley. That includes recent stories digging into a spike in teen suicides the past two years in Ohio and what local schools and mental health providers are doing to reverse that disturbing trend. Next we will investigate how insurance covers mental health care. To share your story about dealing with insurance or how to pay for treatment, contact reporter Katie Wedell at firstname.lastname@example.org or 937-328-0353.