New forces are affecting the use of health care services. The two most powerful are the aging of the population and the growth of health technology. General health is much more affected than is mental health, which explains a good deal of the divergence between reescalating medical costs and premiums and, in contrast, stable mental health costs and declining premiums. Additional forces that affect the use of health care services include pharmacotherapeutics, alternative medicine, the Internet, direct-to-consumer advertising, and the Human Genome Project. Socioeconomic trends, such as a growing number of state mandates and regulations and a low unemployment rate, have contributed to better benefits and progress toward parity of mental health benefits with medical benefits. What will happen to psychiatrists in this changing world?
Reflecting on the modern history of organized mental health services, we see a repetitive pattern of initial engagement and clinical leadership and service by psychiatrists, followed by disengagement and marginalization. Beginning in the middle of the 20th century, this pattern became the reality in the public sector, first in state hospitals and then in community mental health centers and staff-model health maintenance organizations. The pattern was repeated in the medical open-network managed care organizations. In each structure, psychiatrists eventually came to function almost entirely as medication managers.
This phenomenon appears to be occurring again in the specialized—carve-out—managed behavioral health organizations. Need this be the case? Are psychiatrists indeed disaffiliating from managed behavioral health organizations? Many in the field see a growing functional problem of access to private-practice psychiatrists in organized care systems. In seeming contradistinction, between 1998 and 2000, the number of psychiatrists in the United Behavioral Health network increased by 10 percent to about 6,000. While a larger number of younger psychiatrists are accepting salaried positions, older psychiatrists have retreated to their private offices and are as busy as they want to be.
The conventional wisdom on the problem of the availability of psychiatrists is that network reimbursement rates for managed behavioral health organizations have not kept up with private fees, which suggests a straightforward marketplace explanation. However, the problem is much more complex, involving more of an imbalance between demand and supply. That psychiatrists would prefer to receive their full fee for seeing patients rather than a discounted rate is a given. However, although competitive reimbursement in managed behavioral health organizations and softening attitudes of psychiatrists toward managed care may be necessary conditions for mitigating this problem, they will not be sufficient. Thus arises the question, "Is there a shortage of psychiatrists?"
From the perspective of delivering mental health services, one way to pursue this question is to examine the relationship between demand and supply. I will look at the shortage question as it affects outpatient treatment for adults, which is the most frequently requested service in the general population. However, in approaching professional workforce issues, I offer a caveat. We are operating in an arena without benchmarks and with incomplete—even fractured—data. I present the data that are available.
The past decade has seen an increase in the demand for psychiatric services. The most apparent reason for this increase is population growth—10 percent between 1990 and 1999. In addition, greater evidence for the treatability of mental illness through replicated efficacious treatments and greater availability of medications with few side effects has increased the prevalence of treatment. The frequency and number of diagnoses of mental illness has increased without evidence of any corresponding increase in the prevalence of mental illness itself.
Direct-to-consumer advertising, especially for psychotropic medications, has also had a dramatic impact. Large employers have increased expectations for mental health services secondary to the growing labor shortage and the related recognition that a maximally productive workforce is essential. An increasing number of studies of the workforce have shown the effects of mental illness on work life (1) and, more recently, the effects of the treatment of mental illness on work performance (2,3).
Related to employers' changing attitudes, the use of managed care has been increasing. This greater use has resulted in more outpatient benefits, mainly the change from 50 percent coinsurance to an in-network copayment of $10 to $20; improved access; and a growth in outpatient treatment. This change has also opened the therapist's office to the working class (4,5). In addition, the growing acceptance of new psychotropic medications for acute and long-term stabilization has led to an increase in the number of referrals to psychiatrists by other mental health professionals and by other physicians.
The work of advocacy groups has contributed significantly to a decrease in the stigma associated with mental illness, resulting in a change in social attitudes and a shift in public policy. The clearest evidence is the increase in parity of mental health benefits with medical benefits. This social change was compounded in the late 1990s by a growth in general affluence, a psychological wealth effect, and an increase in annual out-of-pocket spending for mental health—more than for medical care (5.8 percent and 2.6 percent, respectively).
Psychiatry is the fifth largest medical specialty and ranks sixth in the number achieving board certification (6). The best estimate of the number of active clinically trained practicing psychiatrists in the private sector is 27,000.
However, these numbers can be deceptive. Who is really available to treat adult outpatients? More than 15 percent of practicing psychiatrists are child psychiatrists. An unknown—but growing—percentage of adult psychiatrists practice full-time in private closed systems, such as Kaiser Permanente. The number of practicing psychiatrists who restrict themselves to inpatient-only practice—90 percent or more of their clinical time—is reported to range between 3 percent and 6 percent. These psychiatrists tend to be younger, but they must be subtracted from the total number of available practicing outpatient psychiatrists. On the basis of these data it was estimated that about 22,000 psychiatrists (not full-time equivalents) were available to see adult outpatients in private clinical practice in the late 1990s. However, there are no benchmarks for appropriate targets.
Age matters. Nineteen percent of psychiatrists are over the age of 65, compared with 12 percent of other physicians; 30 percent of psychiatrists and 20 percent of other physicians are over the age of 60 (7). The median age of psychiatrists is in the mid-50s. Older psychiatrists work fewer hours and will soon be retiring from practice.
Gender also matters. The majority of younger psychiatric practitioners and trainees are women. They train and practice part-time in significantly greater numbers than men. They report fewer patient contacts per week and are represented in managed care networks in numbers disproportionately smaller than their percentage among all practicing psychiatrists. Women are more likely to practice in groups and are more likely to be salaried than men. About half of the clinical outpatient practice hours of psychiatrists are spent outside private office practice (8).
Adding to this picture during the 1990s, the number of visits to all physicians that resulted in a diagnosis of a mental illness per 1,000 of the population, especially primary care visits, increased significantly more than the number of such visits to psychiatrists only (9). We suggest that this disparity has occurred, at least partially, by default as a result of problems with access to psychiatrists. The number of visits per 1,000 population to psychiatrists has not increased substantially in the past decade, but the average duration of the visits has decreased; psychiatrists are spending fewer hours per week in patient contact than they were ten years ago, but they are seeing more patients (9). Psychiatrists report that 32 percent of their patients receive medication only, without psychotherapy. In 1996, psychiatrists reported significantly less patient contact time—28 hours a week—than physicians in other major specialty groups (6). The same study showed that psychiatrists and obstetrician-gynecologists were significantly less satisfied with their work than were other physicians.
The workforce of mental health professionals has been growing and changing. Yet in the past decade the number of psychiatric residency slots nationally has decreased by 10 percent. In the past five years, the average number of psychiatric residents has declined by 5 percent, and the number of clinicians leaving practice has increased; there has been a net replacement deficit in the number of practicing psychiatrists from one year to the next—more than 100 a year. The numbers of psychiatric nurse practitioners, who recently acquired prescribing privileges, increased steadily during the past decade, as did the number of master's-level licensed counselors. The numbers of psychologists and psychiatric social workers increased sharply during the first half of the 1990s but to a lesser extent during the past five years.
Psychiatrists practice differently than other medical specialists. In 1997, 70 percent of primary care physicians nationwide reported difficulty in obtaining high-quality outpatient mental health care for their patients (10); this percentage is four times greater than that reported by other medical specialists. More than any other medical specialists, psychiatrists tend to practice in urban areas; they also show the most extreme variations of all specialties in national distribution—for example, 6.2 per 100,000 in Mississippi and Idaho, 64.6 in Washington, D.C., and seven to nine per 100,000 in large urban areas in the South and the Midwest (11).
Of all medical specialties, psychiatrists remain the least affiliated. Private, solo, and small-group office practice is still the most common pattern of outpatient private practice, particularly for psychiatrists over the age of 55 years. In addition, psychiatrists appear to be less electronically connected than other physicians; 70 percent say they have access to the Internet, but a majority—particularly women—do not use the Internet in their practice (12). In the general population, only 15 percent of people over the age of 65 use the Internet.
By the mid-1990s, trainees and former trainees were reporting a disconnect between their preparation for practice and the reality of increasingly managed service delivery systems (13). Private, office-based psychiatrists report that only one out of three patients is covered under a managed care plan, for which they accept discounted fees. Older psychiatrists report a larger proportion of payment as "self-pay" full fees (14).
Solo practice and age over 60 seem to be the significant factors associated with physician dissatisfaction. Taken together, these factors help explain why psychiatrists, as a group, report greater dissatisfaction than other physicians with their careers, given that more psychiatrists are over the age of 60 and practice alone (7).
Is there a shortage of psychiatrists? How important is this question? Psychiatry has traditionally been an atypical medical specialty with a unique culture and sociology. The psychiatric profession, like it or not, practices in the current age of accountability. Psychiatry is expected to address the changing expectations—on the part of both the public and payers—that actual practice be verified in accordance with published professional guidelines for psychiatric services. However, regular prescribing and laboratory data are not as available in psychiatry to the extent that they are in other branches of medicine.
The integration of pharmacotherapy and psychotherapy in the treatment of mood disorders—to choose one example of a generally agreed-on psychiatric quality measure—is a case in point (15,16). Only psychiatrists are specifically trained to provide this form of integrated treatment (17). Legally, primary care physicians can provide the treatment, but they are neither trained nor inclined to do so. Psychiatric nurse practitioners can also provide integrated pharmacotherapy and psychotherapy; permissive licensing legislation gives them limited prescribing privileges in 50 states, but they are few in number and are less extensively trained than psychiatrists. Psychologists are inching closer to achieving similar privileges. Because ease of access to care is the precondition for meeting the quality standard mentioned above, and the first level of expectation, the question of availability of psychiatrists seems central to quality. If psychiatrists are not available, who will be?
As we review the factors that affect the supply of outpatient psychiatrists in the private sector, what is most striking is the growing divergence between increasing demand and shrinking supply. Not only are psychiatrists less available today for providing integrated psychotherapy and pharmacotherapy, but many are increasingly unavailable for providing any psychotherapy. Even in their role simply as medication managers in split treatment, most psychiatrists in private practice seem accessible only to affluent, full-fee patients outside managed care. I see few short-term remedies and little to applaud.
The author thanks Barbara J. Burns, Ph.D., Norman Clemens, M.D., Paul Fink, M.D., Ronald Manderscheid, Ph.D., Roger Meyer, M.D., Robert Michels, M.D., Roland Sturm, Ph.D., and Joyce West, M.P.P.
Dr. Goldman is clinical professor of psychiatry at the University of California, San Francisco, and senior vice-president for behavioral health sciences at United Behavioral Health, 425 Market Street, 27th Floor, San Francisco, California 94105 (e-mail, firstname.lastname@example.org). Steven S. Sharfstein, M.D., is editor of this column.