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There is no single issue in the movement to integrate physical and behavioral health system that trumps the workforce shortage and training problem. Primary care needs a moonshot initiative to bridge that gap. I have some ideas. They are mine alone – I can’t speak for all of the Collaborative Family Healthcare Association (CFHA), but here goes my attempt to outline our moonshot program for integrated care.
For context, as difficult as reimbursement is in many states for integrated care services, reimbursement has never been better for CoCM (Collaborative Care Model) and PCBH (Primary Care Behavioral Health) in the US health system and signs point to further improvements. We have good evidence behind the two main models and continue to develop evidence to support PCBH and CoCM as complementary models. That evidence has led the highest levels of the US government to invest millions of dollars in the last two decades into supporting implementation and research efforts and to produce a roadmap that places integrated behavioral health as a centerpiece of efforts to meet the mental health need in the country. So what’s holding us back?
The answer is, qualified people.
We just do not produce enough professionals right out of training with the intention of placing them in the health system, specifically in primary care. So we have a quantity problem and a quality problem. The quantity problem is exemplified by the numerous challenges health centers face in hiring licensed mental health providers. Our job board at CFHA and our experience with assisting our technical assistance clients confirms that finding mental health professionals is challenging, especially in a post-pandemic environment where competition from remote provider companies has increased the competition.
The quality problem is an even more significant barrier. Since we have very few training programs that train specifically for primary care, organizations have to expend thousands of dollars and person-hours to re-train mental health professionals to work in primary care environments and specifically in the PCBH and CoCM models. Often-times organizations make due with professionals who muddle along in their primary care roles because they simply do not have other options.
So, primary care needs a moonshot program to significantly expand the pool and quality of professionals to fill care manager, consulting psychiatry and Behavioral Health Consultant roles. Any moon shot program needs a goal, so here’s my back-of-the-napkin attempt at setting some numeric goals. Note that this is the roughest of estimates and this entire blog piece represents my opinion and my opinion alone (and perhaps my poor math skills).
So, here goes. If we assume a US population of 332 million and a current primary care provider workforce of 265.3 providers per 100,000 people, for PCBH we can calculate (based on a 1 to 4 BHC to PCP ratio) a need for about 220,013 BHCs or a ratio of 66.25 BHCs per 100,000 people in the population (1 BHC per 1509 people). Lots of assumptions there of course given that distribution of talent is never equal to the population and practice characteristics determine a great deal of actual need. But for now, the number has some face-validity given the size of the health system.
For CoCM, if we assume 19.2 million depressed persons annually and assume that 50% of those will seek care in primary care (9.6 million) then using a mid-point of AIMS Center recommendations for care manager panel size of 90 patients per care manager works out to a need for about 107,000 care managers. This of course ignores other condition types for which CoCM may be applied. Further if we assume 3 hours/week consulting psychiatry time per every care manager then we end up with a need for 8,025 full-time consulting psychiatrists (working 40 hours per week) to oversee those care managers. Again, lots of assumptions there, but again the number makes sense on its face.
So, whew! That’s a lot of workforce to generate. For context, given that there are no know figures documenting the actual number of care managers and BHCs at present, CFHAs membership is at an all-time high of 2000 members. Now clearly not all current BHCs, consulting psychiatrists or care managers belong to CFHA (they should!) but we are clearly far from the goal given that CFHA is the flagship organization for these folks.
For additional context, 2022 data show 305 mental health professionals for every 100,000 people (265 PCPs per 100,000 people) or according to 2017 figures about 732,110 non-psychiatry mental health professionals (53,740 psychiatry mental health professionals). So, it makes total sense then that if we are going to truly build out a primary care level of behavioral health that we would be adding about 220,000 BHCs, 107,000 care managers and 8,000 consulting psychiatrists to those numbers (that’s right adding, not moving the existing workforce into those roles!).
So, we (I’m looking at you academic training centers) have a lot of work to do. I think we can do it. In the next decade we need to transform the training paradigm to mirror what medicine does. Medicine trains specifically for either primary care or one of the specialities. Right now behavioral health trains only for specialties and then retrains on the job for primary care after the fact. Behavioral health thus by default prioritizes specialist training, which a quick glance at the numbers tells you is woefully inefficient. We have more mental health professionals than primary care providers and yet we are far short of meeting the need in the population.
Practically this means that pilot efforts like BHWET grants have to become more robust. It means behavioral health departments need to create strategic plans for creating primary care tracks. It means undergraduate mental health programs need to include primary care courses in their curricula and prepare students to fill behavioral health care manager roles. It means that psychiatry residencies need to be providing rotations in primary care consultation as a standard of training. And, perhaps most importantly, the guild groups and accreditation bodies that have a strangle-hold on the professional licenses must re-think training and licensing guidelines with the primary care behavioral health workforce in mind.
Of course the above also does not take into account the obvious need to train a workforce that reflects the overall population of the United States in terms of key demographic and identity variables such as race/ ethnicity, language, gender, gender identity and sexual orientation. Our current workforce is not terribly well aligned along these variables to the population, a subject for another post.
It is also important to note that not all integrated care professionals work in the models specified above. You have professionals in hospital and specialty care settings as well as in bidirectional care settings (integrating physical healthcare into mental health/ SA settings), along with community health workers and other care enhancers that are part of the modern care team that are not covered by the above. Again, topics for future posts.
So, there’s your moonshot program primary care. If we can transition to electric cars by 2035 we should be able to muster the will to train the workforce we sorely need by then as well.