Focus #19

10/18/18

Rural Counties Face Psychiatrist Shortage

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Fifty-five of 72 Wisconsin counties face a “significant shortage” of psychiatrists and 20 have no practicing psychiatrists at all. The dearth of psychiatrists in these areas, along with the high prevalence of mental illness and substance abuse in the state, likely contribute to a gap in which more than half of Wisconsin adults in need of services for a mental health disorder go without care.

More than three-quarters of the state’s counties have a significant shortage of psychiatrists under the state’s definition and more than half have a shortage under a tighter federal standard, a Wisconsin Policy Forum (WPF) analysis has found.

As providers charged with diagnosing and treating mental health disorders, including prescribing medications, psychiatrists play a critical role in the behavioral health care delivery system alongside other professionals, such as therapists and psychologists. For that reason, the availability of psychiatrists is one important component to patients’ overall access to mental health care. As discussed below, the costs of not providing such care can be substantial.

In 2015, WPF assessed outpatient behavioral health capacity in Milwaukee County and found that lack of access to psychiatrists, particularly among children, is a serious problem in the state’s largest metro area. Here, we use data from the Wisconsin Medical Society to expand the analysis statewide and find significant shortages, particularly in rural areas.

State Numbers Mask Shortage

The data list 759 psychiatrists in Wisconsin, roughly 1.3 per 10,000 state residents. However, the statewide number masks significant regional variation.

Twenty of Wisconsin’s 72 counties have no practicing psychiatrists and 10 more counties have less than one full-time equivalent psychiatrist because they share one with multiple counties. For example, a single psychiatrist currently serves Ashland, Bayfield, and Iron counties. As shown in Figure 1, counties with few or no psychiatrists are most common in the northern portion of the state.

The Wisconsin Department of Health Services says areas with fewer than one psychiatrist for every 10,000 residents have a “significant shortage.” The U.S. Department of Health & Human Services generally identifies “shortage areas” as those with one psychiatrist or fewer for every 30,000 people.

Under the state standard, the Medical Society data show 55 of the 72 Wisconsin counties have a psychiatrist shortage. More than half of the counties (37) have fewer than one psychiatrist per 30,000 residents and meet the federal shortage criteria.

Exacerbating this problem is the fact the state’s psychiatrist workforce is aging rapidly. The average Wisconsin psychiatrist is 50 years old and 15% of the state’s psychiatrists are 65 or older. Average ages vary geographically, as well; psychiatrists in the central and northern portions of the state tend to be, on average, older than those in the southeast and south-central regions. (See Figure 2)

Though the shortages observed here can be found within other health care disciplines (such as primary care doctors and nurses), there is evidence to suggest the shortage among psychiatrists is particularly severe. From 2003 to 2013, the number of U.S. physicians increased by 14.2%, but psychiatrist numbers declined by 0.2%, the journal Health Affairs found. Additionally, as medical doctors with the training and authority to prescribe, psychiatrists provide services that other mental health providers generally cannot. For this reason, a dearth of psychiatrists represents a challenge for those struggling with mental illness.

Treatment Gap is Substantial

This is particularly true in Wisconsin, where mental illness is relatively common and often goes untreated. According to Mental Health America, Wisconsin is ranked 41st of the 50 states for prevalence of mental illness (the low ranking indicates a higher prevalence of mental health and substance use issues).

A 2017 DHS report found Wisconsin’s overall treatment gap (the difference between the population in need of mental health disorder services and the population that is served) totaled 54% in 2015 among adults. The gap among those struggling with addiction is worse: less than one-quarter of the estimated 456,000 state residents in need of treatment for addiction receive it, for a gap of 77%.

DHS estimates suggest substance misuse and addiction alone cost an estimated $6.8 billion annually in Wisconsin. A 2014 report from the agency estimates depression and schizophrenia cost the state $800 million and $1 billion each year, respectively, in treatment and medication, criminal justice, capital costs for mental health facilities, and lost productivity.

A number of initiatives aim to draw psychiatrists and other physicians to underserved areas. For example, there are three loan assistance programs available to Wisconsin psychiatrists: the Health Professions Loan Assistance Program and Rural Physician Loan Assistance Program, which are run by the state Office of Rural Health; and the federal National Health Service Corps.

Additionally, the Primary Care and Psychiatry Shortage Grant (2013 Act 128) was created to encourage primary care physicians and psychiatrists to practice in underserved areas. The Medical College of Wisconsin opened two new psychiatry residency programs in northeastern and central Wisconsin in 2017. Other opportunities include the Wisconsin Conrad Waiver program, which offers an expedited immigration process to foreign-trained physicians in return for providing primary care or general mental health care in federally designated shortage areas. Wisconsin has also created rural and urban outreach curriculum programs: Training in Urban Medicine and Public Health and the Wisconsin Academy for Rural Medicine.

Going forward, policymakers may want to consider increasing psychiatry residency class sizes or rural psychiatry residency programs, as approximately half of medical residents practice within the state in which they trained. In addition, expanding the use of integrated care models and of telemedicine for both patients and other health care providers could help to widen the reach of the existing psychiatrist workforce.