Psychologist shortage: factors affect access to care

The Kaiser Family Foundation issued a report in January citing a significant shortage of mental health care practitioners nationwide. In New England, the “percent of need met” ranged from 34.26 percent in Connecticut to 61.17 percent in Rhode Island.

According to regional psychologists, a variety of reasons, from an aging profession and inadequate training/education programs to low reimbursement rates and health plan disparities, may account for the shortage of licensed mental health providers.

For states like Maine, geography and the number of licensed professionals pose a challenge, according to Carly Rodgers, Ph.D., postdoctoral fellow and public education chair of the Maine Psychological Association.

She reported that Maine has only 537 licensed psychologists. “This means .39 psychologists per 1,000 people, which is under the national average of .5 per 1,000,” she said. “Another significant issue is the distribution of psychologists.”

For instance, the Portland area has 122 psychologists, but rural counties, particularly in the north, have a serious dearth, she added.

Rodgers also pointed out that an aging profession could foretell shortages in the future. In Maine, 68 percent of practicing psychologists are 50 and older; 28 percent are 60 years old or older, she said.

In New Hampshire, many individuals seek treatment at community mental health centers (CMHCs) that often operate with restricted budgets, which impacts level of service. Evan Greenwald, Ph.D., executive director, Counseling Center in Nashua, New Hampshire, said, “[CMHCs] are forced to hire unlicensed staff and/or providers with less training. Literally none are Ph.Ds.”

Furthermore, fewer individuals are becoming doctoral level practitioners, partly because of reimbursement rates, according to Greenwald. “I’d say the insurance industry doesn’t reimburse for the differential when it comes to the investment in schooling for a Ph.D versus a Master’s,” he said.

New Hampshire is attempting to get a clearer picture of the psychology landscape, according to Melissa Chase Levesque, Psy.D., primary care psychologist,  Live Well/Work Well (LWWW) Program and assistant professor of psychiatry at Dartmouth Hitchcock Medical Center. “There is a bill currently (HB322) in the legislature that would require mental health providers to complete a short survey when they renew their licenses if this passes,” she said. “It would help tremendously with our ability to capture workforce information.”

In Vermont, 175 active practicing licensed Master’s level psychologists and 314 doctoral level psychologists serve a population of 630,000, according to Rick Barnett, Psy.D., LADC, private practitioner in Stowe.

He said that while many patients are seen in private practice, others – like those in New Hampshire – are treated at CMHCs, which offer markedly different services, such as help with transportation, housing, food and case management. “What gets lost is that even patients with serious mental illness are not getting psychotherapy,” he said.

Fortunately, insurance coverage in Vermont does not pose a significant challenge. Blue Cross/Blue Shield and state-run Medicaid impose no session limits or pre-authorization for mental health services, Barnett said. “And there is no need to request additional services.”

However, the situation in Massachusetts is quite different. Brian Doherty, executive director, Massachusetts Psychological Association, reported health plan network restrictions as the primary problem in the Commonwealth.

He cited statistics from a couple of years ago – some of which are estimates – that indicated “…some health plans in Massachusetts have more than 2,000 psychologists in network and some have fewer than 200. In our experience, when the consumer says he’s having trouble finding a psychologist, it’s not due to shortage per se, but due to limitations of health plan networks with regard to behavioral health.”

“We hear from consumers that it is an issue with specific plans. For example, MPA has a referral service for the general public where anyone can call MPA and describe the psychologist they’re looking for, explain what issues to address and we send [the request] to the network of 1,000 [of our member] psychologists in Massachusetts who will respond if they are willing to take on that patient,” Doherty said. “We run into a lot of trouble finding a psychologist who will accept certain insurances and in certain geographic areas.”

Jennifer Warkentin, Ph.D., MPA’s director of professional affairs, pointed out that, in some instances, psychologists have been denied attempts to join a panel. “The main reason we hear is that [the insurer has] sufficient coverage, enough providers in the network and is not taking on more. We don’t know if that’s true at the Master’s levels. We do know they are turning away doctoral level people,” she said.

“There’s not a whole lot of transparency when it comes to information with health plans so it’s very difficult for us to address anything on a detailed level, even getting specific numbers of providers.”

She added that finding a list of psychologists on a particular health plan network is also challenging. “We have heard of people being on a list for a health plan who are no longer practicing.”

Warkentin said that Ruth B. Balser, representative for the 12th Middlesex district, introduced a bill (H487) into legislative session that addresses transparency and would require health plans to report more data.

“Hopefully this summer or fall we’ll see some movement on that,” she said. “To be honest, the first thing we need is data transparency. If we were able to look at numbers in terms of denials of services and out-of-network services, I think there would be more to stand on to push for change. Not getting the information severely limits the options we and other professional groups have in making changes.”

In addition to insurance complications, Warkentin echoed Greenwald’s thoughts on the cost of schooling versus the financial gains following licensure as a professional barrier.

“Recent grads from bachelor programs are seeing unprecedented levels of student debt. To incur additional debt to go to doctoral level training, which requires four or five years of training, is too much for many people,” she said. “If they look at the debt and how much they make with the reimbursement rate, that’s a real deterrent.”