Psychiatry: The Silent Shortage

Psychiatry: The Silent Shrtage A resurce prvided by Staff Care, the natin s leading lcum tenens staffing firm and a cmpany f AMN Healthcare (NYSE: AHS), the largest healthcare wrkfrce slutins cmpany in the United States. www.staffcare.cm 800-685-2272 2015 Staff Care 8840 Cypress Waters Blvd. #300 Dallas, TX 75019 WE VE EARNED THE JOINT COMMISSION S GOLD SEAL OF APPROVAL CERTIFIED BY THE NATIONAL COMMITTEE FOR QUALITY ASSURANCE

PSYCHIATRY: THE SILENT SHORTAGE A resurce prvided by Staff Care, the natin s leading lcum tenens staffing firm and a cmpany f AMN Healthcare Abut Staff Care Staff Care is the leading prvider f lcum tenens staffing services in the United States and is a cmpany f AMN Healthcare (NYSE: AHS), the largest healthcare wrkfrce slutins rganizatin in the natin. As part f ur rle as industry leaders, Staff Care generates riginal survey data regarding trends in lcum tenens staffing, presents educatinal seminars n physician staffing and related tpics, and develps a series f white papers examining physician and advanced practitiner staffing issues. Staff Care executives authred the bk n lcum tenens staffing. Entitled, Have Stethscpe, Will Travel: Staff Care s Guide t Lcum Tenens, the bk utlines lcum tenens staffing principles, uses and prcedures fr bth healthcare facilities and physicians. Staff Care is prud t spnsr the Cuntry Dctr f the Year Award, a natinal hnr that recgnizes the spirit, skill and dedicatin f America s rural medical practitiners. This white paper is ne is a series that Staff Care has prduced. Others in the series include: Nurse Practitiners and Physician Assistants: Supply, Distributin, and Scpe f Practice Cnsideratins Wmen in Medicine: A Review f Changing Physician Demgraphics, Female Physicians by Specialty, State and Related Data Physician Supply Cmparisns: Physicians by Select Specialties Practicing in Each State and Licensed in Each State but Practicing Elsewhere The Physician Shrtage: Data Pints and State Rankings Ppulatin Health Management and Physician Staffing Overview The shrtage f physicians in the United States particularly primary care physicians has been well dcumented, with a variety f rganizatins, including the American Medical Assciatin (AMA), the Health Resurces and Services Administratin (HRSA), the Assciatin f American Medical Clleges, and multiple state medical and specialty scieties prjecting a dctr deficit. In March, 2015, the AAMC released a study entitled The Cmplexities f Physician Supply and Demand: Prjectins frm 2013 t 2025. The AAMC cncluded in this study that the U.S. will face a deficit f between 46,000 and 90,400 physicians by 2025. The reprt emphasized that while primary care dctrs will be in shrt supply, the steepest deficits may be amng specialist physicians wh care fr the elderly, including psychiatrists. Accrding t Dr. Tm Insel, M.D., Directr at the Natinal Institute f Mental Health (NIMH), a disturbing trend cntinues t develp in the supply f psychiatrists and verall quality f mental healthcare natinwide. This emerging crisis is due t a multitude f factrs, including an aging psychiatrist ppulatin, a small percentage f medical schl graduates chsing psychiatry residency prgrams (4%), and mental healthcare mdels that perate like a bus statin, stressing patient vlume ver value f care (See Where are We Ging?, NIMH, June 2011).

The reference in the new AAMC physician shrtage prjectins t psychiatrists therefre is welcme because psychiatry ften is verlked in physician supply discussins. The lack f emphasis given t the psychiatry shrtage is partially rted in pervasive stigmas abut mental illness in the United States. Thse suffering frm depressin and ther frms f mental illness frequently are reluctant t discuss their prblems, and are ften reluctant t seek treatment. While the symptms f thse with heart, lung, rthpedic r ther physilgical prblems typically are readily apparent, the symptms f thse with psychlgical prblems ften are nt. In additin, mental illnesses generally cannt be addressed thrugh medical prcedures, but nly made manageable thrugh lng-term treatment with drugs and/r therapy. Hspitals and clinics tend t be prcedure riented, a cleaner frm f medicine where the apprpriate surgery/interventin is perfrmed and the next patient is addressed. Histrically, if gvernment and ther payers pay well fr a prcedure, particular attentin is given t that prcedure. Cardilgy prcedures and rthpedic surgery prcedures usually fall int this highly desirable prfit center categry. Psychiatry, by cntrast, is nt a prfit center fr mst hspitals (psychiatric services are nt cvered by sme insurance cmpanies) s such services smetimes are nt given a high pririty. As a general rule, mental health prblems in the United States, their causes, cures and thse wh suffer frm them, tend t be swept under the carpet. Fr these reasns, Staff Care refers t the dearth f psychiatrists as the silent shrtage. A GROWING DEMAND The shrtage f psychiatrists in the United States is driven in part by a grwing need fr psychiatric services. Cnsider: One in every five adults in America experiences sme frm f a mental illness Nearly ne in 20 adults in America (13.6 millin) live with a serius mental illness 60% f adults with a mental illness received n mental health services in the previus year Suicide is the 3 rd leading cause f death in yuths ages 10-24, and the 10 th leading cause f death fr adults in the U.S. The average delay between nset f mental health symptms and interventin is 8-10 years Over $193 billin dllars in lst earnings a year result frm serius mental illness 24% f state prisners have a recent histry f a mental health cnditin Surce: Natinal Alliance n Mental Illness (NAMI; www.nami.rg) These alarming statistics and trends make it imperative t cnsider the availability f psychiatric services, particularly because the entire subject f mental illness has fr s lng been avided by bth plicy makers and the public. Prir t further examining supply and demand trends in psychiatry we have prvided a brief backgrund n the specialty.

Histry and State f Psychiatry A psychiatrist is defined by the American Psychiatric Assciatin (APA) as a medical dctr wh specializes in the diagnsis, treatment and preventin f mental health illness, including substance use disrders. A psychiatrist has earned a medical degree (either M.D. r D.O.) in additin t cmpleting a fur-year residency prgram in psychiatry and additinal specialized fellwship training as applicable. They are bard certified by the American Bard f Psychiatry and Neurlgy, and must be re-certified by written and ral examinatin every 10 years. Psychiatry and inquisitin int the human mind has a lng-established histry in the United States. Accrding t the APA, in 1812 Benjamin Rush, M.D., cnsidered the Father f American Psychiatry, published the first psychiatric textbk in the U.S. called Inquiries and Observatins n Diseases f the Mind. In 1844, superintendents frm the existing 24 mental hspitals met and established the Assciatin f Medical Superintendents f American Institutins fr the Insane, cnsidered the precursr assciatin t the APA. Thrughut the 19 th century, significant wrk was dne t rerient the management and placement f mentally ill patients, emphasizing the mvement f insane individuals frm incarceratin and inhumane treatment thrugh the creatin f state mental hspitals. The American Psychiatric Assciatin received its mdern name in 1921. The time fllwing saw great advancements fr psychiatry in the United States. Smatic therapy methds were intrduced int psychiatry in the 1930s, including the use f insulin, metrazl, and electr-cnvulsive therapy. In 1946, Cngress passed the Natinal Mental Health Act, establishing the Natinal Institute fr Mental Health and prviding federal funds fr mental disrder research, training fr prfessinals, and cmmunity services fr the first time. In 1955 psychactive drugs were intrduced in the United States, with widespread implementatin leading t increased discharges frm state mental hspitals (a reductin frm 560,000 hspital beds and 315 public mental hspitals t 53,000 beds and 230 hspitals ver the past half-century). As the APA has mved int the 21 st century, cntinued evaluatins n prper treatment prtcls, implementatin f research, and verall rganizatin have remained a tp pririty. Surce: APA Histry, American Psychiatric Assciatin PRACTICE Psychiatrists tday wrk in a wide range f specialties and practice settings. Specialties fr which certificatin is granted include: Child and adlescent psychiatry Geriatric psychiatry Frensic (legal) psychiatry Addictin psychiatry Pain medicine Psychsmatic (mind and bdy) medicine Psych/Family Medicine Pediatrics/Psychiatry Psychiatry/Neurlgy Practice settings are wide-ranging fr psychiatrists, including cmmunity health centers, clinics, private practices, general and psychiatric hspitals, prisns, gvernment and military settings, university medical centers and ther settings. Abut 50% f psychiatrists in the United States wrk in private practice. Supply Distributin There are currently 28,250 psychiatrists in active practice in the U.S. A distributin by state can be seen belw, with the tp 5 mst ppulus states f Califrnia, New Yrk, Texas, Pennsylvania and Flrida

cmprising 39% f all psychiatrists and 37% f the general ppulatin. State Number f Psychiatrists Percentage f Psychiatrists Percentage f U.S. Ppulatin Califrnia 3,842 13.6% 12.2% New Yrk 3,044 10.8% 6.2% Texas 1,546 5.5% 8.5% Pennsylvania 1,309 4.6% 4.0% Flrida 1,288 4.6% 6.2% Massachusetts 1,207 4.3% 2.1% Illinis 1,056 3.7% 4.0% New Jersey 960 3.4% 2.8% Ohi 916 3.2% 3.6% Nrth Carlina 868 3.1% 3.1% Maryland 818 2.9% 1.9% Michigan 733 2.6% 3.1% Virginia 717 2.5% 2.6% Gergia 661 2.3% 3.2% Cnnecticut 567 2.0% 1.1% Arizna 511 1.8% 2.1% Washingtn 498 1.8% 2.2% Missuri 468 1.7% 1.9% Clrad 459 1.6% 1.7% Wiscnsin 456 1.6% 1.8% Minnesta 433 1.5% 1.7% Tennessee 433 1.5% 2.1% Suth Carlina 398 1.4% 1.5% Oregn 377 1.3% 1.2% Indiana 346 1.2% 2.1% Luisiana 333 1.2% 1.5% Kentucky 310 1.1% 1.4% Alabama 304 1.1% 1.5% Puert Ric 271 1.0% 1.1% Oklahma 270 1.0% 1.2% Kansas 212 0.8% 0.9% Arkansas 199 0.7% 0.9% New Mexic 187 0.7% 0.7% Utah 185 0.7% 0.9% Rhde Island 182 0.6% 0.3% Iwa 173 0.6% 1.0% Mississippi 159 0.6% 0.9% Washingtn, D.C. 158 0.6% 0.2% Maine 153 0.5% 0.4% Hawaii 152 0.5% 0.4% Nevada 146 0.5% 0.9% New Hampshire 143 0.5% 0.4% West Virginia 121 0.4% 0.6%

Nebraska 117 0.4% 0.6% Vermnt 102 0.4% 0.2% Idah 83 0.3% 0.5% Alaska 72 0.3% 0.2% Mntana 72 0.3% 0.3% Delaware 68 0.2% 0.3% Nrth Dakta 65 0.2% 0.2% Suth Dakta 58 0.2% 0.3% Wyming 34 0.1% 0.2% Ttal 28,250 Surce: American Medical Assciatin (AMA) Master File/MMS Distributin f psychiatrists can als be displayed n a per capita basis. The average natinwide is 8.9 psychiatrists per 100,000. A breakdwn by state is belw: State Psychiatrists/100,000 Washingtn, D.C. 24.0 Massachusetts 17.9 Rhde Island 17.2 Vermnt 16.3 Cnnecticut 15.8 New Yrk 15.4 Maryland 13.7 Maine 11.5 New Hampshire 10.8 New Jersey 10.7 Hawaii 10.7 Pennsylvania 10.2 Califrnia 9.9 Alaska 9.8 Oregn 9.5 New Mexic 9.0 Nrth Dakta 8.8 Nrth Carlina 8.7 Virginia 8.6 Clrad 8.6 Suth Carlina 8.2 Illinis 8.2 Minnesta 7.9 Wiscnsin 7.9 Ohi 7.9 Missuri 7.7 Puert Ric 7.6 Arizna 7.6 Michigan 7.4 Kansas 7.3

Delaware 7.3 Luisiana 7.2 Washingtn 7.1 Mntana 7.0 Kentucky 7.0 Oklahma 7.0 Suth Dakta 6.8 Arkansas 6.7 Tennessee 6.6 Gergia 6.5 West Virginia 6.5 Flrida 6.5 Utah 6.3 Alabama 6.3 Nebraska 6.2 Wyming 5.8 Texas 5.7 Iwa 5.6 Mississippi 5.3 Indiana 5.2 Nevada 5.1 Idah 5.1 Natinal Average 8.9 Surce: AMA Master File/MMS As these numbers demnstrate, psychiatrists are nt evenly distributed thrughut the cuntry, with cnsiderably mre psychiatrists cncentrated in the Nrtheast, histrically the lcatin f the prepnderance f training prgrams. Accrding t Richard Buz Cper, M.D. f the University f Pennsylvania, a nted natinal authrity n physician supply, distributin and utilizatin, a ppulatin f 100,000 can supprt 14.7 psychiatrists, r ne fr every 6,800 peple (this is a natinal average and may vary based n the ecnmic, demgraphic and healthcare cnsideratins f lcal areas). As the numbers abve indicate, all but six states fall belw this average. Aging Outlk Psychiatry is ne f the ldest specialties n average in medicine. Of the 28,250 active psychiatrists, 59% are 55 years f age r lder, placing it as the 3rd ldest specialty (see list belw). Percent f Physicians 55 and Older Specialty Percentage Pulmnlgy 73% Onclgy 66%

Psychiatry 59% Cardilgy 54% Orthpedic Surgery 52% Neurlgy 50% General Surgery 48% Ophthalmlgy 48% Urlgy 48% Radilgy 47% Gastrenterlgy 45% Neurlgical Surgery 45% Otlarynglgy 45% Anesthesilgy 44% Dermatlgy 43% Hematlgy/Onclgy 41% Internal Medicine 40% Vascular Surgery 40% Family Practice 38% Obstetrics/Gyneclgy 38% Pediatrics 38% Emergency Medicine 34% Nephrlgy 34% Surce: Merritt Hawkins Physician Staffing Resurce, AMA Master File Given the large percentage f psychiatrists ver the age f 55, it can be anticipated that many psychiatrists will retire in the near future. This reduced wrkfrce creates a premium n increasing psychiatrist supply thrugh graduate medical educatin (GME). Hwever, when lking at the state f GME fr psychiatry, the numbers reveal a cncerning state f affairs. Accrding t the APA Resident Census fr 2013-14, there were 1,037 residents entering their final year f residency training fr general psychiatry prgrams fr the 2013-2014 year. Belw is a breakdwn by year in general psychiatry residency prgram: Year in Residency Prgram Number f Residents Percentage f Residents 1 1,261 25.3% 2 1,340 26.9% 3 1,332 26.8% 4 1,037 20.8% 5 r Over 9 0.2% Surce: APA Resident Census, Characteristics and Distributin f Psychiatry Residents in the U.S. 2013-2014 Ttal resident enrllment in psychiatry prgrams (including specialty prgrams) shws a majrity f residents are enrlled in general psychiatry prgrams (82.5%), with child and adlescent psychiatry cmprising the secnd largest percentage f residents (14.2%). Belw is a breakdwn f prgram specialties:

Prgram Specialty Ttal number f Residents Percentage f Residents Psychiatry 4,979 82.5% Child and adlescent psychiatry 859 14.2% Addictin psychiatry 64 1.1% Frensic psychiatry 66 1.1% Geriatric psychiatry 64 1.1% Ttal 6,032 Surce: APA Resident Census, Characteristics and Distributin f Psychiatry Residents in the U.S. 2013-2014 Based n the data abve, it can be prjected that an average f 1,243 psychiatrists will cmplete GME prgrams fr general psychiatry each year frm 2014-2017, with 6,032 psychiatrists ttal cmpleting GME prgrams ver the next 4 years. With 59% f the active psychiatrist ppulatin at 55 years f age r lderr 12,486 psychiatrists- there is a ptential in the near future t have mre psychiatrists leaving the specialty per year than entering. The Silent Shrtage The United States is currently facing a mental illness cverage crisis- ne in which a large percentage f the ppulatin is suffering frm mental illness, and current resurces available drastically underserve thse in need. As indicated by the Natinal Alliance n Mental Illness (NAMI), nearly 44 millin adults experience mental illness in a year, with 60% f thse adults receiving n mental health services in the previus year. In additin, 50% f yuths ages 8-15 with a mental illness received n health services in the previus year. This lack f treatment leads t real cnsequences, including lst incme/prductin, unemplyment/hmelessness and harmful behavirs that can lead t suicide. There are currently 3,968 mental health care health prfessinal shrtage areas in the U.S., and mre than 50% f the cuntry des nt have the necessary amunt f practitiners t meet the needs f their area. Belw is a list f all 50 states shwing the percent f mental health care need that is met per state. The list was cmpiled by the Kaiser Family Fundatin. The percent f need met is cmputed by dividing the number f psychiatrists available t serve the ppulatin f the area, grup, r facility by the number f psychiatrists that wuld be necessary t eliminate the mental health HPSA (based n a rati f 30,000 t 1 psychiatrist (20,000 t 1 where high needs are indicated). Percent f Mental Health Need Met Per State Lcatin Ttal Mental Health Care HPSA Designatins Percent f Need Met Practitiners Needed t Remve HPSA Designatin Alabama 51 45.6% 83 Alaska 63 22.7% 8

Arizna 95 24.1% 204 Arkansas 43 63.3% 33 Califrnia 339 43.9% 167 Clrad 62 76.5% 23 Cnnecticut 28 32.0% 63 Delaware 10 25.6% 6 District f Clumbia 9 59.8% 3 Flrida 143 49.8% 83 Gergia 91 42.3% 123 Hawaii 27 64.0% 4 Idah 36 58.0% 24 Illinis 123 69.5% 71 Indiana 53 43.4% 106 Iwa 67 60.8% 30 Kansas 63 56.5% 17 Kentucky 90 72.0% 34 Luisiana 109 41.6% 83 Maine 51 35.8% 8 Maryland 49 66.3% 32 Massachusetts 57 55.0% 19 Michigan 191 41.4% 73 Minnesta 59 61.4% 30 Mississippi 41 77.8% 59 Missuri 83 69.1% 89 Mntana 69 25.5% 21 Nebraska 75 76.3% 9 Nevada 31 59.2% 44 New Hampshire 19 94.9% 1 New Jersey 31 71.9% 4 New Mexic 63 29.5% 45 New Yrk 147 43.1% 120 Nrth Carlina 88 52.2% 25 Nrth Dakta 50 83.1% 9 Ohi 97 56.6% 59 Oklahma 108 25.2% 64 Oregn 75 50.5% 44 Pennsylvania 116 61.9% 37 Rhde Island 10 100.0% 0 Suth Carlina 46 55.0% 40 Suth Dakta 49 15.2% 22 Tennessee 63 38.6% 88 Texas 333 46.8% 193 Utah 37 62.9% 47 Vermnt 23 NSD NSD Virginia 50 61.0% 35 Washingtn 112 40.4% 71

West Virginia 83 66.1% 22 Wiscnsin 103 20.8% 212 Wyming 16 73.9% 6 Surce: Henry J. Kaiser Family Fundatin As these numbers indicate, nly half f all states have met 50% r mre f their mental health care need, while sme states have nt met even a quarter f their need. Althugh recent legislatin under the Affrdable Care Act has attempted t increase mental health cverage, the current results are mixed. In 2008, the Obama administratin passed the Mental Health Parity and Addictin Equity Act f 2008, requiring insurance cmpanies t ffer the same amunt f cverage fr mental health/substance abuse disrders as medical prcedures. Under this law, insurance plans must cver 10 Essential Health Benefits, including mental health disrders. Hwever, the specific services cvered by each categry are nt specified, and may vary largely frm state t state (See Obamacare Hasn t Prpelled Mental Health Treatment, US News, Octber 2014). Sme states, such as Texas, Wiscnsin and Alaska, have prgrams in place that financially reward psychiatrists fr practicing in underserved areas. Thrugh tw new medical schls, Wiscnsin is adding ten new psychiatry residents psitins by 2017. In February, 2015, Wiscnsin initiated the Child Psychiatrist Cnsultatin Prgram in which child psychiatrists are n-call thrugh phne r email t cnsult with primary care physicians. In additin, Illinis, New Mexic and Luisiana are the first states t pass laws allwing psychlgists t prescribe pharmaclgical drugs (in at least the case f Illinis, they can nly d s in cperatin with a physician). In additin, mental health and psychiatric nurse practitiners and physicians assistants als may take n mre f the mental health wrklad. As discussed previusly, the stigma against mental health in the United States plays a large rle in lack f mental healthcare cverage and the dearth f psychiatrists available t prvide adequate care. While ther prminent specialties such as cardilgy and rthpedic surgery ffer healthcare prviders prfit center -based care where patient illnesses can be treated with medical prcedures r tangible interventinal care, mental health cverage ften requires lng-term management withut a defined cure. Thus, mental health care is nt as desirable a service line fr hspitals and private insurance cmpanies as are ther specialties. The current supply f psychiatrists in the United States places patients in a precarius state. There are currently 28,250 psychiatrists practicing active patient care in the U.S.; in additin, 59% f psychiatrists are 55 years f age r lder, meaning a large percentage f the active psychiatry ppulatin will be retiring r reducing wrklad in the near future. Despite these facts, the shrtage f psychiatrists and mental health cverage ges largely unnticed- a silent shrtage. While mental health issues are nt ging away, psychiatrists are, nly exacerbating a grwing gap between supply and need fr increased care.

Cnclusin Althugh largely swept under the rug, mental health issues remain a significant hurdle in the United States, with lack f adequate cverage resulting in lss f prductin and harmful individual behavirs. The shrtage f psychiatrists, and lack f attentin paid t this prblem, will have t addressed, particularly as an aging psychiatrist ppulatin exits the wrkfrce. Fr additinal infrmatin abut psychiatrist supply, demand, cmpensatin and recruiting issues, cntact: Crprate Office: Staff Care 8840 Cypress Waters Blvd #300 Dallas, TX 75019 800-685-2272 www.staffcare.cm 800-685-2272 2015 Staff Care 8840 Cypress Waters Blvd. #300 Dallas, TX 75019