James Harle says the phone calls to Bellingham’s Sendan Center — the child and adolescent mental health clinic where he works as a board-certified child psychiatrist — can be heartbreaking.
Parents call to report suicidal children, only to be told the clinic can’t help them. A basic clinical psychiatric evaluation can incur a one- or two-month waiting time, while waitlists for therapy sessions are even longer. For Sendan’s Applied Behavioral Analysis (ABA) program, which provides intensive behavioral therapy for children with autism and other neurodevelopmental disorders, the wait time stretches beyond a year.
“It’s not a pretty picture,” said Harle, who founded Sendan in 2011. “I just wish I had a bigger army of people to serve the need.”
More than 162 million Americans live in federally designated health professional shortage areas (HPSAs) for behavioral health, according to the Health Resources and Services Administration. Altogether, these 6,500 areas are short an estimated 8,200 practitioners.
“There are not enough psychiatric providers in the country to go around,” said Danielle Kizer, an adult- and geriatric-certified psychiatrist at Bellingham’s PeaceHealth St. Joseph Medical Center. “We’re not training enough to meet the needs of our society.”
Locally, federally funded community mental health clinics are so busy they are forced to turn away new patients, while private practices like Sendan Center are either waitlisting patients or just encouraging them to call until an opening occurs.
And although the number of overall mental health providers is beginning to increase locally, it isn’t enough to meet a relentlessly increasing demand in the wake of the COVID-19 pandemic and other emotionally destabilizing societal factors.
Nationally, a 2021 Academic Psychiatry journal report shows that while the U.S. population increased 37% between 1995 and 2014, the number of psychiatrists only increased 12%. More than half of U.S. counties have no practicing psychiatrists at all. And of the nation’s more than 40,000 psychiatrists, 61% were 55 or older in 2017.
Washington ranks 11th worst nationwide in the number of mental health shortage areas, with a total of 193. Each area is given a score between 0 and 25, based on criteria including population-to-provider ratio, travel time to the nearest care source outside that area and percentage of population below the federal poverty level. The higher the number, the more pressing the need.
In Whatcom County, mental health coverage for low-income, homeless and migrant farmworker populations is scored at 10, about 1.48 full-time equivalent providers short of the target ratio for population-to-provider.
Skagit County is scored at 16 for that same population, though it comes in just .44 providers short of balance. San Juan County also scored at 16.
‘Bursting at the seams’
Richard Spitzer, a clinical psychologist who specializes in eating and attention-deficit disorders, has seen dramatic change in the 41 years he has treated patients in Bellingham for 41 years.
Government-based mental health funding in the 1970s, ’80s and ’90s, he said, was more plentiful than it is now. These community centers, Spitzer said, also served as training grounds for many providers who might later launch a private practice. Larger mental hospitals, like Sedro-Woolley’s long-shuttered Northern State, were an important part of the system for those with severe and chronic illness.
Over time, reduced funding resulted in closures and cutbacks in community mental health facilities, Spitzer said. Locally, the mental health clinics operated by Sea Mar, Unity Care, Compass Health and Catholic Community Services (CCS) are now “bursting at the seams,” Spitzer said.
Norman Hale, an adolescent psychiatric consultant to Skagit County’s CCS clinic since 2001, is seeing this firsthand.
“We’ve never had to close our doors until COVID,” Hale said. “And now, because of staffing issues, we just don’t have the staff to serve the kids that need to be served.”
Hale said there is no timetable for reopening Skagit’s CCS clinic to new patients. In private practice, he and his colleagues see completely full caseloads, often fitting in patients whenever a temporary opening occurs.
In Whatcom County, the average wait to see a psychiatrist is four to six months, Spitzer said.
Worst for young, aging, addicted
Three psychiatric specialties in are in particularly high demand: child and adolescent psychiatrists (CAPs), geriatric psychiatrists (GPs) and addiction psychiatrists (APs).
Children fare the worst. In fact, the American Association of Child and Adolescent Psychiatry reports 41 states — including Washington — with a “severe” CAP shortage, and nine with high-level shortages. Washington, D.C., is the only area with a sufficient supply.
The American Academy of Child and Adolescent Psychiatry listed Whatcom County as having six CAPs, one more than Skagit County and far above the state average. Thirty counties have two or fewer CAPs; only King, Pierce, Snohomish and Spokane have more than Whatcom. San Juan County has none.
This is especially worrisome for CAPs including Harle and Hale, who see mounting evidence that social media is having extremely negative effects on adolescent mental health. If those who need help cannot get it early, their outcomes are less likely to be positive. “Treating problems,” Hale said, “isn’t as effective as preventing (them) from the get-go.”
insurance makes therapy more affordable to many people, but those same insurance companies can present issues for providers.
Spitzer said some companies put restrictions on what they’ll cover or how they’ll reimburse providers.
Several years ago, Spitzer said one insurance company limited patients to 20 covered sessions per year, a number woefully inadequate for someone with a major mental illness.
“Twenty sessions for somebody who has an eating disorder is ridiculous,” he said. “Usually by the 15th session, you’re (just) developing trust in order to be able to make some effective changes.”
Some insurance companies also reimburse telemedicine appointments at different rates than in-person appointments. With COVID-19 less of a concern now than in 2020, many insurers are requesting in-person sessions again be the norm.
“It’s a volatile landscape,” Spitzer said. “Things change according to what, I think, suits insurance companies. And people are having to justify the need for continuation of what they’ve been doing.”
Harle also encounters frustration with insurers who have sometimes taken months to reimburse his practice. As a result, the insurances his clinic takes are based mainly on how reliably they pay in a reasonable timeframe.
“It feels, at times, like there are significant administrative hurdles that we have to spend money on, hiring a pretty robust billing service to get the money that they’re paying us,” Harle said. “This is why a lot of mental health therapists … are not (accepting) any insurance.”
Caught in an eddy
This can lead to a vicious cycle. Those using Affordable Care Act or state-based health plans, or who are insured through companies like Molina, are also often the most financially disadvantaged. Because those plans also pay less to providers, providers are less likely to accept those patients, and providers who do serve them may have more difficulty maintaining a private practice.
Kizer, who is working to expand the number of psychiatric staff in the local PeaceHealth network, said that people on Medicare cannot even be added to waitlists at many community mental health clinics.
“Getting in to see someone if you have Medicare is practically an act of Congress,” she said. “There isn’t anybody taking Medicare because it’s very low reimbursement.”
The Sendan Center does not accept Medicaid for most of its services because of low reimbursement rates. And Harle said it is becoming increasingly common in places like Seattle for private practices to require out-of-pocket payments, leaving the patients themselves to submit insurance claims for personal reimbursement later on.
Even when patients receive a list of in-network providers from their insurance company, that information may not be accurate. Kizer said she often shows up on lists for outpatient providers, even though she isn’t one.
“I’ve had patients burst into tears when I’ve answered their phone call and tried to help them find somebody,” she said.
Serving the need
Some therapists and psychiatrists still do take on patients regardless of their insurer, viewing what they do as too important to do otherwise.
Spitzer hasn’t raised his $100 hourly rate in 15 years, and said most of his caseload is comprised of ACA patients.
“The community has been good to me, so I want to give back to the community,” he said. “And a lot of therapists who I know and work with feel the same way. They don’t set limits for Molina patients, or look to take more Regents, Premera or Kaiser patients. The people I know who are in practice are trying to do a community service. And cost shouldn’t dictate that.”
In addition to raising reimbursement rates, Spitzer also hopes insurance companies will consider reducing requirements to determine medical necessity of mental health treatment. These requirements can include invasive intake forms with humiliating questions, such as asking for the methods a person has previously used to attempt suicide.
“It makes people not want to seek treatment,” he said.
Clinicians are searching for ways to expand access.
Telehealth therapy has served many people well, Spitzer said. He has continued employing it for most of his patients, particularly those with social anxiety, mobility issues or transportation concerns.
“It just is too much of a benefit for too many people who otherwise wouldn’t get treatment,” he said.
Kizer also sees the benefit.
“I think it will help those very, very rural populations, and those populations that aren’t in highly desirable areas where people want to live,” she said.
Still, she cautions that the current provider shortage is too big to be fixed by telemedicine alone, especially when clients in those same areas may also struggle with adequate internet access or technical know-how.
For providers in highly desirable places like Whatcom County, there is still the overall concern about inflationary cost of living. Spitzer surmises that the cost of living in this area, despite its idyllic environment, is a drawback, especially for those just starting out. “It’s going to be a battle for a lot of people trying to open a practice here,” he said, adding that if more clinical internships and fellowships incentivized jobs, it might help more providers eventually launch their own practices. Likewise, properly funding those clinical programs is essential, he said.
Collaboration between providers and other organizations can also provide a community with behavioral health treatment. The Sendan Center contracts with the Mount Vernon School District, Harle said, and Compass Health has established working relationships with Whatcom County districts to help students.
Catching issues earlier
One model making a difference is that of “integrated behavioral health,” where psychiatric staff are assigned to primary care clinics and provide short-term psychotherapy to patients referred to them by primary care doctors.
This collaboration between in-clinic therapists, primary care physicians and psychiatric prescribers (either a psychiatrist or nurse practitioner) can be beneficial in addressing mental problems before they become more serious, Kizer said.
It also has the benefit of moving patients through the system more quickly, ensuring that newer patients continue to be brought in. PeaceHealth currently uses this system in nine local clinics, including in Burlington and on San Juan Island.
PeaceHealth is working to expand its longer-term mental health treatment, opening a new outpatient psychiatric clinic this summer in Bellingham’s Barkley neighborhood. The clinic, which will cater to those with both Medicare and private insurance, will have a master’s-level therapist, PhD-level psychologist, and nurse practitioner/psychiatrist prescribers.
They also hope to open an intensive outpatient program, helping patients transition out of the in-patient mental health unit at St. Joseph Medical Center, and preventing others from needing to be sent there in the first place. Currently, that 20-bed unit is Whatcom County’s only in-patient mental health option.
Despite the dire challenges facing the mental health system, it’s clear that local providers aren’t about to give up.
“We’re doing everything we can to get going,” Kizer said.
— Reported by Matt Benoit