Every week, Peter Evers wonders if one or more of his psychiatric staff will get stolen by a medical facility offering better pay and benefits.
“In some ways there’s a talent war,” Evers said. “Our medical director says he probably gets 20 offers of employment a week unsolicited through email and snail mail. The system is desperate for psychiatry.”
And Evers, the CEO of Riverbend Community Mental Health in Concord, says he’s not alone.
Hospitals and clinics are struggling to hire new psychiatrists as old doctors in the field retire, demand for their services grows and most newly minted psychiatrists choose to put down roots in cities like Boston rather than the Granite State.
Experts say this will negatively affect the quality of and access to care for New Hampshire residents with mental illness, a group that advocates say is already underserved, helped too late and forced to wait for beds.
“I don’t want to be doom and gloom, but 15 years ago, New Hampshire was known as one of the best community mental health systems in the country. Now, it’s in the bottom three,” Evers said. “That is a direct result of neglect of the system post-2008, when we had the financial crisis.”
The problem may be coming to a head as potential pay cuts for psychiatrists at the state’s mental hospital could trigger an exodus to places willing to pay higher rates, while other hospitals’ inpatient psychiatric wings are closing because they can’t recruit or retain psychiatrists, and a majority of psychiatrists are nearing retirement in the coming years.
The government has taken note. On April 29, Gov. Maggie Hassan issued an executive order creating a commission to study the medical workforce shortage and make recommendations for improving recruitment methods, pay structures, regulatory burdens and more.
That announcement came days before Cheshire Medical Center/Dartmouth-Hitchcock Keene released a statement saying it would be closing its inpatient Adolescent and Adult Mental Health Unit, affecting 33 jobs. The reason? After at least three years of recruitment efforts aided by national search firms, Dartmouth-Hitchcock recruiters and local agencies, Cheshire failed to fill vacant psychiatric staff positions.
“A national shortage of psychiatrists has negatively impacted these efforts,” the statement read.
Cheshire only needed two psychiatrists to keep it open besides on-call psychiatrists from the community to cover nights and weekends.
“We deeply regret that it has come to our being forced to close the unit, but we have exhausted every option available to maintain inpatient services,” Cheshire’s CEO Don Caruso said in the press release.
Over the past decade, inpatient psychiatric units at Catholic Medical Center in Manchester and St. Joseph Hospital in Nashua have also closed due to staffing challenges.
Meanwhile, Dartmouth College is planning to lay off its psychiatric staff (including those contracted to work at New Hampshire Hospital, the state-run mental hospital), and most of that staff will receive offers to be employed by Dartmouth-Hitchcock Medical Center as part of a planned transition.
College spokesperson Justin Anderson says the move is part of a larger effort to fix a structural deficit in the medical school and to adopt the model already used by most other major medical schools, which use faculty employed by the affiliated hospital rather than the school.
But Matthew Davis, a psychiatrist at New Hampshire Hospital, says the hospital is offering lower compensation packages even though they already work for pay that’s below the market rate. Davis, who is organizing a collective bargaining unit in an effort to get a seat at the table during contract negotiations between the DHMC and the state, says the new proposed packages have some folks losing out on bonuses and vested retirement contributions, while contributions and time off will be reduced overall.
He thinks if these cuts go through, it may mean a significant loss in psychiatric staff.
“At the end of the day we could all take jobs that pay far more than we get paid now,” Davis said. “We all talk about how often we get called by recruiters or emailed by recruiters.”
The average salary for psychiatrists in the Northeast is the lowest in the country at $215,000 compared to $226,000 nationwide and as much as $243,000 on the West Coast, according to the Medscape Psychiatrist Compensation Report 2016.
While Davis stresses he and others would never neglect their duties and that they all want to stay there, Davis says the doctors also can’t neglect their massive student loans.
Ultimately, he worries about how the patients will be affected by all of this.
“If people start to leave here, it’s going to go from a crisis to a catastrophe, I think, pretty quickly,” Davis said.
While it’s still unclear how the contract negotiations will play out, William Torrey, the vice chair of clinical services at Dartmouth’s department of psychiatry, says he’s confident psychiatrists employed by the hospital will see compensation rise to market rate levels over the next year.
Psychiatrists are fully trained medical doctors and are the top of the mental health food chain. They rarely provide the kind of one-on-one talk therapy provided by psychologists with Ph.D.s, psychoanalysts with professional degrees or licensed clinical social workers, but they do supervise medical treatment, both directly and indirectly.
Lisa Mistler, the president of the New Hampshire Psychiatric Society and a psychiatrist at New Hampshire Hospital, says a worsening shortage of psychiatrists here will mean the most vulnerable populations will get less access to quality care.
“People with serious and persistent mental illness, people with schizophrenia, people with bipolar disorder, people with major depressive disorder, folks who are requiring a lot of ongoing care, those are the folks who are going to lose out on the quality of care if they’re unable to access psychiatrists,” Mistler said.
The population New Hampshire Hospital cares for represents the most severe and most persistent illnesses, and there’s already a waiting list to get in.
“If there are fewer psychiatrists in the community, that list could get bigger,” Mistler said.
Bill Rider, the president of the Mental Health Center of Greater Manchester, says psychiatrists are crucial for providing a knowledge base for everyone on the team at a mental health institution.
“To be woefully short of the individuals such as psychiatrists and other specialty physicians puts the community at a disadvantage in terms of attaining top mental health,” Rider said.
In the worst-case scenario, a patient could be misdiagnosed or given the wrong prescription. That’s assuming a person gets treated in the first place.
“Right now, what we’re concerned about is the quality… and availability,” Rider said. “I think access will be a big issue.”
How did things get this bad? In short, the med schools aren’t graduating enough psychiatry students.
The industry has long known of a severe shortage in psychiatrists and other medical professionals nationwide:
• As the U.S. population grew by 37 percent from 1995 to 2013, the number of psychiatrists grew by 12 percent, according to the American Medical Association.
• There are 143 psychiatrists active in New Hampshire, a rate of 10.8 per 100,000 compared to a national rate of 12.4, according to a 2015 white paper by consulting firm Merritt Hawkins titled Psychiatry: “The Silent Shortage.” That’s one psychiatrist for 10,000 residents.
• About 1,037 med school residents in psychiatry were entering their fourth year for the 2013-2014 year, according to the APA resident census.
• About 6 out of about 80 Dartmouth College med school students are currently pursuing psychiatry, according to the medical director of the Dartmouth-Hitchcock psychiatric department.
• Merritt Hawkins projects about 6,000 new psychiatrists will graduate med school over the next four years while about 12,500 psychiatrists (nearly 60 percent) are already 55 or older, suggesting more will retire than enter the field in the near future.
Mistler says one thing that may explain why there are so few psychiatrists entering the healthcare industry, besides lower pay, is the stigma attached to mental illness and even the field of study of mental health.
“Psychiatry is always considered kind of the stepchild of medicine and psychiatrists can be kind of the butt of jokes even in medical schools — like, ‘Didn’t you want to be a real doctor?’” Mistler said.
Granite State problems
Those working in the industry locally say the problem is more pronounced in New Hampshire because of its aging demographics, rural character, geography and relatively low pay for psychiatrists in the region compared to other parts of the country.
And the timing couldn’t be worse, as the state is trying to build up its mental health infrastructure both in response to the substance abuse epidemic and to comply with the terms of a 2014 class action settlement.
Several people reported that child psychiatry has the greatest dearth and has struggled for some time, while geriatric psychiatry is the second greatest need. Folks like Torrey agree.
“Child psychiatrists have been harder to recruit for some time,” Torrey said.
About 14 percent of the roughly 6,000 psychiatry residents from 2013 to 2014 were in the child and adolescent specialty nationwide. But it’s only been within the last 10 years or so that Torrey’s noticed difficulty recruiting general psychiatrists for adults.
“We have an approaching crisis, if we’re not in a crisis right now,” Evers said.
An aging population means a likely larger percentage of psychiatrists are older here than the national average, hastening the dropoff of providers caused by retirement, but Evers and others say that with old age comes an increased likelihood of mental illness, either caused by old age or detected late in life. That means a growing demand in the state.
New Hampshire is already struggling to keep up with existing demand because of an ongoing brain-drain.
Evers says young med school graduates will often gravitate toward major cities for their residency and careers.
“They tend to stay around metropolitan, urban areas with big teaching schools. So, New York, Boston, Seattle, Chicago, L.A., those kinds of places,” Evers said. “There’s a state to the south of us that pulls much of our talent away and that’s not unique to behavioral health.”
Cities have high concentrations of psychiatrists who can act as a consultative and career support network, plus there’s more competitive pay, jobs, academic resources, options for spouses developing their careers and a lifestyle more attractive to younger people.
And while the shortage is felt even in New Hampshire’s most urban areas, it hits the rural north the hardest because everything is more spread out, making access more difficult.
When there is a shortage of something in the marketplace, the law of supply and demand usually kicks in to correct the imbalance. In the case of psychiatrists, the need for them far outweighs their availability nationwide, but wages aren’t going up as much as needed.
One thing that local psychiatrists and mental health institutions repeatedly point to is the fact that psychiatrists are not moneymakers for the hospitals and clinics that employ them. If anything, they represent a net loss, financially. That’s because unlike doctors who perform surgeries, CAT scans or other expensive, one-time procedures with significant reimbursements, mental health doctors treat patients with prescription medications over a long period of time, often in tandem with therapy.
And while a growing consensus around the need for mental health services is a positive step, the industry hasn’t really figured out a way to make sure it pays for itself and subsequently allow for psychiatrist wages to rise during times of disproportionate demand.
Meanwhile, there are fewer incentives for future doctors to get into psychiatry because of growing pressure to see more patients and see them less frequently, all while dealing with a mounting pile of paperwork. The “regulatory creep,” as Rider puts it, created by government bureaucracies, redundant middlemen and software programs meant to make things easier, has, for many psychiatrists, become an outsized share of their workload.
So, potential psychiatrists look at all this and see a diminished return on their med school investment.
To solve the shortage problem, Rider and others say the state and federal government need to ease up on the regulatory burden, find a way to raise wages and enforce parity laws so insurance companies fairly reimburse for mental health treatment. Another possible solution is student debt forgiveness for psychiatrists. Bills have been floated in Congress and states like Texas have implemented programs that would help pay off student loans if psychiatrists work in underserved areas. Rider says if New Hampshire funded such a program, it would create a huge incentive for mental health docs to set up in the Granite State, even at lower rates of pay.
Meanwhile, until the shortage is resolved, institutions are leaning more heavily on specialized nurse practitioners, telepsychiatry and, in the worst cases, locum tenens, which are transient physicians who temporarily fill key vacancies.
Cheshire Medical Center has been keeping its psychiatric unit in operation these past few years by paying locum tenens, which is too expensive to do indefinitely.
“To get locum tenens, which is the sort of rent-a-doc kind of idea, will cost you three times as much as hiring a psychiatrist. So, that’s a bit of a deathknell to your bottom line,” said Peter Evers of Riverbend.
But there are already some glimmers of light at the end of the tunnel. William Torrey at Dartmouth says more students are getting interested in psychiatry as the mental health stigma gives ground to better understanding of the problem and emerging neuroscience. Still, there is a significant lag time before the industry feels that shift.
And, as the community mental health network in the state continues to implement its mobile crisis units and proactive “Assertive Community Treatment” teams, less severe cases will be caught in the early stages before they get worse. That, experts say, will nip some of the future demand in the bud.