Shortage of mental health care providers hits crisis point just as more teens seek help
Rory Linnane
By the time many teenagers sit down with Peg Rauschenberger, they are already dealing with serious mental illnesses and need carefully targeted medication and therapy.
But the registered nurse may be the first professional they've ever seen.
Rauschenberger works at Milwaukee County's youth detention center, where young people wait in lockup to find out whether they'll be going to prison or back home — often with referrals for mental health services.
"It's almost like they have to get into some sort of trouble before they get into services," said Rauschenberger, who also serves as interim dean of Alverno College’s JoAnn McGrath School of Nursing. "They end up being incarcerated for really what is a health issue, and it shouldn't have gotten that far."
The shortage of mental health professionals is a crisis — particularly for youth, and more particularly for low-income families who use public insurance.
Demand for mental health services is up, as USA TODAY NETWORK-Wisconsin has explored in the Kids in Crisis series. Teachers report more kids struggling to cope with traumatic experiences while suicide rates rise. Families are becoming more comfortable seeking help.
But seeking help and getting it are two different things.
A Journal Sentinel analysis of 2016 workforce data found that Wisconsin is worse than most states in its per-capita workforce of all types of mental health professionals: nurses, counselors, social workers, psychologists and psychiatrists. Data were compiled by researchers at County Health Rankings & Roadmaps based at UW-Madison.
"Our society is recognizing the value of mental health care and yet we haven't really increased the supply," said Jon Lehrmann, a psychiatrist who chairs the psychiatry and behavioral medicine department at the Medical College of Wisconsin.
Funding flaws
Experts identify several financial and regulatory bottlenecks choking the supply. Some argue they are part of the legacy of treating mental health as a less important field of medicine.
On the financial side, insurers reimburse behavioral health services at a lower rate than other medical specialties. Exacerbating the situation, many patients are covered by Medicaid, which generally pays even less.
In Wisconsin, government funds reimburse mental health providers for about half their costs for seeing Medicaid patients, according to Linda Hall, executive director of the Wisconsin Association of Family and Children's Agencies.
The result? Health systems have put fewer resources into expanding behavioral health services, particularly when compared with more lucrative specialties such as orthopedics, cardiology and oncology. And some psychiatrists set a limit on how many Medicaid-enrolled patients they will accept, causing long wait lists or no list at all.
Children's Hospital of Wisconsin is one of those systems taking a financial loss on its psychiatry services, according to Tracy Oerter, director of mental health services for Children's. Most of the patients are on Medicaid.
The wait list to see a child psychiatrist stretches for months, Oerter said. Children's attempts to schedule a first appointment within three months of a family's' call, but that doesn't always happen.
"We could probably double our workforce and still not meet the demand," Oerter said.
Gov. Scott Walker recently announced that the state will be increasing Medicaid rates for behavioral health services, but exact numbers have not been released.
Sparse training opportunities
In addition to the financial disincentives, becoming a child psychiatrist is a long road.
There are three or four years of medical school, then four years of residency, and then another year or two of a fellowship specializing with children — a total of eight to 10 years beyond a bachelor's degree.
Physicians tend to practice where they do their residencies, so expanding Wisconsin's psychiatric workforce means expanding its residency opportunities.
There are two major pipelines for psychiatrists in Wisconsin: UW-Madison and the Medical College of Wisconsin. Lehrmann, of the Medical College, said it's been challenging to expand the school's psychiatry program because of a lack of residency opportunities in clinics.
Not every hospital or health system has residents and even fewer train psychiatrists.
In 1997, the federal government capped the number of residency positions it would fund in existing programs. If hospitals want to expand their programs, they must come up with their own funding for the residents' salaries.
"We've been fairly stuck as far as the ability to expand residency training," Lehrmann said. "We know we need more psychiatrists because demand is up, but we can't easily find placements."
The Medical College was recently able to expand residency opportunities by partnering with health systems in northeastern and north-central Wisconsin. Clinics and county health systems have been willing to put up money in light of severe needs for psychiatric services, Lehrmann said.
Nurses underutilized
One glimmer of hope is that primary care doctors are stepping into the role of prescribing psychiatric medication, which has been the territory of psychiatrists. They are learning more about mental health and consulting with psychiatrists through new models like shared clinics and helplines.
Another glimmer is that nurses are stepping in after decades of being underutilized — in part due to gender-based stereotypes, according to Gina Bryan, director of the UW-Madison School of Nursing's psychiatric certificate program.
Unlike psychologists and counselors, advanced nurse practitioners are allowed to prescribe medication. After receiving a bachelor's degree in nursing and becoming a registered nurse, these nurses must attain a master's degree, learn how to prescribe psychotropic medication, and pass national and state exams.
One roadblock is that in order to prescribe medication, nurse practitioners in Wisconsin are required to have a physician agree to supervise them. As a result, the Journal Sentinel analysis found, the state ranks 43rd in the nation for the reported number of psychiatric nurse practitioners per capita, according to 2016 data.
Bryan, who has a leadership role with the Wisconsin Nursing Association, said some nurse practitioners choose to open practices in neighboring states where regulations are looser.
Still, the workforce is growing thanks to programs at UW-Madison and Alverno College.
Rauschenberger, dean of Alverno's nursing school, said there were fewer than 20 psychiatric nurse practitioners in the state when the college started its psychiatric nursing program in 2013. Now nearly 100 students are enrolled in the program.
"We are blown away by the number of students who want to work in that field," Rauschenberger said. "Employers are lining up to hire them, simply because everyone recognizes there aren't enough psychiatrists and other mental health providers."
Demand is high not only for nurse practitioners with advanced degrees, but also for registered nurses with bachelor's degrees.
Milwaukee County's Behavioral Health Division is running a recruitment campaign for registered nurses and has hired 25 this year.
RELATED:By understanding trauma, Wisconsin youth find path to healing
Vie Lucas, a registered nurse who has worked in the division's emergency department for over three years, had originally planned to work in labor and delivery. But when she saw a position open in mental health, she decided to try it and now says it's exactly where she wants to be.
"I didn’t realize how many people lived with mental health issues, and it’s really something that needs to be addressed," Lucas said. "We’re able to be that resource for people who really need it."
Lucas expects more nurses will opt to specialize in mental health as it gains respect, and as more nursing schools expose their students to the field, and to its profound needs.
"If I were speaking to someone coming out of college, I would tell them if they want to find a job where they feel fulfillment, and one where they’re working with the most vulnerable people, I know mental health nursing would give you that," Lucas said. "I absolutely love my job and wouldn’t choose to do anything else."
Guy Boulton of the Journal Sentinel staff contributed to this report.