Exacerbated by the pandemic, inadequate access to mental health care is a longstanding crisis in the United States, and the mental health workforce shortage is a key contributing factor. Currently, the shortage of psychiatrists in the US is around 6,500 physicians. The Health Resources and Services Administration (HRSA) predicted that we will have 13,000 fewer psychiatrists practicing in 2030. The story is similar for clinical psychologists, for whom the HRSA predicted a 14,000 psychologist shortage relative to need by 2030.
Existing support for mental health training programs consists primarily of several small federal grant programs, the Medicare Direct Graduate Medical Education (DGME) program and the Medicare Indirect Medical Education program. This strategy provides unpredictable funding for startup programs, stymieing the development of new training practices. Moreover, the total dollars doled out through these programs is insufficient.
Moving forward, if Congress were to create 2,000 new Medicare-supported psychiatry residency positions today, it would take 40 years to generate the 20,000 missing general psychiatrists (since each slot generates a new psychiatrist every four years). Since there are only 7,500 total residency slots in psychiatry presently, every residency program would have to increase in size by more than 25 percent to accommodate the 2,000 new positions. This level of growth would be a challenge for smaller residencies that struggle to attract clinical teachers. Furthermore, none of these positions could be allocated to clinical psychology trainees. While increasing Medicare-supported residency positions would be valuable policy, a more comprehensive approach is necessary to resolve the mental health workforce shortage.
The 10,000-Foot View
If Congress wants to enlarge the mental health workforce, it should support the educators that develop these professionals. Specifically, reforms should bring billing rules for psychotherapy (talk therapy) provided by trainees on par with the billing rules for trainees in other medical specialties. Second, Congress should require all payers to reimburse bedside clinical teaching using a service modifier on the mental health code billed by a teaching practice. If Congress builds a financial environment that supports clinical teaching, training programs will multiply. Pursuing workforce policy through payment reform, as opposed to grants, ensures the policies are sustainable and scalable.
The Easier Avenue For Reform
Medicare GC and GE modifiers authorize reimbursement of care provided by medical residents if there is an appropriate level of supervision by their attending physician. In more precise terms, the modifiers permit fully licensed physicians to delegate tasks to medical residents and fellows. The rules associated with these modifiers vary based on context. In the emergency department, the attending must be present for the whole visit; however, in the gastrointestinal suite or operating room, the attending need only be present for the “critical portion” of the procedure. Under the primary care exception, residents can “bill” virtually independently in a wide range of outpatient settings, provided that a supervising physician reviews the visit soon afterwards. In other words, to train new doctors, our health care system permits trainees to provide evaluation, management, and procedural services and reimburses these services. The mechanism is a service modifier with a specific set of supervision rules.
Under current regulations, a psychiatrist must be present for the entire time that psychotherapy is being provided by a resident for the service to be billable. In effect, this rule prohibits psychiatry residents from practicing in traditional outpatient practices and is at odds with best practices for trainee supervision. Currently, medical schools typically operate independent psychiatry resident clinics where patients pay out-of-pocket fees and no insurance is billed. This system is functional and may expand access to care to the underinsured and uninsured; however, these clinics are a challenge to scale because the trainees and supervisors working at them do not generate any revenue yet are salaried employees. Clinical psychology programs run into similar issues; care (under appropriate supervision) provided by trainees is not reimbursable by insurance. Again, these revenue losses make it difficult to expand training programs.
A few states have recognized this issue and mandated that their state Medicaid programs reimburse care provided by psychology interns. These policies are a good first step but insufficient for addressing need.
As congressional leaders propose expansions to direct funding for resident salaries, they need to make sure clinical placements are available. To address this issue, legislators should develop policies that make psychotherapy training programs scalable by ensuring providers and practices are rewarded for training students. New billing policies should permit trainee integration into outpatient psychiatry and psychology practices consistent with practices in primary care and other health services.
The first step is to create a new Medicare modifier useable by psychiatrists and psychologists in training with psychotherapy and other time-based mental health care codes. The key is to mandate more appropriate supervision, best practices for which have been well-researched and delineated. Private insurance may voluntarily follow Medicare’s lead, given that a few private payers have already adopted similar policy.
Congress should also pursue Medicaid coverage of the new modifier. To avoid incurring a cost to state governments, Congress should not mandate but incentivize changes in state Medicaid programs with a Federal Medical Assistance Percentage increase. The policy would be particularly impactful for the teaching services that serve mostly Medicaid patients, such as child and adolescent mental health. In sum, coverage of the proposed modifier would permit trainee integration into traditional outpatient clinics, making it easier for teaching practices to recruit clinical educators and find placements for students.
The Ambitious Avenue For Reform
Our health care system relies upon nonprofit and public training institutions to do the right thing with public, philanthropic, and patient dollars. The specialty surgical departments typically subsidize unprofitable departments, such as psychiatry and labor and delivery. This system is functional, but it does not encourage health systems to expand unprofitable training programs. If a clinician in any specialty spends time teaching, they see fewer patients and generate less revenue. If Congress wants a more efficient, equitable, and auditable system, Congress must pay directly and adequately for what it wants done.
Congress should require Medicare and private payers to reimburse mental health codes billed with the new service modifier, or the GC modifier, with an additional 10 percent of the base code’s Medicare fee, compensating training sites for the time clinicians spend teaching. Under this policy, a teaching practice would generate 10 percent more reimbursement revenue than a private practice clinician for the provision of any mental health service in which a resident was involved. This policy would offset the cost of supervision and enable teaching practices to offer more competitive salaries to prospective clinical educators. This policy must apply to all payers if it is to create a reliable revenue stream that encourages practices to treat every patient equitably.
Concurrent with passage of this policy, Congress would need to ban copayments for clinical teaching time charges and prohibit insurers from discriminating against teaching practices due to their higher costs. To ensure all payers follow the same rules and all patients have access to the same care, Congress should pay state Medicaid programs to adopt this policy. To ensure teaching systems spend new funds appropriately, Congress could require that new revenue generated be spent on trainee and supervisor salaries, like the DGME program.
Compared to grants, this policy is inherently scalable. The more residents and interns that a practice trains, the more money the practice earns. An ease of implementation is facilitated by the fact that provider systems, private payers, Medicare, and Medicaid already know how to collect the data needed, since all parties are accustomed to the GC and GE modifiers. This fact represents one advantage of this proposal over past reform attempts. What’s more, unlike the Medicare GME program, this policy would distribute funds in a manner independent of geographic location and medical setting.
Building The Financial Arena
Inadequate access to mental health care is a longstanding, worsening crisis. To solve the problem, the US needs a substantially larger psychiatry and clinical psychology workforce. If Congress builds the financial arena in which training programs can thrive, existing programs will expand, and new programs will pop up. Feasible methods to address this issue include creating a service modifier that permits mental health trainees to bill for psychotherapy provided under realistic, appropriate supervision, and paying teachers to teach by increasing reimbursement for all mental health codes billed with the new and GC modifiers. Both policies employ payment policy as workforce policy.
The opinions stated in this article are the authors’ opinions as individuals and not as representatives of any organization. Dr. Aggarwal serves on the Council of Medical Education and Lifelong Learning and as an Assembly representative for the American Psychiatric Association and is the program chair-elect for the American Association of Directors of Psychiatric Residency Training.