The professionals who provide care at community mental health clinics around the state are leaving their positions faster than they can be replaced, worsening access just as the stresses of the pandemic have intensified the need among their mainly lower-income patients, according to a survey released Tuesday.
The survey, conducted by the Association for Behavioral Healthcare, found that for every 13 clinicians who leave these outpatient facilities, only 10 can be found to replace them. As a result fewer patients are getting care than before the pandemic, while many more are seeking it. The 37 clinics that responded to the survey had nearly 14,000 people on waiting lists.
The number one reason workers gave for leaving clinic jobs: the low pay. Many are going into private practice or taking hospital jobs that pay significantly more.
The survey focused on one critical component of the mental health care system, the state-licensed community mental health centers, most of whose patients are enrolled in the state’s Medicaid program, MassHealth.
But the clinics’ troubles reveal yet another stress point in the broader health care workforce as it confronts the pandemic’s extraordinary challenges.
“This is something that was known before the pandemic. [Patients] were having a prob
lem with accessing services,” said Rebekah Gewirtz, executive director of the National Association of Social Workers, Massachusetts chapter. “Then the pandemic hits and we have an exacerbated crisis that isn’t going to go away.”
Diane Gould, chief executive of Advocates, a Framingham-based agency that encompasses five mental health clinics, described a “convergence of an already strained workforce, and layer COVID on top of that and a mental health crisis related to isolation and illness and loss.”
The Association for Behavioral Healthcare, the trade group for outpatient mental health clinics, surveyed 60 of its members in November and December last year and received responses from 37 organizations with a total of 124 outpatient sites. Together, those agencies had served nearly 100,000 people in the previous year.
Among the clinics that responded, nearly all had vacancies – an average of 17 per clinic – for a total of 640 unfilled jobs.
Advocates has 40 vacancies among a staff of 110, resulting in a waiting list of 132 children and 22 adults, Gould said.
In the past month, Advocates hired 16 clinicians but 26 left. “The money they can make elsewhere is a significant draw,” Gould said. Some have major student loan debts to pay off and say they like the work but can’t afford to stay, she said.
One clinician making $60,000 moved to a private practice paying $90,000, she said.
According to the association’s data, a licensed social worker can make $52,437 at a mental health clinic and $67,600 at a hospital. A psychologist who makes $78,603 in a clinic could pull in $104,125 at a hospital.
There’s a dark irony to this, noted Lydia Conley, chief executive of the Association for Behavioral Healthcare. Hospitals need mental health providers to take care of the hundreds of people waiting in the emergency department for scarce psychiatric beds. But, she said, many of those patients wouldn’t need inpatient care if they’d received help earlier in their illness – and that help is now getting ever harder to obtain because outpatient clinicians have left for hospital jobs.
“It just has never made sense,” Gould said. “The investment in the outpatient system has been so lacking. It will save money in the long run.”
The issue has not escaped the notice of Governor Charlie Baker’s administration, which won praise from Conley and other advocates. MassHealth recently approved a 10 percent pay increase for clinicians, considered a significant move although not enough to solve the problem.
There are also high hopes for the administration’s “Roadmap for Behavioral Health Reform,” a multiyear initiative intended to ease access through such programs as a centralized service to connect people with care, night and weekend treatment options, locating mental health and addiction care in primary care offices, and setting up community-based crisis intervention services to prevent emergency room visits.
Additionally, the Legislature has directed federal COVID-19 relief money toward a loan-repayment program for the educational debt of mental health providers.
But commercial insurers, which pay for roughly a third of the clinics’ patients, have so far failed to address the problem, advocates for the clinics said. The association recommends that the state use its purchasing power through the Massachusetts Health Connector and the state employees’ insurance program to push insurers to do more.
Lora Pellegrini, chief executive of the Massachusetts Association of Health Plans, the trade group for most health insurers in the state, said health plans have “made significant investments, both prior to and during the pandemic, to increase reimbursement rates, expand access to providers, and offer telehealth services to members.”
The association also supports reallocating spending to emphasize primary care and mental health, Pellegrini said in a statement, but must also be mindful of overall costs to the system.
Dr. Gregory Harris, senior medical director for behavioral health at Blue Cross Blue Shield of Massachusetts, said the basic problem is multilayered, not just financial. “Over the last two years we’ve had a massive increase in demand but the provider networks haven’t increased at the same rate,” he said. “Just paying more for the same service isn’t necessarily a solution to the access problem. ... Our providers are very busy. Every single one wants to get paid more. That doesn’t mean they will have space for more patients.”
Blue Cross increased its payments to child psychiatrists but required them to provide swift access in return. So any improvement, Harris said, must involve both payment and structural changes.
In addition to seeking higher pay for its clinicians, the behavioral health association also recommended expanding loan repayment programs and reducing paperwork.
The challenges at the clinics could reverberate to the rest of the mental health system, Conley said, because they are the setting where clinicians such as social workers and mental health counselors undergo clinical training needed to get a license. The clinics are thus the pipeline for the mental health workforce, and Conley said that pipeline is thinning. “More people are leaving than are coming in to be trained,” she said.
“Ultimately we are living with this legacy of mental health care not being treated on a par with physical health,” Conley said.
But several advocates expressed hope that changing attitudes may ameliorate that problem. One positive outcome from the pandemic and the widespread mental distress it spawned is that more people are talking about mental health. “I am hopeful that the increased awareness about the importance of our mental health and well-being … will persuade people across the board to take action,” said Danna Mauch, chief executive of the Massachusetts Association for Mental Health, an advocacy group. “It’s going to take time and money. We have to act with compassion and urgency.”