Increasing the supply of behavioral health professionals
Several states have taken action to increase the overall supply of behavioral health professionals through partnerships with educational institutions and residency programs. These partnerships can encourage students and early career professionals to practice in rural and underserved communities.
Career pathways introduce students, from kindergarten through college, to health care careers through “a combination of education, training and other services that align with the skill needs of industries of the economy.” Research shows that career pathway participants are more likely to attain higher wages and to complete a training-related credentials than their peers.
States often pursue career pathways for professions in high demand and/or low supply, both of which apply to behavioral health care. While local and regional career pathway programs exist for health care professionals across the country, several Western states with many rural and frontier communities have created statewide career pathway programs in behavioral health to address workforce shortages.
- Colorado (2015) developed career pathways for behavioral health—including counseling, therapy, social work, psychology, psychiatry and psychiatric nursing—in 2019-2020 through the My Colorado Journey platform. “My Colorado Journey” expands access to education and data to help students and job seekers find pathways to career and upskilling opportunities.
- Washington (2019) created a work group to identify strategies to address behavioral health workforce shortages. Based on recommendations from the work group, Washington appropriated $1.5 million in 2021 to establish apprenticeship programs, compensate providers and apprentices, develop on-the-job training and provide incentives for providers in communities serving rural communities and communities of color.
Exposure to clinical training in rural and underserved communities may increase the number of providers that practice there. Rural residency trainees are three times more likely to practice in rural communities than those who completed residencies in urban or suburban communities. This is especially true for students who lived in rural communities prior to medical school.
The number of psychiatry residencies continue to increase annually, growing from 4.1% of all medical residencies in 2011 to 6.5% in 2021. Even so, at least five states did not offer a psychiatry residency as of 2020. Four of the five states (Alaska, Idaho, Montana and Wyoming) had the lowest count of psychiatrists and three (Alaska, Montana and Wyoming) had the highest suicide rates in the country. In response, universities and clinics in Idaho and Montana created residency programs in 2021 to increase access to behavioral health services. Residency program directors often cited the shortage of psychiatrists or subspecialists in their geographic area as the primary motivation for expanding psychiatry residencies.
Funding is often the primary barrier for expanding residency programs. New programs are predominantly funded by health facilities, the state, Medicare, Medicaid and the Department of Veterans Affairs.
Some states invest in psychiatry residencies or set requirements for residency programs to increase the supply of psychiatrists practicing in communities with the greatest demand for services. For example:
- Iowa (2019) required psychiatry residency programs to provide rural rotations as an option for residents. The law also called for the University of Iowa to conduct a physician workforce study including workforce data, identified shortages, the number of residencies and recruitment and retention strategies.
- New Jersey (2020) appropriated $4 million for 10 four-year psychiatry residencies focused on the treatment of lower income individuals, including those with serious mental illness and co-occurring mental health and substance misuse conditions. Residency programs must ensure physicians have rotations in a range of publicly funded and community-based health settings.
In addition to medical residencies for psychiatrists, many states are also implementing postgraduate training and fellowship programs for nurse practitioners, often referred to as “nurse practitioner residency programs.” While many postgraduate programs for nurse practitioners focus on increasing access to primary care, others for psychiatric mental health nurse practitioners focus on filling gaps in behavioral health care across the U.S.
Emerging Behaviroal Health Professionals
States also use various emerging professionals, with appropriate training and experience, to expand the capacity of existing behavioral health workforce. Two examples of behavioral health professionals becoming increasingly formalized in state statute are peer support specialists and addiction counselors.
Peer support specialists use their own lived experience with mental illness and/or addiction, plus skills learned in formal training, to provide behavioral health services, education, recovery support and connection to other services. Addiction counselors help people suffering from addiction to develop treatment goals, plans, skills and strategies necessary for recovery. Both professionals bolster the behavioral health workforce by providing a support network for individuals with mental or substance use disorders to ensure a successful pathway to recovery and wellbeing.
State strategies to professionalize peer support specialists and addiction counselors include credentialing and reimbursement.
- Credentialing: To practice, health professionals must obtain a credential—either a license provided by the state or certificate provided by a third-party organization—indicating that they have reached a minimum acceptable level of training. Credentialing requirements vary across states.
Peer support specialists work in all 50 states and D.C. and credentialing varies across states. Credentialing for peer support specialists may be administered by a nonprofit entity, state agency or specific board.
- Montana (2021) required the board of behavioral health to set professional, practice and ethical standards for behavioral health peer support specialists. Montana (2019) also allowed certain peer support services to qualify as medical assistance under the state Medicaid program.
Credentials for addiction counselors are offered by the International Certification and Reciprocity Consortium (IC&RC) and the Association for Addiction Professionals (NAADAC). Thirty states accept the IC&RC certification while 11 states accept the NAADAC certification; nine states accept both. States may modify credentialing requirements with each national credentialing body.
An individual can enter the field of addiction counseling by earning a certificate with a high school diploma or completing a behavioral health graduate degree with an addiction treatment focus.
A greater level of education may be substituted for practice requirements in some states. States with lower minimum degree requirements often require more practice hours.
- New Mexico (2021) requires licensed alcohol and drug addiction counselors to complete either:
- An associate’s degree and 3,000 hours of experience, or
- A bachelor’s degree and 2,000 hours of experience.
- Reimbursement: Low funding levels—such as insurance coverage for substance use disorder services—are cited as the largest disincentive to enter the behavioral health workforce. In many states, licensure serves as a facilitator for independent billing status, allowing emerging providers such as peer support specialists and addiction counselors to be directly reimbursed by Medicaid and commercial plans.
Medicaid is the largest funding source for peer support services since 2007 guidance from CMS authorized Medicaid reimbursement. As of 2019, at least 39 states allow Medicaid reimbursement for peer support services, with 23 states allowing reimbursement for services to individuals with addiction and/or mental disorders, 12 states for mental disorders only and four states for addiction only.
Most state Medicaid programs also reimburse for community and rehabilitative supports, crisis intervention, case management and care coordination, counseling services and screening, evaluation and assessment.
Eleven states allow addiction counselors to enroll as independent billing providers. According to a 2020 study, federally qualified health centers that received Medicaid reimbursement for behavioral health services were five times more likely to offer addiction counseling and employ certified addiction counselors than those who did not.
- Kentucky reimburses licensed clinical alcohol and drug counselor at 60% of the rate of a Kentucky-specific Medicare Physician Fee Schedule. Reimbursable services may include the diagnosis, prevention, treatment and amelioration of psychological problems, emotional conditions or mental conditions of individuals or groups.