Workforce challenges hit mental health system hard

Vacancies and turnover can mean increased wait times, reduced continuity and quality of care

Workforce shortages in the health care sector have come to the forefront of critical public policy issues that New Hampshire needs to address this year and in the 2017 legislative session.

The problems health care providers have in recruiting and retaining nurses, home health care providers, primary care physicians, psychiatrists, substance abuse counselors and other professionals are significant. These problems are not unique to New Hampshire, but they have been exacerbated by our state’s low unemployment rate, its proximity to Boston, competition among providers, licensing and reciprocity requirements that may be onerous or outdated, and the challenges all employers face in trying to keep young people here to build their careers.

Right now there are, by one count, 13 different commissions, committees and task forces that have been formed to study workforce issues in New Hampshire, ranging from initiatives at the Business and Industry Association and the NH High Tech Council, to the Bi-State Primary Care Association and the Governor’s Commission on Health Care and Community Support Workforce. Recently, the NH Community Behavioral Health Association presented to the governor’s commission provided eight months of staffing data collected from its nine community mental health center members. Highlights include:

• Vacant postings: In August, there were 173 vacant positions in our nine community mental health centers, and the month-to-month trend is increasing.

• Vacancy rates: Across the nine community mental health centers, vacancy rates average between 7 and 8 percent but vary between 3 and 15 percent for specific centers; variations also exist when examining education requirement levels and for advanced practice registered nurse and M.D. vacancies.

• Wage gap: There is as much as a 57 percent gap in what master’s licensed therapists earn between centers compared to the state mean.

• Length of time to fill postings: ranges between 68 days to 157 days among the nine centers.

The major concerns of our front-line providers are, of course, the impacts of the workforce crisis on the more than 50,000 seriously mentally ill adults and children we provide services to annually.

Vacancies and turnover of staff can mean increased wait times for consumers, reduced continuity and quality of care, less individualized care, and less timely access to services. And an overriding concern for the community mental health centers is their ability to comply with the Community Mental Health Act, the agreement that resulted from the 2013 Department of Justice suit that requires the state to provide more community-based mental health care. Centers were not parties to the DOJ suit but, as the providers of community-based services, they are responsible for implementing many of its mandates, all of which require adequate staffing.

One number we chose to highlight for the commission was the financial impact of our centers’ open positions on the New Hampshire economy.

The 173 open positions in August represent between $6.8 million and $7.6 million in wages that are not entering the economy. This is a serious consequence of the workforce shortage that negatively impacts many communities, especially in the most rural areas, and if our sector is seeing numbers this high, the cumulative cost impact of vacancies across industries has to be substantial. 

Proposed solutions for all of these problems fall into several levels of urgency, but the most immediate fix to the workforce solutions would be an increase in Medicaid rates beyond the 2006 levels, where they have been stuck for more than a decade. The fact that community mental health centers cannot pay people enough puts us at a serious workforce disadvantage, particularly in retaining staff – staff that are critical in providing services to tens of thousands of vulnerable citizens.

In many cases, our centers have become training facilities, where practitioners get their first jobs and some experience, then move on to hospitals or other providers who can afford to pay higher salaries. Until the Medicaid rate issue is addressed, this will be a chronic issue for community mental health centers.

Additional solutions we offered to the governor’s Commission for consideration were: reducing the administrative burden the state imposes on centers and their staff; removing impediments for licensing out-of-state providers and allowing reciprocity; and eliminating “silos of care” at the Department of Health and Human Services. There are also federal policies – such as “incident-to billing” which requires a physician to be on-site before Medicare can be billed, and telehealth payment rules – that are burdensome and impractical. These need to be addressed at a federal level through our congressional delegation. 

We will continue to collect, refine and interpret this data as we prepare for the upcoming legislative session, when we trust that legislators will take a hard look at the complete picture. We stand ready to help. 

Suellen M. Griffin, president of the NH Community Behavioral Health Association, is CEO of West Central Behavioral Health in Lebanon.