Addressing National Workforce Shortages by Funding Child Psychiatry Access Programs

For decades, the medical community has been dealing with a shortage of child psychiatrists in the United States. A study published in Pediatrics in November 2019 demonstrated that although the number of child psychiatrists increased in the last 10 years, there are still not enough to meet demand, and counties in the United States with lower levels of income and education particularly struggle to meet demand.¹  Thirty-six states have fewer than 10 child psychiatrists per 100 000 children, with only 3.3 child psychiatrists per 100 000 in the most extreme case.¹  This imbalance translates into wait times of over 11 months for an appointment with a child psychiatrist in some areas.²  Furthermore, up to 20% of children in the United States have a mental health disorder, with suicide the second most common cause of death among 12 to 17 year olds.³  A commentary by David Axelson, MD,⁴  published alongside the Pediatrics study, called for innovation in the delivery of mental health services to children to leverage the existing workforce to make the greatest possible impact. Over the years, many proposed solutions have addressed the workforce shortage, including developing accelerated training pathways for child psychiatrists, recruiting nurse practitioners to the field, and expanding federal loan forgiveness programs, but the shortage has persisted despite these efforts.

One promising strategy to improve access to mental health services for children is to help primary care pediatricians provide more robust mental health care. The shortage of child psychiatrists often necessitates that pediatricians manage children’s mental health, despite self-reported inadequate training in medical school and residency to address mental health and low confidence during mental health visits.⁵  Additionally, pediatricians have been asked to play a larger role in screening and managing mental health disorders. In 2018, the American Academy of Pediatrics updated its guidelines on the management of adolescent depression, recommending annual depression screening for all children over age 12.⁶  Although engaging pediatricians in the screening, diagnosis, and treatment of depression is important, asking them to play a larger role without better access to child psychiatrists or training may lead to increased identification without adequate treatment.

Many states have implemented Child Psychiatry Access Programs (CPAPs) as an innovative model to help primary care pediatricians provide mental health care.⁷  The services provided by CPAPs vary, but almost all provide pediatricians with free, same-day telephone consultations with child psychiatrists. Pediatricians can ask questions related to diagnosis, management, and care coordination of patients with mental health issues. Additional services offered by some programs include face-to-face evaluations, telemedicine, and provider education.^6,7  Programs like the Massachusetts Child Psychiatry Access Program in Massachusetts and the Partnership Access Line in Washington State demonstrate encouraging outcomes, including high pediatrician use and satisfaction⁷  and increased pediatrician confidence in assessing and treating mental health disorders.⁶  Data on outcomes for CPAPs has generally been limited to provider satisfaction surveys because the consultative nature of these programs makes patient outcomes difficult to track. Although further research on outcomes is needed, the existing data and anecdotal evidence indicate that CPAPs are an effective strategy for leveraging the existing workforce of child psychiatrists help more children.

In 2017, Rhode Island created the Pediatric Psychiatry Resource Network (PediPRN), becoming the 32nd state to develop a CPAP. Although PediPRN is effective and frequently used by pediatricians, its future is uncertain. PediPRN was originally funded by a 3-year grant, and, although it secured funding for 5 additional years from a Health Resources and Services Administration grant and private partners, the program will need to determine a permanent sustainability model. This funding uncertainty is not unique to Rhode Island. CPAP funding mechanisms are heterogeneous but can be broadly categorized as private grants, state grants or contracts, legislative support, Medicaid, and private insurance. Many programs are dependent on grants, short-term contracts, or yearly budgetary decisions by state organizations, which are all highly vulnerable to discontinuation.⁷  In fact, several programs lost funding when grants were not renewed, which caused the permanent closure of programs in some states. The Health Resources and Services Administration recently provided grant funding for 21 states, including Rhode Island, to continue existing CPAPs, start new programs, or revive programs in states who had previously closed their CPAP because of loss of funding such as in Maine and Delaware (Fig 1). Although this support has been crucial, the funding will end after 5 years and each program will need to secure further funding or risk closing. Unfortunately, traditional insurance mechanisms are ill-equipped to reimburse child psychiatrists’ time spent on pediatrician consultation. Without a straightforward payment model, many programs face uncertainty about their own financial stability and sustainability.⁷ 

One possible solution is exemplified by Massachusetts, the first state to develop a CPAP and the program after which most CPAPs are modeled. Massachusetts’s program, known as MCPAP, uses multiple funding sources to ensure its stability, including the Massachusetts Department of Mental Health, Medicaid, and commercial insurance, because of 2015 legislation requiring private insurers to pay a share of MCPAP’s costs.⁷  Another option is for the federal government to enact legislation mandating that states develop and fund CPAP programs. This strategy was successfully used to mandate the development of School Wellness Programs by including language in the Child Nutrition and WIC Reauthorization Act of 2004. Similar legislation could be enacted to support CPAPs. Finally, insurers could create a billing code to cover this service. Although this option has previously seemed unlikely, we have seen swift and decisive action from insurance companies amid the coronavirus disease crisis to build mechanisms to reimburse for telemedicine, and similar mechanisms could be used to cover CPAP services.

Although there are many potential paths forward to ensuring that CPAPs continue to receive funding, they all depend on continued support and advocacy from pediatricians, child psychiatrists, families, and other stakeholders. In states with existing CPAP programs, pediatricians can visit the Web site of the National Network of Child Psychiatry Access Programs at www.nncpap.org to find the contact information for their state’s program and learn how to enroll in the service. Those who are already enrolled can continue to use these services and seek opportunities to get involved as a pediatrician peer champion. For parents in states with programs, asking pediatricians if their office is enrolled in the state’s CPAP is a great way to increase pediatrician awareness and use of these services. In states without a CPAP program, the best first step is to build a coalition of stakeholders, including pediatricians, child psychiatrists, and parents, who are interested in developing a program for their state. Once key stakeholders are assembled, the group can start by contacting surrounding states with active programs to learn more about how they established their CPAPs. At a national level, recruiting the support of specialty organizations like the American Academy of Pediatrics or the American Academy of Child and Adolescent Psychiatry would help build momentum for federal legislative action.

CPAPs provide a scalable and effective means of addressing the shortage of child psychiatrists in the United States. Guaranteed funding for CPAPs through legislation at the state and federal levels is an important step toward ensuring that children receive timely mental health treatment. Action to support the existing programs and encourage the development of new ones is crucial to securing mental health services for children in all states.

CPAP

Child Psychiatry Access Program

PediPRN

Pediatric Psychiatry Resource Network