Nebraskans Getting Creative to Address 'Staggering' Mental Health Provider Shortage

Aug. 22, 2019, 6:45 a.m. ·

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A stark shortage of behavioral health care providers across the state means long wait times and a big price tag for the one in five Nebraskans who have a mental health disorder.

This story is part of our ongoing reporting project “Nebraska: State of Mental Health.”

Imagine getting diagnosed with diabetes – and then learning you can’t discuss treatment options with a doctor for three to six months.

That’s how long you have to wait to see a mental health professional through at least one provider we spoke with in Omaha.

"And that's about the average in Omaha, which has more providers per capita than rural places," said Dr. Marley Doyle, a psychiatrist and director of the Behavioral Health Education Center of Nebraska.

"But if you think about, when you go to seek treatment, and you're having an issue, and you're ready to kind of accept treatment, that's a long time to wait," she said.

Nationwide, there are about 15 psychiatrists per 100,000 people. Here in Nebraska, the statewide average is half that. With current trends, the shortage will grow even more by 2030.

A map from the American Psychological Association Center for Workforce Studies shows the "very low concentration" of licensed psychologists across Nebraska.

A map from the Nebraska Center for Rural Health Research shows that most counties have no psychiatric prescriber.

There are a lot of reasons not many people are choosing behavioral health careers, and they often boil down to financial stability.

That comes into play pretty early on. Dr. Doyle says a lot of students complete the degree but never get the state license to practice.

Nebraska requires 3,000 hours of supervised counseling for licensure – and it can be hard to find a supervisor willing to work with you.

"And not only that, but it's unpaid. And so a lot of times, it requires you to support yourself working another job," Doyle said. "And so that's a tough time, that you're sort of not getting paid a lot, you're doing all this work, and then you might not be able to even find a supervisor."

Counselors who do make it through certification have a hard time making enough money to live.

Annette Dubas is a former state senator and current executive director for the Nebraska Association of Behavioral Health Organizations.

She says many providers in Nebraska get at least 70% of their revenue from public sources like Medicaid. And that’s a problem because those reimbursement rates are incredibly low.

For example, the Nebraska Division of Behavioral Health reimburses providers, on average, 18% less than what it actually costs for the service – and Dubas says the difference could be as much as 35%.

"And the Division of Behavioral Health tends to pay even more than Medicaid does," Dubas said. "So they're that far below, then Medicaid is even farther below."

Add to that significant student debt. A survey from The American Psychological Association of Graduate Students found psychology doctorate students delay saving for the future, planning for retirement and having kids because of their education debt.

Doyle says it’s a really tough spot for providers, especially ones starting out.

"And as a provider, you have to make the decision of what insurance you're going to accept based on reimbursement," Doyle said. "And if it's a lot easier to make ends meet by not taking Medicaid, a lot of people do choose to do that in private practice."

That leaves low-income Nebraskans with even fewer options for care; it doesn’t matter how many providers are in your area if none of them take your insurance.

It’s a grim picture for the future of mental health care, but officials are working to turn that around.

One strategy is getting young people interested in pursuing behavioral health careers, showing college and even high school students how much they can impact their own communities.

Hannah Woodward is a student at the University of Nebraska at Omaha completing a master’s degree in social work and public administration.

But she never would have considered being a therapist without a program at her high school in Kearney through Health Occupation Students of America.

Hannah Woodward is getting a master's degree from UNO and currently works as a Child and Family Services specialist for the Nebraska Department of Health and Human Services.

"They had a weekend program where we could see different behavioral health clinics, we could go to learn more about," Woodward said. "So I tried it out my junior year and I absolutely loved it. And ever since then I've kind of decided that I wanted to pursue this career."

Woodward is excited about the possibility of being a resource for struggling families. With graduation a couple of years away, she’s not as focused on the challenges of getting licensed — yet.

"It's been more on the back burner because I'm just so focused on one step at a time, I think, right now," she said. "But it's a very big consideration."

Leaders are also trying to address reimbursement rates.

This year, the unicameral passed a law to increase Medicaid reimbursement rates for behavioral health care and treatment by 4%.

That’s a change the Nebraska Association of Behavioral Health Organizations fought for.

"This was certainly a step in the right direction, but for the last several years, we've either had no increase or a cut," Dubas said. "So you know, we're really just trying to make up some lost ground right now."

The increase is less than the 5% they asked for.

Dr. Doyle says the Behavioral Health Education Center of Nebraska is focused on how to use the small number of providers Nebraska has in the most effective way. For example, making sure primary care physicians understand mental illness and how to treat it.

"I think that they're doing the best with the training that they have. But a family practice doctor, for example, during their three-year residency, they get one month in behavioral health," she said. "An internal medicine doctor doesn't get any training in their three-year residency. So that's pretty striking if you consider that the estimate for mental health conditions in the primary care setting is about 30% of visits."

The impact of the shortage is stark: one in five Nebraskans has a behavioral or mental health disorder. And of the state’s 93 counties, 88 are considered mental health shortage areas.

But possible solutions are pretty clear: encourage more people to go into behavioral health fields, and do that by making the demanding jobs more financially stable.

Tune in Friday on NET Radio to hear about how mental health provider shortages hit rural communities especially hard in the next story in “Nebraska: State of Mental Health.”