Publications

Recruiting and retaining behavioral health workers in rural America: Our report and action guide

Lack of behavioral health workers in rural america

In the U.S., there are not enough behavioral health workers to meet the demand for mental health and substance use services, particularly in rural areas.

Over the past year, the Center for Health and Research Transformation (CHRT) has worked closely with the University of Michigan’s Behavioral Health Workforce Research Center (BHWRC) to explore the approaches states have taken to address this concern through recruitment and retention initiatives.

Throughout 2019, CHRT Health Policy Director Nancy Baum and Lead Healthcare Analyst Jaque King interviewed experts from 47 states to learn which types of behavioral health workers they needed most, to explore the factors that exacerbate shortages, and to discuss state efforts to address this demand for mental health and substance use services.

Through a qualitative analysis of the interview transcripts, Baum and King have isolated an array of approaches including loan repayment programs, pipeline programs, Visa waivers, public-private partnerships, tax credits, tiered certification initiatives, scope of practice expansions, telehealth investments, and more.

Findings from this research are now available in three publications:

Funding for this project was provided by the Health Resources and Service Administration (HRSA) of the U.S. Department of Health and Human Services

Michigan at a Crossroads

Michigan’s Key Health Policy Issues, 2018

The Michigan government has jurisdiction over a wide array of health policy issues. From the regulation of insurance products, to oversight of the state’s Medicaid program, to investing in local public health efforts, Michigan policymakers craft policies and budgets that impact the health of millions of Michiganders.

This brief will provide an overview of four key and timely health policy topics: Medicaid and the Healthy Michigan Plan; the individual health insurance market and the Health Insurance Marketplace; the opioid epidemic; and integration of services to address social determinants of health. It will explore some of the forces influencing our state’s health and discuss policy approaches to today’s health and health care issues.

Read the full brief.

 

Issue Brief: Bipartisan Budget Act adds $3B for substance abuse, mental health, more

The Bipartisan Budget Act was signed into law on February 9, 2018. While the main purpose of the legislation is to temporarily fund the federal government through March 23, 2018, it also includes an agreement to raise the caps on domestic and military spending for the next two years.

The legislation includes many health care policies, as well. The major policies are described in Health Care Policies in the Bipartisan Budget Act (H.R. 1892).

 

Access to Mental Health Care in Michigan

Access-mental-health-cms-2013-brief-3-cover

 

 

 

 

 

 

 

 

Introduction

One in five Michiganders report having been diagnosed with depression at some point in their lives.(1)C. Fussman. September 2013. Health Risk Behaviors in the State of Michigan: 2012 Behavioral Risk Factor Survey. 26th Annual Report. Lansing, MI: Michigan Department of Community Health, Division of Genomics, Perinatal Health, and Chronic Disease Epidemiology, Surveillance and Program Evaluation Section, Chronic Disease Epidemiology Unit. (accessed 11/21/13). Mental health disorders cause more disability among Americans than any other illness group.(2)CDC. N.d. CDC Mental Illness Surveillance. Fact Sheet, CDC Report: Mental Illness Surveillance Among Adults in the United States. (accessed 10/11/13). Using data from the Cover Michigan Survey and the Michigan Primary Care Physician Survey, both fielded in calendar year 2012, this brief explores issues related to prevalence of mental health disease, specifically depression and anxiety, and the capacity of the Michigan health care system to serve people with these conditions. Overall, it is clear that there is high need for mental health services in Michigan and the capacity to serve those in need is not adequate to the task. Without addressing increased capacity for care, the increased mental health coverage provided to many under the Affordable Care Act will do little to help those most in need.

Key findings

  • Depression and anxiety are prevalent in Michigan and higher than the U.S. average. Twenty percent of Michiganders reported ever being diagnosed with depression, compared to 18 percent of Americans.(3)Centers for Disease Control and Prevention (CDC). N.d. Behavioral Risk Factors Surveillance System. Prevalence and Trends Data, Nationwide (States and DC), 2012 Chronic Health Indicators. Prevalence is greater when diagnoses of depression and/or anxiety are combined.
    • One in four Michiganders surveyed reported ever being diagnosed with depression and/or anxiety.
    • Depression and/or anxiety were reported in Michigan at particularly high rates among those with Medicaid (59 percent) and the uninsured (33 percent).
  • People with depression and/or anxiety had greater difficulty completing everyday activities, including work, than did Michiganders with other or no chronic conditions.
    • Respondents with depression and/or anxiety reported twice as many limited activity days compared to those who reported having other chronic conditions.
    • Respondents with depression and/or anxiety reported an average of five days in which poor health limited their activity.
  • The health care system in Michigan is inadequate to serve adults and children with mental health needs.
    • Fifty-seven percent of primary care physicians reported that availability of mental health services in their community was inadequate for adults and 68 percent reported it was inadequate for children.
      • Adult mental health services in the St. Joseph, Muskegon, and Petoskey regions had the highest inadequacy ratings (89, 82 and 77 percent, respectively).
      • Child mental health services received the poorest ratings in the Muskegon and Petoskey regions (100 and 94 percent respectively).
      • Even in regions where primary care physicians reported the best access (Pontiac and Royal Oak), more than a third noted that access was inadequate.
    • The availability of psychiatric beds in Michigan is extremely low compared to other states—Michigan was ranked 42nd among the 50 states and the District of Columbia in availability of inpatient psychiatric beds.(4)U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Mental Health, United States, 2010 (Washington, D.C.: SAMSA, 2012).

      Prevalence

      Aside from hypertension, depression and anxiety were the most commonly reported chronic conditions among Michiganders who responded to the Cover Michigan Survey in 2012. One in five respondents reported ever being diagnosed with depression at some point and 18 percent reported ever being diagnosed with anxiety. Overall, more than one in four respondents (26 percent) reported ever having depression and/or anxiety, just under the 30 percent who reported having been diagnosed with hypertension.

FIGURE 1: Chronic Disease in Michigan, 2012

ConditionPercentage Ever Diagnosed with Condition
Hypertension30%
Depression and/or Anxiety26%
Depression20%
Anxiety18%
Asthma13%
Diabetes10%
Coronary Heart Disease9%
Note: Percentages do not equal 100% because respondents could select more than one condition.

One in three uninsured adults, compared to one in four insured adults, reported ever being diagnosed with anxiety and/or depression.

FIGURE 2: Mental Health Diagnosis, by Coverage Status, 2012

 InsuredUninsured
Depression and/or Anxiety25%33%
No Diagnosis of Depression or Anxiety75%67%
TOTAL100%100%

Respondents with Medicaid were almost one-and-a-half times more likely than those with Medicare, and almost three times as likely as respondents with employer-sponsored or individually purchased coverage, to report ever being diagnosed with depression and/or anxiety.

CovMI_Mentalhlth_fig3

Larger proportions of lower-income respondents reported ever being diagnosed with depression and/or anxiety, compared to people with a higher income. Almost 40 percent of respondents with an annual household income below $30,000 (roughly the 25th percentile for income in Michigan(5)Data from the United States Census Bureau’s Easy Stats tool were used to calculate annual income percentiles. (accessed 8/2/13). reported ever being diagnosed with depression and/or anxiety, while only 14 percent of respondents whose annual income was over $100,000 (roughly the 75th percentile for income in Michigan(6)Ibid. reported ever being diagnosed with depression and/or anxiety.

FIGURE 4: Mental Health Diagnosis, by Income, 2012

 $29,999 or less$30,000–$59,999$60,000–$99,999$100,000 or more
Depression and/or Anxiety39%24%21%14%
No Diagnosis of Depression or Anxiety61%76%79%86%
TOTAL100%100%100%100%

Impact on Daily Living

Depression is a significant and costly health problem that has a negative impact on daily living. Nationwide, it is estimated that depression results in a direct loss of $31 billion in productivity each year.(7)W.F. Stewart, J.A. Ricci, et al. 2003. Cost of Lost Productive Work Time Among US Workers With Depression. Journal of the American Medical Association. 289(23): 3135–3144. doi:10.1001/jama.289.23.3135. In Michigan, people with depression and/or anxiety had greater difficulty completing everyday activities, including work, than did Michiganders with other or no chronic conditions.

Respondents with depression and/or anxiety reported an average of five days in which poor health limited their activity in the month prior to the survey—twice the average number of days reported by respondents with at least one other chronic condition (hypertension, heart disease, diabetes, and/or asthma). Those with depression and/or anxiety reported more than seven times as many limited activity days compared to respondents with none of the chronic conditions listed in our survey.

CovMI_Mentalhlth_fig5

Access to Care

Ability of Consumers to Get Care

Respondents with depression and/or anxiety were more likely than people with neither of these conditions to forego care they felt they needed and to report difficulty getting primary and specialty care appointments. Forty percent of those with depression and/or anxiety did not seek care they felt they needed in the six months prior to the survey, compared to 25 percent of respondents without depression and/or anxiety. Respondents with depression and/or anxiety were also more likely to cite either cost or that they did not have a doctor or clinic as a reason for foregoing needed care, compared to people with no diagnosis of depression and/or anxiety.

FIGURE 6: Care Seeking, by Anxiety and/or Depression Diagnosis, 2012

 Diagnosis of Depression and/or AnxietyNo Diagnosis of Depression and/or Anxiety
Did not seek medical care that they thought they needed at least once in the past 6 months40%25%
Sought medical care when they thought they needed it during the past six months60%75%
TOTAL100%100%

CovMI_Mentalhlth_fig7Respondents with depression and/or anxiety were just as likely to have a primary care provider as those with neither diagnosis. However, having an identified provider is no guarantee of easy access to care.

FIGURE 8: Proportion with a Primary Care Provider, by Mental Health Diagnosis, 2012*

 Diagnosis of Depression and/or AnxietyNo Diagnosis of Depression and/or Anxiety
With a Primary Care Provider85%82%
Without a Primary Care Provider15%18%
TOTAL100%100%
* Comparisons not statistically significant at p<.05, see methodology section for more information.

Respondents with depression and/or anxiety were more likely to report difficulty getting primary or specialty care appointments than those with chronic physical conditions or those with no chronic conditions. Compared to respondents with other chronic conditions, those with depression and/or anxiety are nearly four times as likely to report that it is “somewhat” or “very” difficult to get primary care appointments, and more than three times more likely to report that it is “somewhat” or “very” difficult to get specialty care appointments. While this survey did not delve into reasons why this is the case, the disparity alone is worth noting.

CovMI_Mentalhlth_fig9

Primary Care Physician Perceptions

Physician perceptions of the availability of mental health services can serve as a good barometer of the capacity within their communities to adequately address the needs of consumers. Based on survey data from CHRT’s fall 2012 primary care physician survey, Michigan physicians overwhelmingly reported the availability of mental health services to be “inadequate” or poorly coordinated for adults (72 percent) and for children (80 percent), and 78 percent of providers considered the availability of substance abuse services in their area “inadequate” or poorly coordinated.

CovMI_Mentalhlth_fig10

The perceived availability of mental health services for adults varied across the state. Primary care physicians in the St. Joseph, Muskegon, and Petoskey regions(8)This geographical analysis uses hospital referral regions as the basis for comparison. These regions were developed by the Dartmouth Institute as a means to measure regional variation in health services. For more information, please see the Dartmouth Atlas, Atlas Downloads: Zip Code Crosswalks 2011. (accessed 10/11/13). were most likely to have rated availability in their communities as “inadequate.” Eighty-nine percent of primary care physicians in the St. Joseph region, 82 percent of those in the Muskegon region, and 77 percent of those in the Petoskey region rated the availability of mental health services as “inadequate.”

FIGURE 11: Percentage of Primary Care Physicians who Reported Inadequate Availability of Adult Mental Health Services, by Region, 2012

resizedimage667634-brief-3-figure-11

 

There was also variation in physician perceptions of the availability of substance abuse and child mental health services. Physicians in the Muskegon and Petoskey regions were more likely than their colleagues in other parts of the state to rate the availability of child mental health services as “inadequate.” Physicians in the northern and western regions of the state (Traverse City, Muskegon, St. Joseph, and Flint) were more likely to consider the availability of substance abuse services as “inadequate.”

In all three categories, adult, child, and substance abuse services, the Royal Oak and Pontiac regions, consistently had the lowest inadequacy ratings, ranging from 33 percent to 52 percent. Even though these regions still had lower inadequacy ratings than other regions, a significant number (one in three to one in two) of primary care physicians rated the availability of services in their community as “inadequate.”

FIGURE 12: Percentage of Primary Care Physicians who Reported Inadequate Availability of Child Mental Health Services, by Region, 2012

resizedimage667634-brief-3-figure-12

FIGURE 13: Percentage of Primary Care Physicians who Reported Inadequate Availability of Substance Abuse Services, by Region, 2012

resizedimage667634-brief-3-figure-13

Inpatient Psychiatric Bed Capacity

One basic measure of local capacity for mental health services is the ratio of inpatient psychiatric beds per 100,000 people. In 2007,(9)The most recent year for which data are available from the Substance Abuse and Mental Health Services Administration biannual report, Mental Health, United States, 2010, is 2007. The full report can be accessed here (accessed 10/11/13). Michigan ranked 42nd among all states for total psychiatric bed capacity, with 40.4 beds per 100,000 adults—far below the national average of 52.2. These totals include state- and federally owned facilities as well as private for-profit and not-for-profit facilities.

FIGURE 14: Total Inpatient Psychiatric Hospital Beds (including State and Federal Facilities), FY2007(10)U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Mental Health, United States, 2010 (Washington, D.C.: SAMSA, 2012).

RankStatePsychiatric Beds per 100,000 Adults
1District of Columbia222.7
2Wyoming122.4
3Mississippi115.7
4New Jersey87.9
5New York81.4
6Massachusetts74.7
7Nebraska73.7
8South Dakota72.6
9Missouri71.6
10Alabama71.0
11Delaware69.8
12North Dakota65.5
13Louisiana64.3
14Pennsylvania63.3
15Kansas61.8
16Connecticut60.5
17Oklahoma60.1
18Maryland59.3
19West Virginia57.4
20Minnesota57.3
21Indiana55.6
22Tennessee55.4
23Georgia54.7
24Idaho53.7
25Kentucky53.7
26Virginia53.1
27Arkansas52.8
28Maine50.8
29New Mexico48.4
30New Hampshire48.1
31Wisconsin48.1
32Illinois47.9
33North Carolina47.8
34Iowa43.9
35Utah43.8
36Alaska43.0
37Ohio42.1
38Montana41.5
39Hawaii41.4
40Texas41.1
41Vermont41.1
42Michigan40.4
43Washington39.9
44South Carolina39.8
45Oregon39.0
46California38.5
47Nevada37.8
48Colorado37.3
49Rhode Island36.4
50Florida31.6
51Arizona21.8
United States52.2

Conclusion

Based on survey responses from both consumers and providers, as well as available data on inpatient bed capacity, there is a compelling need to improve the availability of mental health care services in Michigan. The Affordable Care Act will expand mental health coverage for hundreds of thousands of Michigan citizens. But even before this expansion, physicians and patients alike describe a mental health system where appointments for care are already hard to get and care is poorly coordinated. These gaps in mental health care in Michigan take a personal toll and a toll on the productivity of our state. Unless these gaps are addressed, the expansion of coverage will not help the state or those with mental health needs nearly as much as it could.

Methodology

This report is based on two surveys conducted by the Center for Healthcare Research & Transformation in calendar year 2012: the Cover Michigan Survey and a survey of Michigan primary care physicians.

Cover Michigan Survey: The results presented in this report were produced from a series of survey questions added to the Michigan State University Institute for Public Policy and Social Research (IPPSR) quarterly State of the State Survey. The survey was fielded in the third quarter of calendar year 2012 and included a sample of 1,018 Michigan adults. The margin of error for the entire sample was ±6.5 percent. The sampling design, a random stratified sample based on regions within the state, was a telephone survey conducted via landline and cellular phones of Michigan residents.

For analytical purposes, survey data were weighted to adjust for the unequal probabilities of selection for each stratum of the survey sample (for example, region of the state, listed vs. unlisted telephones). Additionally, data were weighted to adjust for non-response based on age, gender, and race according to population distributions from the United States Census 2010. Results were analyzed using SAS 9.3 software. Statistical significance of bivariate relationships for single year data were tested using a chi-square test for independence. All comparison tables are statistically significant at p ≤ 0.05 unless otherwise noted. Relationships in Figure 7 were analyzed using a z-test.

A full report of the IPPSR State of the State Survey methodology can be found at: http://ippsr.msu.edu/soss/.

Michigan Primary Care Physician Survey: The survey data presented in this brief were produced from a mail survey of 1,500 primary care physicians practicing in Michigan, conducted between October and December 2012. Potential respondents received up to two mailings, with $5 included in the first mailing to encourage response.

The physician sample was randomly generated from the American Medical Association (AMA) Physician Masterfile, a comprehensive list that includes both AMA members and non-members. The final sample included 500 physicians each from three primary care specialties: pediatrics, family medicine, and internal medicine. The survey had an overall response rate of 54 percent (714 physicians) and has a margin of error of ± 3 percent. Physicians who responded but reported they were no longer practicing primary care were removed from the analysis. Final results were weighted to adjust for non-response in each of the three primary care specialty groups. Results were analyzed using SAS 9.3 software. Geographic Information System (GIS) was used to create and analyze data for maps.

Suggested Citation: Smiley, Mary; Young, Danielle; Udow- Phillips, Marianne; Riba, Melissa; Traylor, Joshua. Access to Mental Health Care in Michigan. Cover Michigan Survey 2013. December 2013. Center for Healthcare Research & Transformation. Ann Arbor, MI.

References   [ + ]

1. C. Fussman. September 2013. Health Risk Behaviors in the State of Michigan: 2012 Behavioral Risk Factor Survey. 26th Annual Report. Lansing, MI: Michigan Department of Community Health, Division of Genomics, Perinatal Health, and Chronic Disease Epidemiology, Surveillance and Program Evaluation Section, Chronic Disease Epidemiology Unit. (accessed 11/21/13).
2. CDC. N.d. CDC Mental Illness Surveillance. Fact Sheet, CDC Report: Mental Illness Surveillance Among Adults in the United States. (accessed 10/11/13).
3. Centers for Disease Control and Prevention (CDC). N.d. Behavioral Risk Factors Surveillance System. Prevalence and Trends Data, Nationwide (States and DC), 2012 Chronic Health Indicators.
4. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Mental Health, United States, 2010 (Washington, D.C.: SAMSA, 2012).
5. Data from the United States Census Bureau’s Easy Stats tool were used to calculate annual income percentiles. (accessed 8/2/13).
6. Ibid.
7. W.F. Stewart, J.A. Ricci, et al. 2003. Cost of Lost Productive Work Time Among US Workers With Depression. Journal of the American Medical Association. 289(23): 3135–3144. doi:10.1001/jama.289.23.3135.
8. This geographical analysis uses hospital referral regions as the basis for comparison. These regions were developed by the Dartmouth Institute as a means to measure regional variation in health services. For more information, please see the Dartmouth Atlas, Atlas Downloads: Zip Code Crosswalks 2011. (accessed 10/11/13).
9. The most recent year for which data are available from the Substance Abuse and Mental Health Services Administration biannual report, Mental Health, United States, 2010, is 2007. The full report can be accessed here (accessed 10/11/13).
10. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Mental Health, United States, 2010 (Washington, D.C.: SAMSA, 2012).