Growth and Distribution of Child Psychiatrists in the United States: 2007–2016 Ryan K. McBain, PhD, MPH, a Aaron Kofner, MA, MS, b Bradley D. Stein, MD, PhD, c Jonathan H. Cantor, PhD, d William B. Vogt, PhD, e Hao Yu, PhD f abstract BACKGROUND: Historically, there has been a shortage of child psychiatrists in the United States, undermining access to care. This study updated trends in the growth and distribution of child psychiatrists over the past decade. METHODS: Data from the Area Health Resource Files were used to compare the number of child psychiatrists per 100 000 children ages 0 to 19 between 2007 and 2016 by state and county. We also examined sociodemographic characteristics associated with the density of child psychiatrists at the county level over this period using negative binomial multivariable models. RESULTS: From 2007 to 2016, the number of child psychiatrists in the United States increased from 6590 to 7991, a 21.3% gain. The number of child psychiatrists per 100 000 children also grew from 8.01 to 9.75, connoting a 21.7% increase. County- and state-level growth varied widely, with 6 states observing a decline in the ratio of child psychiatrists (ID, IN, KS, ND, SC, and SD) and 6 states increasing by .50% (AK, AR, NH, NV, OK, and RI). Seventy percent of counties had no child psychiatrists in both 2007 and 2016. Child psychiatrists were significantly more likely to practice in high-income counties (P , .001), counties with higher levels of postsecondary education (P , .001), and metropolitan counties compared with those adjacent to metropolitan regions (P , .05). CONCLUSIONS: Despite the increased ratio of child psychiatrists per 100 000 children in the United States over the past decade, there remains a dearth of child psychiatrists, particularly in parts of the United States with lower levels of income and education. WHAT’S KNOWN ON THIS SUBJECT: More than half of the children in the United States with a treatable mental health disorder do not receive treatment from a mental health professional. One of the driving factors contributing to this unmet need is a shortage in child psychiatrists. WHAT THIS STUDY ADDS: We found that child psychiatrists (per 100 000 children) increased by 22% from 2007 to 2016. However, 70% of US counties had no child psychiatrists in 2007 or 2016, and child psychiatrists were much less prevalent in low-income and less-educated communities. To cite: McBain RK, Kofner A, Stein BD, et al. Growth and Distribution of Child Psychiatrists in the United States: 2007–2016. Pediatrics. 2019;144(6):e20191576 a RAND Corporation, Boston, Massachusetts; b RAND Corporation, Arlington, Virginia; c RAND Corporation, Pittsburgh, Pennsylvania; d RAND Corporation, Santa Monica, California; e Department of Economics, University of Georgia, Athens, Georgia; and f Department of Population Medicine, Harvard Medical School, Harvard University and Harvard Pilgrim Health Care Institute, Boston, Massachusetts Dr McBain helped conceptualize and design the study and identify, evaluate, and interpret the data and led the drafting and revision of the manuscript; Mr Kofner generated figures and helped evaluate and interpret the data and write and review the manuscript; Drs Stein and Cantor helped conceptualized the study, interpreted the data, and assisted in the writing and review of the manuscript; Dr Vogt helped analyze and interpret the data and assisted in the review and writing of the manuscript; Dr Yu obtained funding support for the study, led the conceptualization of the study, helped interpret the data, and shared in writing and reviewing the manuscript; and all authors approved the final manuscript as submitted. DOI: https://doi.org/10.1542/peds.2019-1576 Accepted for publication Sep 3, 2019 PEDIATRICS Volume 144, number 6, December 2019:e20191576 ARTICLE by guest on May 27, 2021 www.aappublications.org/news Downloaded from
Transcript
Growth and Distribution of ChildPsychiatrists in the United States:2007–2016Ryan K. McBain, PhD, MPH,a Aaron Kofner, MA, MS,b Bradley D. Stein, MD, PhD,c Jonathan H. Cantor, PhD,d William B. Vogt, PhD,e
Hao Yu, PhDf
abstractBACKGROUND: Historically, there has been a shortage of child psychiatrists in the United States,undermining access to care. This study updated trends in the growth and distribution of childpsychiatrists over the past decade.
METHODS: Data from the Area Health Resource Files were used to compare the number of childpsychiatrists per 100 000 children ages 0 to 19 between 2007 and 2016 by state and county.We also examined sociodemographic characteristics associated with the density of childpsychiatrists at the county level over this period using negative binomial multivariablemodels.
RESULTS: From 2007 to 2016, the number of child psychiatrists in the United States increasedfrom 6590 to 7991, a 21.3% gain. The number of child psychiatrists per 100 000 children alsogrew from 8.01 to 9.75, connoting a 21.7% increase. County- and state-level growth variedwidely, with 6 states observing a decline in the ratio of child psychiatrists (ID, IN, KS, ND, SC,and SD) and 6 states increasing by .50% (AK, AR, NH, NV, OK, and RI). Seventy percent ofcounties had no child psychiatrists in both 2007 and 2016. Child psychiatrists weresignificantly more likely to practice in high-income counties (P , .001), counties with higherlevels of postsecondary education (P , .001), and metropolitan counties compared with thoseadjacent to metropolitan regions (P , .05).
CONCLUSIONS:Despite the increased ratio of child psychiatrists per 100 000 children in the UnitedStates over the past decade, there remains a dearth of child psychiatrists, particularly in partsof the United States with lower levels of income and education.
WHAT’S KNOWN ON THIS SUBJECT: More than half ofthe children in the United States with a treatablemental health disorder do not receive treatment froma mental health professional. One of the drivingfactors contributing to this unmet need is a shortagein child psychiatrists.
WHAT THIS STUDY ADDS: We found that childpsychiatrists (per 100 000 children) increased by 22%from 2007 to 2016. However, 70% of US counties had nochild psychiatrists in 2007 or 2016, and childpsychiatrists were much less prevalent in low-incomeand less-educated communities.
To cite: McBain RK, Kofner A, Stein BD, et al. Growth andDistribution of Child Psychiatrists in the United States:2007–2016. Pediatrics. 2019;144(6):e20191576
aRAND Corporation, Boston, Massachusetts; bRAND Corporation, Arlington, Virginia; cRAND Corporation,Pittsburgh, Pennsylvania; dRAND Corporation, Santa Monica, California; eDepartment of Economics, University ofGeorgia, Athens, Georgia; and fDepartment of Population Medicine, Harvard Medical School, Harvard Universityand Harvard Pilgrim Health Care Institute, Boston, Massachusetts
Dr McBain helped conceptualize and design the study and identify, evaluate, and interpret the dataand led the drafting and revision of the manuscript; Mr Kofner generated figures and helpedevaluate and interpret the data and write and review the manuscript; Drs Stein and Cantor helpedconceptualized the study, interpreted the data, and assisted in the writing and review of themanuscript; Dr Vogt helped analyze and interpret the data and assisted in the review and writing ofthe manuscript; Dr Yu obtained funding support for the study, led the conceptualization of the study,helped interpret the data, and shared in writing and reviewing the manuscript; and all authorsapproved the final manuscript as submitted.
DOI: https://doi.org/10.1542/peds.2019-1576
Accepted for publication Sep 3, 2019
PEDIATRICS Volume 144, number 6, December 2019:e20191576 ARTICLE by guest on May 27, 2021www.aappublications.org/newsDownloaded from
More than half of the children in theUnited States with a treatable mentalhealth disorder do not receivetreatment from a mental healthprofessional.1–3 One of the drivingfactors contributing to this unmetneed is a shortage in childpsychiatrists, which is compoundedby growing demand for treatmentthat places additional pressure ona limited supply of providers.4
Improved screening and diagnostictools for childhood mental disorders,5
expanded child health insurancecoverage,6,7 and greater caregiverawareness of pediatric mental healthconditions all contribute to thisincreased demand. As a result, accessto mental health care for children hasbeen highly variable across states andcounties.8
Historically, the shortage of childpsychiatrists has been most acuteamong disadvantaged populations,such as racial and ethnic minorityyouth,9 as well as youth living inimpoverished and rural areas.8,10 TheAmerican Academy of Child andAdolescent Psychiatry estimates, forexample, that Rhode Island has.6 times as many child psychiatristsper capita as Wyoming does.11 Toattract physicians to rural and remotecommunities, mechanisms like theHealth Resources and ServicesAdministration’s National HealthService Corps (NHSC) LoanRepayment Program have offeredfinancial incentives for childpsychiatrists and other physicians toserve in designated healthprofessional shortage areas.12
However, as little as 13% ofphysicians who participate in loanforgiveness programs select the NHSCover alternatives.13,14 As such, itremains unclear whether and to whatextent recent policies and programssuch as the NHSC’s have improvedaccess to child psychiatrists inunderserved communitiesthroughout the United States.Moreover, although there has been anoverall increase in the number of
mental health providers in the UnitedStates, the current literature does notprovide specifics on the growth in thenumber of child psychiatrists over thepast decade and where the growthhas occurred.
To provide an assessment of nationaltrends in the growth and distributionof child psychiatrists in the UnitedStates, we examined the ratio of childpsychiatrists per 100 000 childrenthroughout all US counties for themost recent 10-year period data wereavailable: 2007–2016. Thisinformation extends an earlier studyof child psychiatrist levels in theUnited States completed in 2006.15
Separately, we examined therelationship between county-levelsociodemographic characteristics andchild psychiatrist workforce supply toidentify characteristics associatedwith greater access to services overthis period.
METHODS
Study Design
This retrospective time-seriesanalysis of all 50 US states employedrepeated cross-sectional data from2007 to 2016 based on the 5 datasources described below. Data wereaggregated at the county level basedon US county Federal InformationProcessing Standard codes.16 Theresearch was deemed exempt fromreview by Dr McBain’s institutionalreview board.
Data Sources
Child Psychiatrists
The Area Health Resource Files(AHRF) of the Department of Healthand Human Services maintainsa county-level inventory of healthprofessionals, including the numberof child psychiatrists, on an annualbasis. These data draw from theAmerican Medical Association (AMA)Physician Masterfile,17 for whichphysicians (including childpsychiatrists) report their primarylocation of practice, including
outpatient facilities and hospitals.More specifically, our analysescomprised licensed physicians whohave met educational andcredentialing requirements topractice as child psychiatrists,including doctors of medicine anddoctors of osteopathy. Residentphysicians are included. Historically,the AMA Physician Masterfile hasbeen considered to maintain highcompleteness, with only a smallproportion of licensed physiciansbeing labeled “missing,” largelybecause of how the AMA and statelicensing agencies update their files.18
Children
Counts of youth ages 0 to 19 wereobtained from the Census ofPopulation and Housing, which isprepared by the US Census Bureau.19
Additionally, the US Census Bureaureports on population density, whichis measured as the total populationrelative to land area in square miles.
County Characteristics
The AHRF contains a repository ofcounty characteristics, elements ofwhich were selected on the basis ofPenchansky and Thomas’s20
canonical framework for consideringdeterminants of access. First, weincluded rural-urban continuumcodes, which classify countiesaccording to population size anddegree of isolation.21 We consolidatedthis measure into 5 commonly usedlevels22–24 that reflect population sizeand proximity to metropolitan areas:counties in metropolitan areas (levels1, 2, and 3), urban counties adjacentto metropolitan areas (levels 4 and 6),urban counties not adjacent tometropolitan areas (levels 5 and 7),rural counties adjacent tometropolitan areas (level 8), andrural counties not adjacent tometropolitan areas (level 9).
A second set of AHRF countycharacteristics comprisessocioeconomic measures. Here, weextracted measures of income,
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education, and employment. The first,median income per capita at thecounty level unadjusted for inflation,was derived from the US Departmentof Commerce.25 The second,percentage of adults by county with 4or more years of college education,was obtained from the US CensusBureau, drawing from the AmericanCommunity Survey.19 Lastly,percentage unemployment amongadults ages 16 and older wasextracted from the US Bureau ofLabor Statistics Current PopulationSurvey.26
A third set of measures from the USCensus Bureau quantified the racialand/or ethnic composition ofcounties. This was representedaccording to 3 categories: percentagenon-Hispanic African American, othernon-Hispanic, and Hispanic.19 Lastly,we used Small Area Health InsuranceEstimates files from the US CensusBureau to measure the percentage ofindividuals ,65 years of age in eachcounty without public or privatehealth insurance coverage27 as wellas the county-level averagemalpractice insurance premium forinternal medicine physicians basedon data from the Medical LiabilityMonitor.28
Data Analysis
After inspecting measures of centraltendency and dispersion,29 we made3 adjustments to account fornonlinearity in measures. First, toaddress the right skew of county-levelmedian income per capita, wesegmented income into quartiles.Second, to account for nonlinearity inthe growth of child psychiatrists overtime, we constructed year variables(1 for each year) and included all ofthem in the analysis except 2007,which was used as the reference.Third, based on the right skew ofpopulation characteristics, weperformed log transformations ofchild population and populationdensity and introduced a square-of-log term for child population.
We next estimated a multivariablenegative binomial regression modelwith state-level fixed effects. Thenegative binomial distribution wasselected over 0-inflated Poissonbecause the former more accuratelyaccounted for overdispersion in thedata based on the Pearson x2
dispersion statistic.30 Fixed effectswere entered for each state toaddress the potential of omittedvariable bias, such as state-levelpolicies that might influenceworkforce supply, by removing state-specific variance components.31 SEswere clustered at the state level toaccount for within-cluster correlation.
We included the following covariatesin the negative binomial model: time(year), child population at the countylevel, urbanicity as connoted by rural-urban continuum code categories,county-level socioeconomic variables(income, education, and employmentcharacteristics), and county-levelracial and/or ethnic composition. Toaid the interpretation of results, wecomputed predicted counts usingStata’s margins command (Stata Corp,College Station, TX).32 Predictedcounts quantified the number of childpsychiatrists in a county on the basisof fitted models calculated withcovariates specified at median valuesfor the subgroup of interest. All testswere 2 sided, used an a level of .05,and were conducted in Stataversion 15.0.
RESULTS
Child Psychiatrists per 100 000Population
Between 2007 and 2016, the numberof practicing child psychiatrists in theUnited States increased from 6590 to7991: a 21.3% gain. Over this sametime period, the number of childrenin the United States ages 0 to 19modestly declined, from 82.22 millionto 81.95 million. As such, the ratio ofchild psychiatrists grew from 8.01child psychiatrists per 100 000children in 2007 to 9.75 child
psychiatrists per 100 000 children in2016. These trends are reflected inFig 1.
The state-level growth of childpsychiatrists varied widely. In 2007,10 states had ,5 child psychiatristsper 100 000 children compared withonly 5 states in 2016 (Table 1).Meanwhile, the number of states with10 or more child psychiatrists per100 000 children increased from 11to 14. Child psychiatrists per 100 000children increased by .50% in 6states (AK, AR, NV, NH, OK, and RI).Conversely, the ratio of childpsychiatrists per 100 000 childrendeclined in 6 other states: Idaho,Indiana, Kansas, North Dakota, SouthDakota, and South Carolina. In severalcases, this was due to faster growth inchild population than in childpsychiatrists (eg, KS), whereas inothers, this reflected an absolutedecline in child psychiatrists (eg, ND).
A preponderance of all US counties(76%) experienced no change in thelevel of child psychiatrists between2007 and 2016, as illustrated byFig 2, which is largely a function ofthe 70% of counties that contained0 child psychiatrists in both 2007 and2016. Among the remaining counties,the degree of change in the density ofchild psychiatrists from 2007 to 2016was substantial. Within states such asCalifornia, Florida, andMassachusetts, an increase in childpsychiatrists per 100 000 children inspecific counties corresponded withdeclining levels in neighboringcounties.
Distribution by Urbanicity
Compared with the ratio of childpsychiatrists per 100 000 children inmetropolitan areas from 2007 to2016, there were fewer childpsychiatrists in urban countiesadjacent to metropolitan areas(P = .02) as well as rural countiesadjacent to metropolitan counties(P = .01). There was not a statisticallysignificant difference in the ratio ofchild psychiatrists per 100 000
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children between metropolitan areasand urban areas nonadjacent tometropolitan areas and, separately,between metropolitan areas and ruralcounties nonadjacent to metropolitanareas (P . .05).
Distribution by SociodemographicCharacteristics
Child psychiatrists were significantlymore likely to practice inhigher–income-quartile counties(fourth versus first income quartile;P , .001), with 74% of childpsychiatrists residing in top-income-quartile counties and 92% in the top-2–income-quartile counties, between2007 and 2016. As of 2016, theexpected number of childpsychiatrists per 100 000 children inlowest–income-quartile counties was1.40 compared with 5.04 in thehighest-quartile counties: more thana threefold difference (Table 2). Aneven more stark contrast wasobserved for education level of thecounty. Counties in the fifth percentile
for completion of postsecondaryeducation would be expected to have1.10 child psychiatrists comparedwith 9.79 in the 95th percentile(P , .001). We observed nostatistically significant relationshipbetween county-level unemploymentand the number of child psychiatrists(P . .05), although counties withlower levels of employment did onaverage have fewer child psychiatrists(Table 2). We further found nosignificant relationship between thedensity of child psychiatrists andpercentage of individuals withoutpublic or private health insurance(P . .05) or between the density ofchild psychiatrists and averageinsurance premium for physicians inthe county (P . .05).
There was a slightly larger ratio ofchild psychiatrists per 100 000children in counties with larger non-Hispanic African Americanpopulations when adjusting for childpopulation and all other
sociodemographic characteristics(P , .001). There was no suchevidence that child psychiatrists weremore abundant in counties withlarger Hispanic populations (P . .05)or in counties with larger percentagesof individuals who self-identified asnon-Hispanic other (P . .05).Supplemental Table 3 provides anoverview of all results from theregression analysis.
DISCUSSION
This analysis provides a timelyupdate on the level and distributionof child psychiatrists in the UnitedStates over the past decade. Althoughthe density of child psychiatrists hasincreased from 2007 to 2016, thereremain ∼70% of counties in theUnited States with no childpsychiatrists. The distribution of childpsychiatrists also remainsinequitable, with a state likeMassachusetts having as many childpsychiatrists as Oklahoma, Indiana,
FIGURE 1Child psychiatrists and children ages 0 to 19 in the United States (2007–2016). Y-axis 1 (right-hand side) signifies the number of child psychiatrists in theUnited States for each year from 2007 to 2016, whereas y-axis 2 (left-hand side) signifies the number of children ages 0 to 19 in the United States over thisperiod.
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Georgia, Mississippi, and Tennesseecombined, despite these latter stateshaving 5 times as many children ages0 to 19.
The shortage of child psychiatristsis consonant with previousfindings,10,15,33 although we did findthat the 1 child psychiatrist for every12 477 children in 2007 increased to1 child psychiatrist for every 10 256children in 2016: a 21.7%improvement. This trend reflects anuptick in the number of childpsychiatrists in the United States overthis period, from 6590 to 7991, aswell as a modest decline in the childpopulation,34 indicating overallimprovement in potential accessto care.
Despite the trend of more childpsychiatrists over time, we alsofind that this growth is largelyrestricted to specific geographicareas of the United States andvaries significantly at the stateand county levels. At the statelevel, we observed a decliningratio of child psychiatrists per100 000 children in 6 states (ID,IN, KS, ND, SD, and SC) and anannualized growth ,2% in halfof all US states. By contrast, 6 statesobserved a 50% or greater increasein the ratio of child psychiatristsper 100 000 children over thisperiod (AK, AR, NV, NH, OK, and RI).These findings parallel trends inthe distribution of mental healthprofessionals in the United Statesgenerally8 as well as psychiatry asa discipline specifically.35 Futureresearch in this area should explorewhether variable growth in thenumber of child psychiatrists is tiedto specific legislative efforts at thenational, state, and local levels.36
Examinations at a local level would beparticularly warranted in settings likeCalifornia or Florida, where we foundthat growth in the number of childpsychiatrists in many countiescorresponded with decliningnumbers in adjacent counties.
One conspicuous factor shaping thedistribution of child psychiatristswas, unsurprisingly, child population:although three-quarters of counties(74.7%) had no child psychiatrists in2016, 80% of children in the UnitedStates reside in a county with at least1 child psychiatrist. In other words,child psychiatrists aredisproportionately located in countieswith larger child populations,suggesting that the general allocationfacilitates access to care. Thisobservation is true more generally forthe distribution of human resourcesfor health in the United States. Forexample, Cummings et al8 found thatmental health treatment resources inthe United States are more heavilyconcentrated in urban areas, servinglarger, more densely populatedcounties. However, 1 in 5 children stilllive in a county without a childpsychiatrist, highlighting the ongoingchallenge of providing children withlocal access to psychiatric services.
Similar to findings reported regardingprimary care physicians,37 countieswith higher levels of education andhigher incomes commonly hadgreater access to child psychiatrists.For example, a county in the 95thpercentile of college graduates wouldbe expected to have 9.8 times asmany child psychiatrists as a countyin the fifth percentile. A similargradient was observed for income,with 3.6 times as many childpsychiatrists expected in counties inthe highest income quartile comparedwith counties in the bottom incomequartile. A number of factors maycontribute to these trends. Forexample, wealthier and more highlyeducated families may be more likelyto seek mental health care and beable to pay cash or afford insurancecopayments, deductibles, and out-of-pocket expenditures.38 Affordabilityof child psychiatric services, asa conceptual feature of access tocare,20 is particularly problematicbecause many child psychiatrists donot accept Medicaid, a form of publicTA
BLE1
Continued
State
2007
2016
PercentChange
Child
Population
Child
Psychiatrists
Child
Population
Child
Psychiatrists
Child
Population
Child
Psychiatrists
Total
Rate
Total
Rate
Total
Rate
Utah
901353
414.5
1012075
515.0
12.3
24.4
10.8
Verm
ont
150407
2516.6
139166
3021.6
27.5
20.0
29.7
Virginia
2041450
178
8.7
2092529
204
9.7
2.5
14.6
11.8
Washington
1701487
109
6.4
1802456
137
7.6
5.9
25.7
18.6
WestVirginia
434287
225.1
419018
286.7
23.5
27.3
31.9
Wisconsin
1478223
124
8.4
1442699
134
9.3
22.4
8.1
10.7
Wyoming
139909
64.3
153726
74.6
9.9
16.7
6.2
aIncrease
.50%.
bDecliningrate.
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health insurance that is the singlelargest payer for mental healthservices in the United States.39
Additionally, we identified 2 sets ofsomewhat surprising results. First,urban and rural counties adjacent tometropolitan counties haveproportionally fewer childpsychiatrists. It is possible that accessto care is more limited inmetropolitan-adjacent countiesbecause child psychiatrists relocate toaffluent metropolitan communitieswith greater social amenities. Second,we observed a slightly greater densityof child psychiatrists in counties withlarger African American populations
after adjusting for all other factors.One possibility is that habitation incommunities with a larger AfricanAmerican representation is merelya proxy for living in specificmetropolitan neighborhoods, anobservation that has been reportedelsewhere.40 If this were the case,examination of the distribution ofchild psychiatrists at the census-tractlevel could provide greater resolutionon where child psychiatristscongregate within metropolitanregions. Unfortunately, these data arenot available. This finding meritsfurther investigation because thebroader literature indicates wide-ranging patterns of access to and use
of mental health services amongAfrican American children andadolescents.41–43
Several limitations should be noted.First, to identify year-on-year trends,population data were drawn from theUS Census Bureau, which classifieschildren ages 0 to 19. This contrastswith previous studies that examinedthe age range of 0 to 17, preventingdirect comparisons. Relatedly, thevariable used for uninsured statusexamined individuals through age 65,not just children ages 0 to 19. Second,the large number of counties with0 psychiatrists precluded our abilityto examine interactions between time
FIGURE 2County-level change in child psychiatrists per 100 000 children (2007–2016).
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and county characteristics. It may bethe case that, over a longer timehorizon or by pooling childpsychiatrists with other mentalhealth professionals, theseinteractions could be studied ata broader level. Third, althoughour models included state-levelfixed effects, other omitted variablesmay have been present at thecounty level. We attempted toaccount for this by a broadinclusion of covariates.
Lastly, we have no informationabout the offices that a childpsychiatrist is practicing at norindividuals’ level of engagement inthe practice. Although the AMAPhysician Masterfile is consideredrobust,44 recent research has raisedconcern about the accuracy ofaddress-level information.45 As
such, we used the file to studychild psychiatrist numbers atthe county and state levelsrather than at a more local level.44
Level of active provider engagementcould also shape unmet need. Forexample, a community with highlevels of need for services mightbe undersupported if childpsychiatrists practice infrequently.In this case, the AMA data wouldoverestimate the availability ofservices. That said, it is also likelythat such measures would beendogenous with the outcomeof interest: namely, countieswith more child psychiatristscould have a greater prevalence ofchild mental illness becausediagnoses in these counties are morefrequent due to the presence of childpsychiatrists.
CONCLUSIONS
We find evidence that the supply ofchild psychiatrists in the UnitedStates has improved over the past10 years but that a shortage is stillprofound in large segments of thecountry. Local and state policies havemade efforts to address this throughseveral mechanisms, such as studentloan forgiveness programs and higherreimbursement rates, to promoteequity in access to services.46
However, our findings suggest thatmore structural community features,such as average wealth andeducation, are closely tied to the levelof child psychiatrists; as such,broader policies that influenceeducational and economicopportunity may be required. Absentthese, counties with few or no childpsychiatrists may need to look toalternative or complementaryframeworks to address child mentalhealth needs, including integration ofbehavioral health in pediatric primarycare settings,47 school-based mentalhealth services,48 child psychiatrytelephone consultation accessprograms,49 and new models oftelepsychiatry.50
ABBREVIATIONS
AMA: American MedicalAssociation
AHRF: Area Health Resource FilesNHSC: National Health Service
Corps
Address correspondence to Ryan K. McBain, PhD, MPH, RAND Corporation, 20 Park Plaza, #920, Boston, MA 02116. E-mail: [email protected]
a Difference is significant at P , .05 compared with the reference group: first quartile or fifth percentile. Expectednumber of child psychiatrists based on fitted values from negative binomial models with year set to 2016, childpopulation set to 100 000, and covariate characteristics set to median values within the county type of interest. Upperand lower bounds represent the fifth and 95th percentile estimates, respectively.
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1. Olfson M, Blanco C, Wang S, Laje G,Correll CU. National trends in themental health care of children,adolescents, and adults by office-basedphysicians. JAMA Psychiatry. 2014;71(1):81–90
2. Whitney DG, Peterson MD. US nationaland state-level prevalence of mentalhealth disorders and disparities ofmental health care use in children.JAMA Pediatr. 2019;173(4):389–391
3. Merikangas KR, He JP, Brody D, et al.Prevalence and treatment of mentaldisorders among US children in the2001–2004 NHANES. Pediatrics. 2010;125(1):75–81
4. Kogan MD, Blumberg SJ, Schieve LA,et al. Prevalence of parent-reporteddiagnosis of autism spectrum disorderamong children in the US, 2007.Pediatrics. 2009;124(5):1395–1403
5. Siu AL, Bibbins-Domingo K, GrossmanDC, et al. Screening for autismspectrum disorder in young children:US preventive services task forcerecommendation statement. JAMA.2016;315(7):691–696
6. Grace AM, Noonan KG, Cheng TL, et al.The ACA’s pediatric essential healthbenefit has resulted in a state-by-statepatchwork of coverage with exclusions.Health Aff. 2014;33(12):2136–2143
7. CMS. The Mental Health Parity andAddiction Equity Act (MHPAEA). 2018.Available at: https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet.html. Accessed April 9, 2019
8. Cummings JR, Allen L, Clennon J, Ji X,Druss BG. Geographic access tospecialty mental health care acrosshigh- and low-income US communities.JAMA Psychiatry. 2017;74(5):476–484
9. Kataoka SH, Zhang L, Wells KB. Unmetneed for mental health care among U.S.children: variation by ethnicity andinsurance status. Am J Psychiatry. 2002;159(9):1548–1555
10. Thomas KC, Ellis AR, Konrad TR,Holzer CE, Morrissey JP. County-level estimates of mental healthprofessional shortage in the UnitedStates. Psychiatr Serv. 2009;60(10):1323–1328
11. American Academy of Child andAdolescent Psychiatry. Workforce mapsby state: practicing child andadolescent psychiatrists. 2018.Available at: https://www.aacap.org/aacap/Advocacy/Federal_and_State_Initiatives/Workforce_Maps/Home.aspx.Accessed April 9, 2019
12. HRSA. National Health Service Corps.2018. Available at: https://nhsc.hrsa.gov/. Accessed October 29, 2018
13. Kamerow DB. Is the National HealthService Corps the answer? (for placingfamily doctors in underserved areas).J Am Board Fam Med. 2018;31(4):499–500
14. Nagaraj M, Coffman M, Bazemore A.30% of recent family medicinegraduates report participation in loanrepayment programs. J Am Board FamMed. 2018;31(4):501–502
15. Thomas CR, Holzer CE. The continuingshortage of child and adolescentpsychiatrists. J Am Acad Child AdolescPsychiatry. 2006;45(9):1023–1031
16. US Census Bureau. 2016 FIPS codes.2017. Available at: https://www.census.gov/geographies/reference-files/2016/demo/popest/2016-fips.html. AccessedFebruary 21, 2019
17. American Medical Association. AMAPhysician Masterfile. 2019. Available at:https://www.ama-assn.org/practice-management/masterfile/ama-physician-masterfile. AccessedFebruary 21, 2019
18. Cherkin D, Lawrence D. An evaluation ofthe American Medical Association’sPhysician masterfile as a datasource–one state’s experience. MedCare. 1977;15(9):767–769
19. US Census Bureau. AmericanCommunity Survey (ACS). 2017.Available at: https://www.census.gov/programs-surveys/acs. AccessedFebruary 21, 2019
20. Penchansky R, Thomas JW. The conceptof access: definition and relationship toconsumer satisfaction. Med Care. 1981;19(2):127–140
21. USDA. Rural-urban continuum codes.2017. Available at: https://www.ers.usda.gov/data-products/rural-urban-
continuum-codes.aspx#.VCBR7vldXAs.Accessed February 21, 2019
22. Fogleman AJ, Mueller GS, Jenkins WD.Does where you live play an importantrole in cancer incidence in the U.S.? AmJ Cancer Res. 2015;5(7):2314–2319
23. Luu H, Slavova S, Freeman PR, et al.Trends and patterns of opioid analgesicprescribing: regional and rural-urbanvariations in Kentucky from 2012 to2015. J Rural Health. 2019;35(1):97–107
24. Patrick SW, Faherty LJ, Dick AW, et al.Association among county-leveleconomic factors, clinician supply,metropolitan or rural location, andneonatal abstinence syndrome. JAMA.2019;321(4):385–393
25. US Department of Commerce.Commerce Data Hub. Washington, DC:US Department of Commerce; 2019.Available at: https://data.commerce.gov/. Accessed February 21, 2019
26. Bureau of Labor Statistics. Local areaunemployment statistics. 2017.Available at: https://www.bls.gov/lau/.Accessed February 21, 2019
27. US Census Bureau. Small Area HealthInsurance Estimates (SAHIE) Program.2017. Available at: https://www.census.gov/programs-surveys/sahie.html.Accessed May 6, 2019
28. Black B, Chung J, Traczynski J, UdalovaV, Vats S. Medical liability insurancepremia: 1990–2016 dataset, withliterature review and summaryinformation. J Empir Leg Stud. 2017;14:238–254
29. Judd CM, McClelland GH, Culhane SE.Data analysis: continuing issues in theeveryday analysis of psychological data.Annu Rev Psychol. 1995;46:433–465
30. Meyer J; The Analysis Factor. Poisson ornegative binomial? Using count modeldiagnostics to select a model. 2018.Available at: https://www.theanalysisfactor.com/poisson-or-negative-binomial-using-count-model-diagnostics-to-select-a-model/.Accessed June 29, 2019
31. Wooldridge JM. IntroductoryEconometrics: A Modern Approach, 5thed. Mason, OH: Cengage Learning; 2012
32. Stata Corps. Margins. Stata StatisticalSoftware: Release 15. College Station,
PEDIATRICS Volume 144, number 6, December 2019 9 by guest on May 27, 2021www.aappublications.org/newsDownloaded from
TX: Stata Corps; 2014. Available at:https://www.stata.com/manuals13/rmargins.pdf. Accessed March 20,2019
33. Thomas CR, Holzer CE. Nationaldistribution of child and adolescentpsychiatrists. J Am Acad Child AdolescPsychiatry. 1999;38(1):9–15–16
34. Frey W. US Population Growth Hits 80-Year Low. Washington, DC: BrookingsInstitution; 2018. Available at: https://www.brookings.edu/blog/the-avenue/2018/12/21/us-population-growth-hits-80-year-low-capping-off-a-year-of-demographic-stagnation/. AccessedMay 6, 2019
35. Butryn T, Bryant L, Marchionni C,Sholevar F. The shortage ofpsychiatrists and other mental healthproviders: causes, current state, andpotential solutions. Int J Acad Med.2017;3(1):5–9
36. American Academy of Pediatrics.Promoting children’s mental health.2019. Available at: www.aap.org/en-us/advocacy-and-policy/federal-advocacy/Pages/mentalhealth.aspx. Accessed May6, 2019
37. McGrail MR, Wingrove PM, PettersonSM, et al. Measuring the attractivenessof rural communities in accounting fordifferences of rural primary careworkforce supply. Rural Remote Health.2017;17(2):3925
38. Dickman SL, Woolhandler S, Bor J, et al.Health spending for low-, middle-, andhigh-income Americans, 1963–2012.Health Aff. 2016;35(7):1189–1196
39. Centers for Medicare and MedicaidServices. Behavioral health services.Available at: https://www.medicaid.gov/medicaid/benefits/bhs/index.html.Accessed July 22, 2019
40. Yang D, Howard G, Coffey CS, RosemanJ. The confounding of race andgeography: how much of the excessstroke mortality among AfricanAmericans is explained by geography?NED. 2004;23(3):118–122
41. Elster A, Jarosik J, VanGeest J, FlemingM. Racial and ethnic disparities inhealth care for adolescents:a systematic review of the literature.Arch Pediatr Adolesc Med. 2003;157(9):867–874
42. Broder-Fingert S, Shui A, Pulcini CD,Kurowski D, Perrin JM. Racial andethnic differences in subspecialtyservice use by children with autism.Pediatrics. 2013;132(1):94–100
43. Mehta NK, Lee H, Ylitalo KR. Child healthin the United States: recent trends inracial/ethnic disparities. Soc Sci Med.2013;95:6–15
44. Konrad TR, Slifkin RT, Stevens C, MillerJ. Using the American MedicalAssociation Physician Masterfile tomeasure physician supply in small
towns. J Rural Health. 2000;16(2):162–167
45. DesRoches CM, Barrett KA, Harvey BE,et al. The results are only as good asthe sample: assessing three nationalphysician sampling frames. J GenIntern Med. 2015;30(suppl 3):S595–S601
46. Mareck DG. Federal and stateinitiatives to recruit physicians torural areas. AMA J Ethics. 2011;13(5):304–309
47. Richardson LP, McCarty CA, Radovic A,Suleiman AB. Research in theintegration of behavioral health foradolescents and young adults inprimary care settings: a systematicreview. J Adolesc Health. 2017;60(3):261–269
48. Langley AK, Nadeem E, Kataoka SH,Stein BD, Jaycox LH. Evidence-basedmental health programs in schools:barriers and facilitators ofsuccessful implementation.School Ment Health. 2010;2(3):105–113
49. NNCPAP. National network of childpsychiatry access programs. 2019.Available at: https://nncpap.org/thenetwork.html. Accessed May 9,2019
50. Alicata DA, Cheng K. Project echo: childand adolescent mental health. J AmAcad Child Adolesc Psychiatry. 2018;57(10):S74–S75
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