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Want to fix Minnesota’s mental health worker shortage? Start with better pay

Mary Rosenthal
Mary Rosenthal

Minnesota faces a significant shortage of mental health workers, especially in rural regions of the state. The shortage of psychiatrists and psychologists in Greater Minnesota has been the stuff of head-shaking legend for some time now: months-long waits — maybe even as long as a year — for appointments; doctors based hundreds of miles from their patients; long-distance therapy done over Skype lines.

But Minnesota’s mental health work-force shortage isn’t limited to the top of the food chain. Employers say more workers are needed in other key positions, particularly licensed mental health and substance abuse social workers. As the number of Minnesotans seeking mental health care grows, there just aren’t enough qualified people to fill all the available jobs.

“In our surveys, we learned that filling mental health social work positions has been difficult,” said Mary Rosenthal, director of work-force development at HealthForce Minnesota, a collaboration Minnesota State Colleges and Universities institutions with industry partners. “Right now, on average throughout Minnesota it can it can take more than three months to fill a licensed independent clinical social work position.”

Why is it so hard to find social workers? The reasons vary, but many who follow state employment trends believe that it has to do with several key factors, including lower pay for the industry’s highly educated workers, uneven insurance reimbursement rates, and societal perceptions about whether mental illness is a valid medical condition like heart disease or cancer.

Some of these problems are easier to fix than others, but something has to be done: Of Minnesota’s 87 counties, all but 13 have been designated by the federal Health Resources and Services Administration (HRSA) as mental health professional shortage areas

I’ll take a closer look at each of these issues in the coming months, but this week, I’ll begin by focusing on the pay gap.

It’s all about the numbers

Teri Fritsma is a numbers person. In 2015, as a senior work-force analyst at the Minnesota Department of Health, she was a member of a HealthForce Minnesota mental health work-force steering committee that focused on state mental health work-force shortages.

As the group discussed the anemic numbers of available health and substance abuse social workers, Fritsma wondered why Minnesota seemed to have more patients than providers. A survey of available jobs data pointed to a problem: Fritsma saw what she considered to be a social work pay gap.

“It’s a well-known, taken-for-granted fact that mental health workers are fairly low paid,” she said. “Maybe people aren’t going into these professions as much as they should because they don’t pay as well as other jobs that require similar levels of education.”

Department of Employment and Economic Development (DEED) Job Vacancy Survey data for the second quarter of 2015 [xlsx] support Fritsma’s pay-gap theory. The median hourly wage offer for licensed social workers, the majority of whom hold four-year postsecondary degrees, is $22.13 in the seven-county metro area. By comparison, the median hourly wage offer for registered nurses, who also usually hold four-year post-secondary degrees, was $28.59 in the metro area. In Greater Minnesota, pay was lower overall, but the gap was lower, too: $21.67 median hourly wage for licensed social workers and $26.58 for RNs. 

Teri Fritsma
Teri Fritsma

Fritsma knows these aren’t exactly starvation wages, but, she posited, the $13,436.80 annual difference in full-time pay between a Twin Cities RN and a social worker may be enough to turn a potential social work student into a nursing student.

“Young people are practical,” she said. “They should be. All else equal, they want the jobs that pay more.” If a young career explorer is considering healthcare jobs, he or she might discount lower-paying options in the industry that require the same level of preparation. 

While she acknowledges that not everyone will see Fritsma’s nurses-to-social-workers pay comparison as apples-to-apples, Rosenthal does believe that most mental health and substance abuse social workers are underpaid, considering the education level required to do their job and the key role they play in many healthcare teams. 

“I remember talking with a licensed independent clinical social worker in Grand Rapids,” she said. “She had four years of undergraduate work, three years of master's degree work and 2,000 hours of supervisory experience. She told me she was making $38,000 a year after seven years of education. At that salary, she was having a hard time paying back her student loans. And that was not uncommon.” 

Why lower pay?

Mental and chemical health social workers’ lower pay rate may have to do with the way society values their work — and the power of the people they serve, said Barbara Shank, dean and professor at the school of social work at St. Catherine University and the University of St. Thomas.   

“Social workers do the hard, important work in our society,” Shank said. “But who are our clientele? Social workers work with children, with the poorest, the most vulnerable people in our society. We work with people with chemical dependency issues, with mental health issues, with education and employment issues. These are the people nobody wants to talk about, the people who have no power in our society.” While most social workers are idealists who find great satisfaction in their jobs, she said, “When you work with the poorest of the poor, the sad fact is you don’t always get the recognition — or the pay — that you deserve.” 

Fritsma sees merit in Shank’s argument. 

Barbara Shank
Barbara Shank

“I’ve given this some thought,” she said. “If I were an HR person, I might have a different answer, but as a sociologist, I’d say that I think this difference in pay has to do with our society’s slowness in recognizing the relationship between mental health and health overall and our slowness in fully integrating mental health professionals into the health care team.” If, like nurses, mental health social workers were considered central to helping a sick person become well, they might be paid more, she said.  

This stigma extends to other mental health workers, including psychologists and psychiatrists, Rosenthal said.

“There are a lot of reasons for lower pay for mental health professions, but I do think one of the reasons is the bias and prejudice that is still attached to mental health. Psychiatrists are not considered to be ‘real’ doctors in the same way that surgeons are considered to be real doctors. And they are paid less.”

In some professions, union representation can equal higher pay and greater benefits. In Minnesota, for instance, 80 percent of bedside nurses are union members, said Matt Keller, regulatory and policy nursing specialist at the Minnesota Nurses Association.  “Anytime you have a union,” Keller said, “the union is going to fight for higher wages for union and nonunion jobs.”

Only a small percentage of social workers, mainly those working in state or county jobs, have union representation. 

Nurses have done a great job representing their profession as an essential element of the health-care team, Shank said. Widespread union representation among hospital-based nurses has also helped to boost wages and benefits within the profession.  

Social workers “have not gotten organized like the nurses,” she said. “Nurses did a masterful job organizing themselves and making sure that everybody knew how essential they were. We haven’t done that. Not yet.”  

Change on horizon?

Both Fritsma and Rosenthal see reason for hope in recent legislative efforts to improve Minnesota’s mental health system and services. The 2015 legislative session was a stellar year for mental health advocates, with $46 million in new funding directed at supporting mental health initiatives in the state.  

Some of that funding will address work-force shortages in mental health fields. Specific initiatives were designed to counter pay inequities, and others were created to make mental health care more accessible to people in Greater Minnesota. 

“All mental health professionals were added to the Minnesota Loan Forgiveness Program,” Rosenthal said. “The amount of money available was bumped up to $5 million over the biennium. An extra $2 million was given to the Medical Education and Research Costs Grant program to help defray the cost for internships and clinical experiences. And they set aside  $773,000 for telehealth, which would include the expansion of telepsychiatry in rural areas.”

Lawmakers, who supported these initiatives on a bipartisan basis, also wanted to develop programs that would encourage a wider range of people to consider mental health careers. Young people, especially young people of color, don’t always think of mental health care as a valid career choice, Rosenthal said.

“We are trying to build a pipeline as far as younger people getting interested in mental health careers,” Rosenthal said. “We are working on building a diverse group of mental health professionals who will go and talk to students at high schools.”

Another initiative aimed at introducing young people to careers in mental health is HealthForce Minnesota-sponsored Scrubs Camps, summer “career camps” that introduce kids to healthcare careers. 

“We work with MmSCU schools around the sate to put together camps for middle school to high school students,” Rosenthal said. “They are 2-5 day experiences in which the campers are exposed to a variety of different healthcare careers. Mental health careers were included in these camps two years ago. We looking at adding another six mental health career camps next year.”

Fritsma thinks that public support like this year’s legislative initiatives goes a long way in changing attitudes about mental health and the jobs that support it. It’s a horse-and-cart situation: If one starts pulling forward, the other follows along behind.

“Wages just don’t change overnight,” Fritsma said. “They get stuck because of people’s expectations and what’s historically been offered. I have to believe that as we grow in our understanding of mental health issues and as people grow in their understanding of the relationship between mental health and physical health, those types of services will be valued more and more. That will kick in higher value, greater demand and, eventually, higher wages.”  

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Comments (3)

Good article!

MN needs to increase reimbursements for mental health professionals or there will continue to be a shortage of mental health services for the poor. Mental health professionals will be forced into private practice where insurance reimbursement is 2-4X higher than MN reimbursement. It is really hard to support a family in MN on $40,000/year...

A couple clarifications

This was a very interesting article. However, a couple clarifications: First, Minnesota law and policy is a licensing, training and workforce induction mess. State law refers to "Qualified Mental Health Professionals" (QMHP) and has five types: abbreviated they are psychiatrists, nurses, clinical social workers, psychologists (marriage and family) therapists and professional counselors. I am not sure what the reporter means by "the food chain." I think everyone recognizes that psychiatrists have much more need for rigorous training and therefore higher pay rates. The other four are in my opinion roughly equivalent (howls of protests here from LP's and nurses.) The licensing of these five have been outsourced by the state to the licensing board of each of the five. State policy is completely fragmented by revolving around this five way split. Proper supervision and training must follow the archaic musings of these five boards as to what a QMHP is in Minnesota-it's a damn mess at the provider level, the five boards do not play well in the sandbox together and are resistive to change. Btw if you happen to go to the University of Minnesota, you get a year long training penalty because they have no approved undergraduate social work program.

Second, I hope readers will recognize that lower wages are the result of low reimbursement rates by health plans and DHS. A typical 50 minute therapy session is paid about $80 while a 15 minute doctors appointment is about $250; both after discounts. That's about a 10 fold discrepancy. Neither the doctor nor the therapist sees that much as there is overhead which must be paid for. In addition, clients who go to a therapist usually go for a series of sessions-6-12 and often longer due to chronicity. They need to pay a co-pay each time while a doctor visit is often a one time event. Changing the co-pay to cover 6-12 sessions and increasing the basic rates are two basic ways to improve wages in the one case and increase access and affordability in the other. Both are costly but believe me the other ways more money has been put in the system have had a less direct effect. Ex: outsourcing the financing of mental health to PMAP's was an implementation disaster. It took them 5-6 years to stumble around in designing their systems to even pay correctly (just this summer finally. ) This resulted in providers not being paid and so that $80 dollars an hour was often less.

Third, county human services workers are exempt from licensing and so are not social workers. calling them so is a 1950's relic. Now if you pass a test you can work for the county (and join the union.) Licensing county "social workers" would require them to follow an ethical code and doing so would probably go along way towards cleaning up the child protection system. Now they are just government workers following orders from above.

Final correction is that I hope no mental health professional is using basic Skype because doing so is a violation of HIPAA. Skype is not a secure protected environment for handling electronic health information.

Interesting article and

Interesting article and interesting comments. Not only is there a shortage of mental health providers in "greater Minnesota" but also in the metro area- more providers are concentrated in the metro area but demand is also much higher due to the concentration of population here. Finding services can be difficult.

I would have to disagree with Chris on a few minor points. First, all new psychologists in Minnesota have to have a doctorate which moves them somewhere between psychiatrists and many of the other providers he mentions in terms of the rigor of training. A main difference with psychiatrists (and all medical doctors) is that they have done four or five years of residency after completing their MD; psychologists have had two years of post-doctoral real world training before being eligible for licensure There are some psychologists with Master's degrees in Minnesota, who have been licensed for a while now and are grandfathered in, but new psychologists have been required to have doctorates for years now. Nurses mostly have BSN degrees and certification (RN,Cs and CNSes), some have Master's degrees- for nurse practitioners- and a few have doctorates who are NPs; the latter category is growing and will eventually be the standard for NPs just like it is for psychologists. Otherwise clinical social workers usually have an MSW and some have DSWs; marriage and family therapists and licensed professional counselors usually have Master's degrees. All of these licensees have been required to have at least two years of post-degree training or have had extensive hands-on training during their education. All mental health providers have a lot of education and training, as all health care providers should have. And they all are required to meet standards for ongoing training to be current.

Chris is correct on the reimbursement issue. Like all service providers, mental health providers basically get to keep what's left over from paying their business expenses (office rent, electronic health record system, telephones, computer and internet costs, malpractice insurance, liability insurance, licensing, continuing education, accounting and billing, wages and benefits for office and support staff, the cost of unpaid bills, etc.). A large clinic can spend millions of dollars a year just to be in business, whether they get paid or not. Patients usually have no idea whatsoever about those costs (and why should they? It's not the patients' problem). The reimbursement for psychotherapy by Medical Assistance is often less than the cost of doing business so the provider loses money on those clients; the reimbursement for psychiatry likewise tends to be below the cost of providing the service. Medicare pays a bit better. Insurance company reimbursement rates are all over the map- some are really bad and some are pretty good- and set those fees by fiat; the provider's option is to accept what the insurance company pays or to not be a provider, which means losing business. As far as PMAP (Pre-Paid Medical Assistance Plans, in which Medicaid pays the insurance premium and the insurance company pays the bills) is concerned, that program has been around more than 20 years; some insurance companies handled it very competently, some did not.

All health care providers have to write off 25-50% of their billings because of the discounts levied by insurance companies- and despite those discounts, insurance companies often lose money when their payments are balanced against the premiums paid by the customers- just look at the recent coverage of the rate changes for insurance companies reported just a few days ago. And of course a percentage of services are just never paid for. Something that also is often not taken into consideration: the clinician is paid, say, $80 for a one hour service. There is about another hour of unreimbursed labor involved with that either by the clinician or someone else (record keeping, billing, etc.) so the fee is effectively $40 an hour. This is also true of almost all other health care providers, by the way.

Compared to other health care costs, mental health costs per service are low. I have been a patient myself this year and my surgeon's fees amounted to about $400 an hour for office visits and $750 an hour for surgery (he did the surgery very successfully, did not leave me with complications and certainly saved my life in the long run. What's that worth to me?). $80 an hour seems high, but a while back I had a plumber out to my house and his effective labor rate was almost $500 an hour. A 10 minute oil change has a labor rate of about $80 an hour.

Mental health problems are at least as prevalent as many other health problems. For example, while 21,000,000 Americans have diabetes (up from 5.6 million 35 years ago!), 30,000,000 Americans have an anxiety disorder. 79,000,000 Americans are obese. 42,000,000 Americans are smokers. 75,000,000 Americans abused alcohol in the past year. 20,000,000 Americans had a major depressive episode in the past year. 12,000,000 Americans have bipolar disorder. 5,000,000 Americans have Alzheimer's disease and this is expected to at least double by 2050 (47% of people have some form of dementia by age 85). There are about 3,000,000 schizophrenics in the US. The direct out-of-pocket costs and the indirect loss-of-earning-power costs of mental illnesses are enormous, costing America an estimated $42 billion a year (which I suspect is a gross underestimate).

Mental illness can be just as- or more- disabling and deadly as physical illnesses. People with these illnesses deserve access to effective treatment. In order to make that happen, the mental health professions need to be paid adequately to attract well qualified, highly motivated people to become providers (and not so highly paid as to attract scoundrels! :-D ). The problems of access are even more pronounced in greater Minnesota where in addition to scarcity there is often a very long drive to get to the provider from home. Our dysfunctional health care finance system only makes matters worse.