Minding Houston Episode IV: The Mental Health Workforce

With the 1115 Waiver making investments in behavioral health services throughout the state, and especially here in Greater Houston, it’s natural to ask the question about the professionals needed to staff these new programs. And we don’t just mean psychiatrists, but the full spectrum of mental healthcare positions, just like those masters degree clinicians from MHMRA riding along with police officers for our CIRT units. In this episode, we’ll look at the best data to describe the mental health workforce shortage that should catch everyone’s attention, especially our lawmakers.

This is Minding Houston, I’m Bill Kelly.

Before jumping into legislative solutions about how to attract more mental health professionals, it makes sense to ask the question, “do we really need them?” Or, to say it another way, what are the consequences of not having an adequate mental health workforce? A 2011 report by the Hogg Foundation for Mental Health entitled “Crisis Point: Mental Health Workforce Shortages in Texas” gives a clear answer on what we face:

The cost of mental illness does not simply disappear when service providers are not available. Instead, these costs transfer to other less effective, more expensive and unprepared environments, such as prisons and hospitals. Research and experience clearly show that the lack of sufficient mental health services often results in hospitalization, incarceration or homelessness, creating far greater economic and human costs.

Supporting a strong system of mental health services isn’t just for the benefit of people with mental illness. Mental health and wellness are important to all Texans. Without a strong mental health system, communities suffer through lost productivity, unemployment, job absenteeism, increased involvement with law enforcement, and increased local hospital costs.

Now, for anyone who cares about the bottom line in budgets, the quality of life for patients, and need for a healthy Texas, these consequences are simply unacceptable. Alright, so we know there is a problem, but how bad is it?

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The report sites the following:

  • Compared to California, New York, Illinois and Florida – the other four most populous states – Texas has the most severe short¬age of psychiatrists, social workers and psychologists
  • The pool of mental health professionals is aging. In the coming decade, many psychiatrists, social workers and other providers will leave the workforce for retirement.
  • These shortages are felt most acutely in rural and under served areas of Texas, such as the border region.

Code Red LogoUnfortunately, things haven’t improved since this report was released in 2011. One of the most respected health care groups in Texas just released a report this January that echoes many of the same concerns. In an interview with Houston Public Media, Code Red’s task force chair and former state demographer Steve Murdock discusses the situation with behavioral health:

Maggie Martin: Medicaid wasn’t the only issue or concern that was raised in this report and something maybe especially raised for Houston, being the home of the Texas Medical Center. What are some of the issues and concerns the task force found within the health care profession itself?

Steve Murdoc: Well, I think that’s one of the things that we found is of course In areas, particularly in behavioral health, we are very short in terms of personnel. We have a wonderful medical center and it does lots of things very well but when it comes to behavioral health we lag behind many other states. I gave you the earlier example of 49th in terms of psychiatry in the country and so certainly we have areas in our health care system where we need to provide more physicians. We have for years, for example, lacked enough residencies. Now the reason that is so important is that one of the best predictors of where a physician will end up practicing is where he or she does their residency and we actually export people to residencies in other states which means that they are likely or less likely to come back and practice in Texas. So a number of things about our program are such that indicate we can also do a better job of ensuring we can get as many of those excellent students that we produce from our medical schools to stay and practice in Texas …

The good news is the Legislature is paying attention. In fact, during the last legislative session in 2013, Republican Representative Cindy Burkett from North Texas, and Democratic Representative Carol Alvarado from Houston co-authored a bill calling for a study of the Texas Mental Health Workforce Shortage and possible solutions.

The final report was issued in the September of 2014, and as you would expect, it confirmed the very serious problems Texas will face without immediate investment. Out of the five themes discussed in the report, the first recommendation is the most important in addressing this problem. Quoting from the report:

At its core, the mental health workforce shortage is driven by factors that affect recruitment and retention of individual practioners. Chief among these factors, as studies and stakeholders suggest, is that the current payment system fails to provide adequate reimbursements for providers, especially in light of the extensive training necessary for practice.

Furthermore, more students may be attracted to the mental health professions by strengthening graduate medical education and by exposing them to opportunities in the mental health field earlier in their education.

Like a lot of public policy, it boils down to money. Our state has failed to invest in this area, and unless we start making a down payment for our mental health workforce, we will undoubtedly suffer the consequence that a lack of access brings.

That’s where Sen. Charles Shwertner comes in. The new Texas Senate Chair of Health and Human Services is tackling the issue of mental health workforce for the full spectrum of providers. The Texas Tribune’s Alana Rocha reports:

Bluebonnet officials say that a bill by health and human services committee chairman Charles Schwertner could elevate the prestige of the profession and help workers balance their desire to serve the mentally ill, make ends meet, and pay off their loans. Schwertner filed a bill Monday to create a grant program to repay loans for licensed professionals, social workers, psychiatrists and psychologists.

“Money spent on mental health is money that is effectively spent. It keeps people out of the emergency room, it keeps people out of the jails and also the school resources that are spent on individuals that need help. If you can catch someone early, get them the right treatment in the right setting that’s the way to handle mental health. It’s cost effective.”

“There’s a huge return on investment for this.”

Andrea Richardson knows first-hand as the executive director of Bluebonnet she worked with Senator Schwertner, himself a practicing physician on developing the bill that creates a commitment from professionals seeking loan reimbursement. The percentage of the loan repayment grows with each year they work in the field.

“It recognizes the value of mental health. It allows for mental health to become a part of the health care system. You know so often we disconnect the mind from the body when in reality it’s the mind and the body working together that keeps us healthy.”

An integrated approach to addressing a growing need.

So, how did this trained orthopedic surgeon suddenly becomes one of the leading advocates for mental health in the entire Texas Legislature? Well, as the Houston Chronicle Editorial Board writes in support of his bill, he might have just been listening to mother:

MASTHEAD-Houston-Chronicle

Each of our incoming legislators will bring varied life experiences to the next session and its upcoming debates over spending and priorities. That’s certainly true of state Sen. Charles Schwertner, R-Georgetown. Schwertner, one of the few doctors in the Legislature, is not only an experienced orthopedic surgeon but also has some familiarity with mental health care. Schwertner’s mother spent over 25 years as a nurse in Texas’ mental health system. The state senator has a habit of saying that he knows firsthand what impact a dedicated mental health professional can have on the life of someone suffering from mental illness.

After reviewing many of the same statistics cited in the previous studies, the Chronicle concludes:

The Legislature should make Schwertner’s mother proud and act to pass his bill, a good first step in heading off this growing crisis.

So we’ve heard from the Hogg Foundation for Mental Health, the medical experts at Code Red, a workforce shortage study of House Bill 1023, and the newly filed mental health loan repayment bills and we hope our Legislators listen to Senator Schwertner’s mom.

But what happens when we don’t listen? In this case, what happens when we fail to provide access for mental health services? Quite simply, we face the same health challenges but we face them in a criminal justice setting. More on that next time.

From Minding Houston, I’m Bill Kelly.


This weeks episode includes “Dirty Night,” “Settling In,” and “Slow Motion Strut” by composer Dexter Britain and “Ego Grinding” by Megatroid. Hear more of Dexter Britain’s music at DexterBritain.co.uk and Soundcloud and listen to “Ego Grinding” at FreeMusicArchive.com

View the 2011 Hogg Report here and read Code Red: The Critical Condition of Health in Texas for detailed information about the Texas mental health workforce shortage. Listen to the full Houston Matters interview with Code Red’s task force chair and former state demographer Steve Murdock and hear more about Charles Schwertner’s loan reimbursement bid at the Texas Tribune website. 

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Minding Houston Episode III: The 1115 Medicaid Waiver in Houston

What if I told you the State of Texas and the federal government are working together, on an $11.4 billion partnership to help increase access to care for Texans? There are no lawsuits, political posturing, or name calling. The program is praised by Republicans, Democrats, and every healthcare organization across the state. Sound impossible? Well, let me tell you: it’s all true. And when it comes to increasing behavioral health services, it’s even better.

This is Minding Houston, I’m Bill Kelly. 

Today, we wanted to talk about the biggest expansion of behavioral health services in Texas. Ever heard of the 1115 Waiver? Well, if not, maybe it’s because it hasn’t generated the, let’s call it the “heat” that other federal initiatives have here in Texas.

So first things first, what is the 1115 Waiver? Simply put, it is a 5 year agreement between the federal Center for Medicare & Medicaid Services, or CMS, and the Texas Health and Human Services Commission, or HHSC. Together, CMS and HHSC have negotiated a plan to combine state dollars spent on healthcare to draw down matching federal funds all in an effort to expand the footprint of healthcare services in Texas.

1115 Medicaid Waiver made easy

       1115 Medicaid Waiver made easy

So what does this really mean for us in Greater Houston? As it turns out, quite a lot. Over our nine county Regional Health Partnership (one of 20 organized throughout the state), we stand to gain over $2.3 billion dollars in expanded healthcare services.

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So, what do these programs look like? Well, let me introduce you to two programs funded
by the 1115 Waiver. First, in a report by Houston Public Media’s Carrie Feibel, is a look at Mental Health Crisis Clinics set up by Memorial Hermann.

Now, as we’ve noted before, the lack of access to mental healthcare leaves an increasing number of cases to be handled by law enforcement. That’s where our second example, the Crisis Intervention Response Team comes in. In this story by KHOU reporter Jeff McShan, you can see first hand the difference having both a mental health professional and law enforcement training has in dealing with a mental health crisis.

Both the Memorial Hermann mental health crisis clinics and three CIRT details are funded by the 1115 Waiver using Delivery System Reform Incentive Payments, or DSRIP funds. In our area, there are 55 projects specifically for Behavioral Health totaling $457 million dollars. Now, remember from last week, our state spends just over 1 billion a year in mental health services through DSHS for the entire state, and DSIRP dollars put almost half a billion right here in our own backyard.

This badly needed expansion of access for mental healthcare represents a huge step forward for the State of Texas. But it also brings a number of challenges. Like, do we have enough of a workforce to staff this expansion? What is the mental health workforce shortage and what we can do about it? More on that, next time.

This is Bill Kelly for Minding Houston, a presentation of Mental Health America of Greater Houston.


Music from this episode: “Rollin at 5 – 210” by Kevin MacLeod and “Sand Castle” by Pitx.

To hear Carrie Fiebel’s full report about the Humble Crisis Center, listen here at Houston Public MediaTo hear more about the HPD Crisis Intervention & Response Team (CIRT), watch here at KHOU.com.

Minding Houston Episode II: Mental Health Money

As the 84th Legislative Session begins, our lawmakers are only constitutionally required to do one thing: pass a budget. While likely to pass over 1,000 other pieces of legislation, the Legislature is legally bound to determine the funding for state services for the next biennium. And that bill, the Appropriations Bill, is where questions about the financing for mental health services are answered.

Before looking at this biennium, it is worth looking at were we started. Historically, Texas has not funded services on the level with other states. The best study of this was done by the Kaiser Family Foundation in comparing per capita spending on mental health services.

From an interview I gave with Houston Public Media’s Craig Cohen on an episode of “Houston Matters” in June of 2014,

“For the Fiscal Year 2010, Texas ranked 49th in terms of per capita spending on mental health with right at $39. Keep that 39 dollar figure in mind for comparison sake. Our neighbors to the east in Louisiana spend $62 per capita, and further down the road, Alabama spends $78. Mississippi, who we are often compared to for social services, spends $114. The national average is $120.”

Meadows

So with that historical under investment in mind, what does Texas spend on mental health now? To best show the answer, our friends at the Meadows Mental Health Policy Institute produce the following slide that breaks down the figures.

Meadows

The vast majority of state spending on mental health comes from the $1.16 billion spent yearly by the Department of State Health Services. Roughly $160 million a year is spent on substance abuse.

Getting your head around those big numbers helps to show just how successful the last legislative session was for funding. A chart from the House Appropriations Committee hearing this summer outlines the additional $312 million in increased spending within DSHS. A breakdown of these additional expenditures is listed on the attached chart.Click for larger photo

While badly needed, last session’s invest won’t solve the problem of serving Texans with mental health needs. Aside from continued investment from lawmakers, Texas needs to expand the footprint of services so more people can have access. Thanks to a partnership between Texas and the federal government, and yes you heard that right, we are doing just that. More on that next time.

This is Bill Kelly for Minding Houston, a presentation of Mental Health America of Greater Houston.


We would like to thank both Houston Matters and the Meadows Mental Health Policy Institute. To hear the rest of the interview, listen here at the Houston Matters website.

This episodes music included “Never Let it Go” by Bluesraiders, “Strange Sensations” by Anitek and “Plethora” by Anitek.