 Dr. Sunita Muta directs the Health Force Center, is a professor of medicine and a primary care physician at the University of California San Francisco. She leads Health Force's efforts to generate knowledge about the healthcare workforce that assists providers, policymakers, and funders in addressing critical healthcare challenges. She's nearly two decades of experience as a workforce and cultural competence trainer and in creating leadership programs for emerging to executive level health professionals. And she's a friend of mine. So welcome to the stage, Sunita. Thank you. Good morning. It's really my great pleasure to be here. And it always makes it easier and more fun to work with friends, including new friends. So let me take a moment for those of you that may not have heard of Health Force Center at the University of California. We are 26 years old. We are based on a health sciences campus at the University of California. And workforce is a huge part of what we do. It's really our origin story. We started out very much interested in the professional workforce in healthcare. And over time, going back almost 15 years now, we've been looking really expansively as new emerging workforce occurs. There's new patterns and trends of who we consider part of the team in healthcare, deliver care. And so it's a really important part of that. And so it's my pleasure to be able to share a little bit of that work and then the larger context. We do also do research, sorry, leadership training programs, because we realize that as we brought new knowledge, we needed to figure out a way to try to empower and skill leaders who are really helping to navigate change. And I think we'll touch on some of those themes during the day. I want to acknowledge a couple of my colleagues who do a lot of our health workforce research, and you'll see their names here. They share between them probably over 40 years of experience, both in methodology in terms of how to think about projections and our future trends, to really looking at very specific workforce, and I'll be able to share some of that research with you this morning. So I want to pause for a moment. When we start programs like this and we think about the day and we're going to talk about policy solutions and public solutions, we want to talk and ground it in what we're thinking about. So I want to for a moment have you just stop and reflect that we're not just talking about trends at a meta level. That probably each of you has a story of somebody who touches your life that you care about who's been affected by mental health issues. I won't share my story, but you have one too, and I wanted to just remind us to perhaps keep that person in mind as we think today about the policy solutions we're talking about, the issues we're talking about, the problems we face, and that there are some really practical things occurring in the delivery side that are intended to help that. So I invite you to just take a moment and think and keep that person in your mind during the course of this morning. I can get wonky about workforce. I think it's the foundation of everything, but actually I think it is really critical. And this is one way that I want to frame some of my comments this morning. So the workforce is really that base foundation that it determines so much of what happens. Even when we have access, we can't address the issues of access without addressing issues of workforce. And that ultimately all of this is intended to get to issues around quality because that's what we are trying to do with all of this, is to improve the quality of care and of the experience that people have. So it is quite foundational. So what I want to do is I want to work down this triangle that I've created very quickly so to get to workforce issues, but I want to frame them. We know that when the quality of care for behavioral health is not addressed, there are consequences. And this image provides a really nice visual of thinking about really through the course of life from conception to death that there are events that can happen for individuals that affect their social and emotional cognitive health, that affect what happens in terms of the behaviors they adopt and health risks, which affects physical conditions and ultimately can shorten life. So quality does matter and there are many ways to do this and there are gaps in some of the knowledge base that we have around these issues as well. We know that there's issues of inadequate access. Don mentioned that less than half the people get access to the mental health that they need. And we are going to use, I think, some two words interchangeably this morning and through the course of the day and that is mental health and behavioral health. And I want to just call out that when we're talking, and I'm using the words behavioral health, I'm talking expansively, mental health issues and then also substance use disorders, which we'll touch on I know during our conversations. For many of you that may be familiar, but I think it's also a good reminder of we use them interchangeably, they're not entirely interchangeable. We know that we know of the large proportions of people who actually are affected by mental health issues, including addiction. We know what percentage don't receive treatment and these are all from national population based studies. We also know and we've known for a while and it's gotten worse that behavioral health shortages are probably the most significant in our rural areas in the country. And I'll show you a couple of quick maps to look at that. So access matters and place matters as it does for so many conditions in health. Going back a few years and in some states it started even earlier, but in 2008 we started first by doing the parody acts to try to increase access to mental health services. And this image just to say we really started to say, you know what mental health is as important as physical health. So we're going to expand the way people have access to that on the insurance side. And then it expanded again with the Affordable Care Act when we looked at what coverage looks like for people, including for preventive services and screening. I added in this because I think and references are on the bottom of these slides that you can see, but happy to share any information with you. The Affordable Care Act also broadened Medicaid coverage for looking at and addressing this other issue that is growing and that we hear about nearly every day and that is the opioid epidemic. So if we look at some of the data we know what the Medicaid covers a significant proportion of adults who have opioid addiction nearly four in 10. We look at the states where the average opioid overdose death rates that have been affected. And we look at what happens in states where there's been expansion of Medicaid and in states there hasn't been. And that's actually had some workforce implications expansion and I'll share a slide with that. And we know that over half of states that have increased enrollees access to naloxone, which is a medication that's used to address an opioid overdose and can actually and is life saving. So expanded access through coverage has really been an important piece. It's also one of the things that's aggravated or exacerbated our workforce issues significantly. We started out with a shortage and now it's much, much more present. I want to talk then really about workforce and in order to talk about this and that's really the crux of today is talking about what we know about the workforce currently and one caveat and you'll hear this for many people I think is we have imperfect data is one of our biggest needs and there is effort to try to get better data but you have to have good data to be able to make informed decisions certainly when it comes to policy and delivery systems change. So I want to call that out. So here is who is in the behavioral health workforce. We are not just talking about psychiatrists or psychologists it's quite a long and robust list. You can see licensed professionals in one side and kudos to our colleagues at the University of Michigan who are doing a lot of this work in the behavioral health workforce including the data issues to try to get us to really advance. There are also certified professionals. These are individuals who are not licensed but can have certification and you can see that list including case from addiction counselors and peer providers that we'll hear about to case managers. I put in the bottom there primary care clinicians and this is I am a primary care clinician and I've heard the data for a long time one and three of patients who are going to come in to see you will have mental health issues. I think it's much more these days and so that reminder that really thinking about how to expand the ability to provide access by looking to engage expand the skills that primary care clinicians matters and embedding and we'll talk about some of the delivery system solutions including embedding and training. So this is who we're talking about in the workforce so what are we actually talking about what is the problem. This is data now most of the data we have is as probably the most recent data is from 2015 2016 those are the the data and I don't think there's any reason to think that there's been a substantial change yet in this. We know that if we look at psychiatrists so why do we look at psychiatrists we have data that we can look at that allows us to track who the different licensed professionals are. This is some of the best data that we have and then we can use that data with geomapping to figure out where the distribution is of individuals so we know that there's an uneven distribution of psychiatrists across the U.S. and they are lacking in rural areas and so let me orient you to this map. The areas that are darker green is where the ratio of psychiatrists is higher but look at all of the rest of that map and if you looked more closely at the map if you're closer to the front of the room you would see that there's gray shaded areas those are some of the urban areas but there are vast parts of our country where access is really limited and it is in some states it's in one corner of the state that you might be able to find access. So the fact that we need to think really expansively about the workforce to figure out our solutions is there's our evidence that we are not going to solve the problem by addressing one particular group and trying to expand or streamline or accelerate even our pace of training. Well what else can we say? We know that most of mental health services get provided in office settings. This data looks at this is data from 2017 publication it looks at office based mental health specialists. So again the map of the country and what you want to just take a look at where that distribution is and so keep this image in mind for a second. So these are non-physicians who are providing services in office based settings mostly psychologists but also social workers and others and here's what happens when you look at the same regions and you look at office based mental health specialists provided by psychiatrists. I'm not adding on all the other layers that we know that matter that it isn't just about distribution and workforce and access to that workforce but you might actually have a psychiatrist in a region or a clinical psychologist or a licensed marriage family therapist and they may not take insurance and so access is affected yet again. But this at least tells us where the people are where the potential opportunities are for providing services. And then let's just pause for a moment. I showed you earlier the map about the paucity of psychiatrists in rural areas. I want to just bring that message home in a different way. More than 60 percent of us live in health professions shortage areas. These are the rural areas we're talking about. Less than 10 percent of psychologists, psychiatrists and 20 percent of MSWs work in these areas. So large amounts of population, very few workforce members to provide that. 65 percent of people in these areas get their mental health from a primary care provider. And we're now mostly I've been touching on things like when there are not crises, when there is mental health, there's chronic conditions, they need continuity, they need services, they need access to medications perhaps and therapy. But when a crisis occurs in these rural areas, the crisis responder is often a law enforcement officer. And so it just speaks to how thin our systems are in these areas to be able to provide services and particularly in times of crisis. I wanted I wanted to share some data. I've been looking out gosh you know what happened since we've talked about expansion. We've said that access has actually gotten exacerbated a little bit because the shortages that already existed. So this is data that says one of the few items of data that we have pieces of data that we have that looks at what has happened in states where there has been Medicaid expansion to the workforce. And this data looks at so on the top you have the first two lines are states in which there has been expansion Medicaid expansion the bottom two are so I'm sorry no I'm misreading this. So the very top line there is a state with expansion and looking at the clinical psychologist workforce. And you see maybe a slight increase but really pretty flat because that scale is is quite expanded to make it look like you can see the difference. In non expansion states the number has actually decreased a slight bit. The bottom two lines are looking at what's happened to a population of psychiatrists in those same states where there has been expansion of Medicaid. And you'll see a little bit of an uptick but not much change in terms of what's happened in non expansion states. So perhaps maybe because this is pretty early still we don't have that much data. There has been some improvement and some worsening on the whole expansion states haven't really affected or shown much impact for our workforce. Again our data are limited. What we don't we don't know and we can guess that I'll show you another slide is what's happened with that rest of the workforce that workforce that is not licensed but is certified. So let's talk about I want to take the the story of California a little further as an example of the kind of data that we can use and what happens and how we can think about it. So these are maps from a study done this February by my colleague Janet Kaufman and Joanne Spetz. And we wanted to look in the state of California what does the distribution look like of mental health workforce. And so you'll see our different counties you'll see colorations that basically the darker the coloring the more likely it the greater the ratio of specific behavioral health professions. So on your top left are psychiatrists top middle is psychologists top right is marriage and family therapists down below you can see it's licensed professional clinical counselors licensed clinical social workers and then the bottom right most is psychiatric technicians. So take a moment and just look to see what's same on every single map pretty much. And that is in our most densely populated urban cities the densities greater of the workforce. Not terribly surprising because actually if I showed you the data for primary care workforce for specialty care workforce it would look very similar people tend to congregate in urban areas. What is interesting though is I want to call out this one section here. I'm going to follow the story of that particular region so take a look at that for psychiatrists psychologists. And then you can see there there's a big drop-off in marriage and family therapists there's really not as many there you follow it down below and again not as many clinical counselors clinical social workers and then an uptake when it comes to psychiatric technicians. So these are different professions and this is an interesting story because that region is the inland empire it is part of a larger region that has doesn't have great workforce distribution but you can what this map I think tells is an interesting story of how you can use various parts of our workforce to try to meet needs. You don't need to meet the need with a single member of the workforce or single type of profession so you may have and they have worked really hard in the inland empire to try to increase the number of psychiatrists and psychologists and many different initiatives from recruitment efforts to tying people into embedded settings and providing professional supports but they haven't they clearly had made decisions in the geographic area that we're not going to do it evenly and every member of that workforce needs to be there. We're going to rely more heavily on the psychiatric technicians to be a big part of the member team and then a little bit of everything else it's partly what you have access to depending on where you are and what the workforce looks like but it's also trying to be intentional in what is the whole solution not a single profession solution to try to address the shortages and I'll talk a little bit later about some of the interesting ways that they have tried to reconfigure and create delivery solutions to address and to work with the workforce shortages that they have currently. The last thing I want to say on this particular slide is I said earlier we have a data issue and so this this piece of work acts to these data from six different sources with a lot of effort and and you might look at the standard like well why do we not have nurse practitioner data because we know we have mental health nurse practitioners well it's really hard to get some of that data and that is part of what my colleagues have been working on and what the University of Michigan I think is doing a great job is trying to make sure that we have standardized ways of both collecting identifying and tracking it but the data are for those of you that are kind of geeky about data and or wonky about this kind of stuff I can tell you as soon as we start to skim the surface of it it gets harder and harder to say some things because we are imputing data we're using Bureau of Labor Statistics categories we're using all kinds of other ways to try to guess at the best guess that we can make an informed guess about distribution okay so a lot of current states saying we have shortages it's not going to get much better and this is what almost all of the studies that have looked at projections including our own based on the February publication that I shared with you there are mostly projected shortages this one says projected shortages and and surpluses and so if you look down about the row you'll see starting with psychiatrists at the top and working your way down on this particular list to marriage and family therapists it looks at what the supply looks like and it looks like what the demand looks like and we're expecting to have the shortages and those are in that right hand column and the easy way to scan this is anything in red is a shortage and you can see the scale of shortages that we expect to see this in part reflects an aging population and other trends that we can look at and most of the time shortages and projections have this tension between demand and supply and what does the flow look like and what can you predictably say about who's going to stay in the workforce who's going to move into geographic regions and what's going to happen in terms of needs over time I wanted to point this out because this looks at Medicaid peer providers I know we'll talk a little bit about that today we have very little data for the reasons that I've mentioned this is data looking at states that provide Medicaid support and payment for peer providers using Medicaid resources and it is way more than I actually thought so I don't know if that surprises you but it certainly surprised me to look at what the distribution is 31 of our 50 states actually provide payment for peer provider services okay I always feel like workforce conversations are a bit of doom and gloom they're sort of inherently you know and I've been doing this for 20 years and yes it's always ends with and there is a shortage and we have to do something about it so what I want to invite us to think about is really thinking about a paradigm shift yes there's a shortage and the way I presented this is I said workforce was foundational and then it was about improving access and it was ultimately about quality and what is it that patients are getting and receiving and are we getting and delivering what we hope we're getting in reality almost all of our decision-making and solutions is the flip this is the workforce we have what can we deliver I intentionally flipped that triangle because I think that is part of the issue that we have to figure out probably the biggest one and we know it and it's so I'm not going to give you a word of wisdom that says here's the way to rethink it though I think there are some really practical ways the way to rethink is to remember that what is at the center of all of this is what does the patient need and want they don't always want to come into an office setting to get what they need increasingly and generationally we have populations that can actually do self-management we have some evidence base on what can be done as self-management through apps so in terms of managing anxiety some cognitive behavioral therapy that can be done and while those are not perfect solutions and we'd like to believe that they are tied into healthcare systems should there be a crisis an emergency a change those are some of the changes that we have to make is and and the one that will come up no doubt today because it comes up in every workforce conversation is how can we best use everyone in our workforce how do we keep how can we expand the skills how can we think about training and how can we think about ensuring that everyone sitting at the table is able to contribute fully to the care of our patients and I think that that is a really really important piece of it we need better data we need to really I think think about balancing this tension between demand and supply that tension is not going to go away until we have some advances that occur in the way that our delivery system changes and we and certainly we need to think about pipelines that don't leak it's one thing to have a pipeline but from all of our research in looking at medical education dental education and every other profession we know those pipelines leak they leak for the most vulnerable the most diverse members of the pipeline those who come from lower socioeconomic settings those who are underrepresented minorities and so really thinking about ways to solve those issues there there are public policy solutions and and we've certainly written about many of them and many of you know quite a bit about them I think we also have to acknowledge that in our paradigm we are so us-centric in our solutions there are many examples of solutions internationally that have been used well and widely everything from criminal justice systems reforms which mental health touches on to really thinking about the labor workforce that is being used and so there are differing needs and probably the biggest paradigm shift to me so there's two things that are really I would put on this list one it is not driven by the workforce we have it has to be driven by the needs of the patients and second it is really rethinking whether everyone needs the same care they don't not everyone needs wants to have a uniform set of services that are always available for when there is mental health and substance use disorder issues so I want to talk up for a moment about some examples of what's happened so in search for solutions and we'll end on that note later on today but I want to share a couple of quick examples of things that are happening that I'm aware of there are many more that I think we'll hear about today and they are taking pieces of the systems we already have the Rubik cube pieces if you will and reassembling them not assuming that's what that is it's a Rubik cube pieces yeah it is you gotta you have to we have to take the whole thing apart and figure out now does that mean dismantle everything absolutely not I am an evidence-based academic who really believes in incremental change for some things and then blowing some things up because that's the only way the innovation is going to happen lucky for us that innovation is happening in areas simply by the fact that there is sheer need and it has to happen it's some interesting examples so I'll go back to these example of inland empire one of the things that they have done in that area there is a Medicaid plan that has a population of a million members which is large for that region and set a pretty expansive region and one of the things that they decided to do is you know we know there's mental health issues we know we don't have enough providers how can we ensure we start to do the prevention things that we wanted to do so depression screening got integrated into the time enrollment happened and who did it administrative staff and they trained them and they use MSW for but it really allowed them to say who are high need members who need an immediate touch and we can track them into the right set of services we have limited services because we have limited people to deliver those services who are sort of who need no touch at all they're fine who needs a light touch and who needs a much more intensive touch and needs to be connected to services more quickly so there are examples like that that I think are system solutions there's also the example at UC Davis which some of you may be familiar with which is a one-year training program that is really designed to take people who are either in training or already in practice often primary care and in one intensive year often through distance education train them to be able to diagnose effectively and manage and treat the most common mental health conditions that show up so you're quickly expanding the workforce not by bringing new members into it by re-skilling and training people who are already in it and that has really expanded and it's and it's designed as a train the trainer model so it's not limited to the benefit to the person who shows up and is at that training but that it has a the ability to spread and scale the other ones there are many policy solutions I think that will get touched on around public policy solutions there is telehealth that's going on I talked about the fact that there is digital health ones we don't we won't touch on all of these but I wanted to end on that note of saying yes there are longer term things that we need to work on and these are actually these are many of our issues are not new issues they are getting the attention they have always deserved so that's great and we're having these conversations but there are delivery system solutions that are happening and I think a big part of the work that my colleagues do really well is not just lay out the data and the quantitative and show us the maps and think about areas we want to focus but it's to actually tell the story it's to do the site visits that say where are the states in this country where peer providers are really being used in new effective ways how are we paying for them how are we integrating them into care what's the data that we can use how are we billing for them everything from pragmatic to the design of the way the structures of our delivery system is so I I am going to end on that hopeful note and I'll open it up to back to Susie okay great thank you so we are going to be taking some questions so please feel free there's microphones in the room there's one right up here so if you have questions please go ahead and feel free to line up but I'll go ahead and get started so you mentioned the the leaky pipeline and issues of having underrepresented groups sort of falling off are you have you seen some innovative practices that are able to retain some of those folks and keep them in the pipeline wow yes and and it's not an easy answer so yes in that there are so you know when I talk about leaky pipeline I it's really just saying that we can often get people the right education or background or preparation level of training and we can put them into our systems to say we're training them towards a licensed profession or a certification process but we will often lose people along the way and the people the groups that I said so the kinds of things that are being done really big easy ones addressing the issue of educational debt huge issue some of it done in a really targeted way to try to make sure that it does not become the barrier to somebody being able to stay in there are now many more expansive frameworks that say it's not enough to get them in and it's not enough to just address money money's important but you have to in fact put a set of social supports around those individuals and so it's tailored apprenticeship programs mentoring programs like linking them to others the importance of role models so there are examples of those and there are many many examples of those great thank you question so I'm Ron Manderscheid I want to do a shout out for Kaiser Permanente of Southern California and the work they've done on depression and anxiety and what I'm going to call measurement based care where there are assessments done in advance but the assessments continue over time and the care is triggered by where the assessment is moving up one of the people who innovated in that was one of my students at USC Gona as a guy and just a shout out to KP for doing that's wonderful work my comment is in terms of Medicaid coverage for peer support the numbers are actually higher than you're showing here so on the mental health side it's about 43 now on the sub the problem is on the substance use side where it's only 13 so part of our agenda here it should be 50 on both sides and there's a political agenda here of moving that ahead with CMS and making that happen great thank you um and you know and I think uh so you raise one point that I'll just I'll comment on and that is I think that systems like Kaiser we take those some of that for granted in a setting like this right we talk about the fact that there are reinforcing structures that are in place that many of these other systems just don't have it's so much more piecemeal and safety net and as somebody who gets my care at Kaiser I'm thankful for those great so um you know the the pipeline and the workforce challenges are not new so a question what are your thoughts around why we have not made more progress to date in these issues I think that we all have a lot of thought bubbles probably at the moment I think it's for a couple of reasons um I think there's not one reason that we haven't made progress I think that um there are so many vested interests in all of these that that is part of the issue that whether it's um around who is responsible for the decision who uh how do you engage multiple stoker stakeholders at one time um as a colleague of mine once said there's no grown up in the room because we don't have a concerted workforce policy that is not by profession that's a big part of the reason um and then I think what happens is uh it's also the room for innovation and um and that and that is how I keep myself optimistic that while we can get a little doom and gloom about the fact that these trends have not improved significantly and they seem to worsen or our attention is drawn to them and they've always existed that it has um proved to be a really important breeding ground I think for new ways of delivering care and then starting to look at not just how do we improve access but there's some interesting work recently that was just published in health affairs that looked at if you can take a Medicaid population and you can do behavioral health integration with a very specific team structure in multiple different settings from a multi-specialty clinic to have behavioral health setting what can we say about use of emergency room services about cost of care which matters um and and what's the composition of the team and the resources and um and is it meeting the needs not only of a generic population but in this case they looked at two specific populations including a monolingual Spanish population and I think that's part of the other workforce issue need is is that our demographics are changing significantly thank you question thank you uh thank you Ceci and Sunita in fact that was a very question I was going to uh to address is around the diversity issues because you did talk about the fact that we are certainly in need of rural providers but there's other dimensions relative to equity you just touched upon in terms of linguistic ability but I was wondering if you could expand on the issues around diversity whether it's around gender whether it's around sexual orientation whether it's around nationality you name it yeah you know um I'll let me use an example to really bring it home in the Bay Area which is actually pretty well populated on that map if you are if you are looking for an adolescent child psychiatrist who's Spanish speaking you are down to an n of one that is I think an emblematic of the problem that we have when it comes to being able to meet the needs of patients whose preferred language is not English for their health care encounters and there is an added level of complexity that happens when it's mental health issues um so yes the issue is big we've I think there's evidence to detail some of it um but the need is really great and then there's a stigma component in many of our cultures uh where um we have a long ways to go to make some of those changes Nathaniel? Hi Nathaniel with Mental Health America um so at KP's last forum they focus a lot on trauma which of course touches on schools and like early care and education and the sort of like earlier half of adults who touch children's lives um and I was wondering sort of your thoughts about them as part of the mental health workforce too um because I imagine like your early care and education provider your teacher ends up probably having a larger life course effect size on children's mental health and development than most health care sectors and I was hoping maybe you could touch on that as well yeah you know um thank you for that question uh the I think the hard part here is so the the short answer is absolutely that I think one of our takeaways in this as we deconstruct that Rubik's Cube is thinking really expansively of mental health and behavioral health in our communities and who in our communities can actually contribute and is already contributing to that solution the challenge in talking about it gets back to data right because we all want to say well how big is the problem who are we talking about how many are there and we just don't have answers yet to being able to quantify that um to to help frame it which I think is necessary and helpful it's not the only thing we need but again the the creative work and the solutions that are happening are already happening with places are happening in school-based clinics both by necessity and by um a desire to innovate and to meet needs a little short uh good morning um I work on community health for kp and my question um pertains to you saying that there weren't a lot of physicians psychiatrists psychologists in their urban or rural areas um what I wanted to know is are there any information sessions or panels or forums to assist people with naming um certain behaviors because sometimes they have symptoms and and thoughts and behaviors and they don't exactly know that they need behavioral health um help so are there any systems in place that are going into their communities or their schools or the neighborhoods that they frequent to give them information so they could say have the aha moment like oh this is something I've been experiencing maybe I need to reach out and talk to someone yeah you know it's a great question it feels like uh it takes me back to my days of really focusing on cultural competence because what we know is that even the things that we consider diagnoses are are culturally constructed and so the kinds of symptoms that we talk about that we think are depression they work and we generally agree on them and they're widely known um but they actually don't work for all of our populations they don't think of their symptoms in the same way and and that's even true in our aging populations uh where they don't manifest in the same way so I don't know systems and maybe we'll hear about that on some of the panels today I do know that there is recognition of these issues um and that probably one of the best ways they get addressed is maybe the example that Don gave in the beginning is that we do these public education these community education efforts to try to raise awareness to at least just get the dialogue started yeah okay thank you thank you thank you so I think um if there's no other questions I'll go ahead and transition us to the next panel so thank you Sunita for your presentations and kicking us off on this