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Nearly 14,000 behavioral health care professionals are licensed in Oklahoma. These nurses, social workers, therapists, physicians, and other professionals deliver critical services in the treatment of, and recovery from, mental illness and substance use disorders. Whether in independent private practice or as part of a larger hospital system, nonprofit organization, or publicly funded treatment setting, providers are the foundation of Oklahoma’s behavioral health care system.
However, many Oklahomans face significant barriers to receiving behavioral health care. The geographic distribution of providers, type of health insurance, and limited numbers of specialists affect the accessibility of Oklahoma’s behavioral health workforce.
To better understand this accessibility, Healthy Minds Policy Initiative conducted a survey of Oklahoma’s licensed behavioral health care providers. The survey received 622 responses from providers across the state.
The survey finds that:
For more information about the survey methodology, click here.
In previously published research on the availability of Oklahoma's behavioral health workforce, Healthy Minds identified only two types of providers available in the state at a per-capita rate above the national average: licensed professional counselors (LPCs) and alcohol and drug counselors. There are shortages of every other kind of licensed behavioral health care provider compared to levels recommended by the federal Health Resources and Services Administration. Rural areas of the state are in particular need of more people in the mental health workforce.
Even if Oklahoma did have adequate availability of providers to meet its residents’ mental health needs, many other factors affect whether care is truly accessible. Health care consumers must first determine the type of services they need and which type of provider can best meet those needs. Each provider type has a specific set of skills and scope of practice, ranging from assessments and evaluations to therapy and medication management.
Although some consumers utilize a primary care provider or case manager in their search, others rely on the internet or referrals from friends and family. Insurance companies produce provider directories that are meant to help consumers find care, but these directories often have incorrect or missing information. Travel time and distance is another significant barrier, particularly for rural Oklahomans. Telehealth provides an alternative when traveling to the closest provider may not be feasible, though this requires the patient to have a reliable internet connection. Furthermore, providers might not accept new patients, only see patients within a specific age range, exclusively see patients with treatment needs that align with their specialty, or only accept certain types of insurance. These barriers are even higher for people with culturally and linguistically diverse needs.
Insurance Coverage Has a Significant Impact on Consumers' Choices
Roughly 44% of practicing survey respondents said they were in independent private practice compared to practicing in a community, inpatient, or nonprofit setting. For the purpose of this survey, community, inpatient, and nonprofit settings include Certified Community Behavioral Health Centers, correctional facilities, hospitals, inpatient psychiatric hospitals, inpatient substance use treatment centers, nonprofit organizations, primary care settings with integrated behavioral health services, K-12 schools, state hospitals, university or college counseling centers, Veterans Administration facilities, and Indian Health Services facilities.
Independent private practice providers are 2.3 times more likely to not accept new patients compared to all other types of providers and twice as likely to be considered in-network on commercial insurance plans than public plans. In other words, if someone with public insurance (e.g., Medicaid) tries to see a private independent practice provider, they are more likely to incur out-of-pocket costs than someone with commercial insurance.
Of all payer sources, self-pay is the most commonly accepted by independent private practice providers. These providers are 1.4 times more likely than community, inpatient, and nonprofit providers to bill and receive compensation from the patient directly. Medicaid and the Children’s Health Insurance Program (CHIP) – operated as a combined program in Oklahoma known as SoonerCare – is the most common form of payment accepted by community, inpatient, and nonprofit practice providers. Among survey respondents of this provider type, 68% accept Medicaid and CHIP compared to only 34% of independent private practice providers who do.
SoonerCare covers some of the most vulnerable people in the state, including the aged, blind, and disabled, as well as children and pregnant women who fall below certain income thresholds. Those who qualify for Medicaid or CHIP are more likely to have co-occurring physical and mental health conditions and experience non-medical factors that impact health outcomes. Having access to fewer providers as a result of insurance coverage type disproportionately affects those who might already have more complex needs.
Many Providers Do Not See Patients Full-Time
A quarter of surveyed providers report spending 20 hours or less per week providing behavioral health services to clients. This indicates that many Oklahoma providers may only practice part-time, which should be considered when determining the adequacy of insurance networks. Providers may also limit their time with patients to complete administrative tasks, collaborate with peers, and/or consult on mental health cases managed by primary care practitioners. As physicians continue implementing collaborative and integrated care models, appropriately compensating behavioral health professionals for their roles on care teams will help extend Oklahoma's existing health care workforce.
Appointment Wait Times Are Longest for Psychiatrists and Psychologists
Of actively practicing survey respondents, 37% said it takes a week or more for a patient to get an appointment, and nearly 4% are not currently accepting new patients. In particular, 23% of psychiatrists reported it takes one to three months to get an appointment, and 27% of psychologists said that it can take one to six months or longer for a patient to secure an initial appointment.
Psychologists and psychiatrists commonly diagnose mental health conditions and provide a set of services other licensed professionals cannot. Psychologists administer particular tests and assessments to arrive at a diagnosis or direct treatment. Psychiatrists, as prescribers, often see the same patients on rotation for medication management, which leaves little margin for them to see new patients.
There are fewer psychiatrists or psychologists in the state compared to other licensed providers – 730 physicians with a psychiatric focus and 613 licensed psychologists. Oklahoma has three times as many licensed clinical social workers (LCSWs) and 10 times as many licensed professional counselors (LPCs) as there are physicians with a psychiatric specialty. This is likely an underestimation, as a doctor can have a psychiatric specialty without being a psychiatrist. Compared to licensed psychologists, there are 3.6 times as many LCSWs and 12 times as many LPCs.
Compensation for Behavioral Health Care Lags Behind Neighboring States
A national report from 2019 shows Oklahoma's in-network behavioral health reimbursement levels relative to those allowed by Medicare are below the national average and below the levels of Arkansas, Kansas, and Texas. Medicare reimbursement levels are a benchmark in the health care industry for ideal reimbursement levels. Oklahoma behavioral health care providers receive reimbursement levels at 91% relative to Medicare-allowed levels for office visits.
The disparity in reimbursement rates between Oklahoma's primary care and behavioral health care providers is 1.1 times higher than the national average. The state's behavioral health care providers are reimbursed an average of 27% less than primary care providers for similar visits. Oklahoma’s disparity is 13.5 times higher than that of Arkansas, where primary care providers receive only 2% more than behavioral health providers for similar services.
Former mental health care providers who responded to Healthy Minds' survey report insufficient pay as the number 1 reason that best describes why they left the workforce. However, only 4.3% of survey respondents indicated they were either “not in behavioral health care, but still in the social services sector” or “not in behavioral health care, and not in the social services sector.” This equates to an extremely small sample of licensed providers in the state who are not currently providing direct services and should not be taken as representative.
Nonetheless, Oklahoma has room for improvement to catch up with the national average and its regional neighbors. Raising reimbursement rates for behavioral health providers would likely make Oklahoma more appealing and competitive for practitioners.
Those Who Don’t to Have to Go Through In-Network Providers Make System More Inequitable for Those Who Do
When issues of access to care exist, patients with insurance can’t always find an in-network provider. A network is a group of health care providers or medical facilities an insurance plan has contracted with to serve its members. In-network providers negotiate rates that are usually discounted for insurance companies. Therefore, it costs more for the insurance company and consumer to see an out-of-network provider because they require full payment, similar to if the patient didn’t have any insurance coverage at all. Children are especially impacted by this and experience having to go out-of-network for outpatient mental health care more than ###???### times more than for general primary care.
In addition to the state lacking an appropriate workforce to meet Oklahomans’ needs, the landscape is primarily rural. With providers spread out geographically and no strong public transportation structure in place to assist with travel, it can be a challenge to have enough providers in a network that people actually have access to. For people with the financial means to pay out of pocket, they might seek an out-of-network provider, especially if it means they can prevent a delay in diagnosis or treatment. This creates a system where people who can afford to pay for services out of pocket receive services more quickly than those who have to find an in-network provider to keep costs down.
TBD
The 21-question survey included the following topics: license type, whether or respondent provides direct services to clients, geographic areas of practice, utilization of telehealth, treatment setting, number of hours spent per week providing direct services, patient ages served, treatment specialty, typical length of time to see a new patient, accepted payer sources, and which for which insurance companies respondent is in-network.
Once the survey was created, licensure boards and provider associations either sent information about the survey to providers or shared contact information for Healthy Minds to contact individuals directly via email. Participation was optional, and providing identifiable information was optional. Even if licensure boards were unable to provide contact information for providers, all licensure boards for each type of license included in the survey were able to provide a list of actively licensed providers with either an associated zip code or county.
Of Oklahoma's 13,859 licensed behavioral health care providers, a total of 622 actively licensed providers responded for a survey response rate of 4.5%.
Respondents were allowed to select all license types that applied. Slightly more than 10% of respondents had at least two licenses or certifications, and 0.6% of respondents held at least three licenses or certifications. When an individual held more than one license or certification, that provider’s responses were counted for each unique license type in the analysis by license type, but only once per respondent for analysis for total survey responses regardless of license type. While this is not a randomized or representative sample, this duplication likely overestimates the access to service, as someone with multiple credentials is only a singular provider.