TABLE 5

Open-Ended Responses Regarding Barriers to Care: Themes, Subthemes, and Exemplar Quotes

Theme and/or SubthemeExemplar Quotes
Provision of DBP care
 Limited DBP workforce“There are not enough pediatricians training in [DBP], and I would like to see more done to provide incentives for pediatricians to specialize in this underserved field.”
“There needs to be another pathway to DBP eligibility than the traditional 3-y fellowship after residency.”
 Need for more training“Despite learning a lot from my experience, I still often feel unprepared for the issues and often lack the support I need to provide the care needed.”
“Most of what I have learned was on the job. I do not feel that residency prepared me very well for something I spend a lot of time doing right now.”
 Poor access to specialists“Due to [the] shortage of psychiatrists, we are being asked to see and manage these complex patients with seizures, developmental issues, ADHD, anxiety, depression, tics, OCD, bipolar [disorder], etc.”
“The long waits for children at the mental health centers [have] encouraged our increased involvement in evaluation and treatment in primary care for those without severe psychiatric disease.”
 Problems accessing services“Insurance does not cover behavioral therapy. There are no behavioral therapists who take Medicaid in our immediate area.”
“[It’s really] challenging to make a diagnosis but then have limited resources to refer [a] patient to; [an] incredible amount of time [is] spent on problem solving and advocating for your patient, which is complicated by little to no care coordination staff.”
Workforce viability
 Inadequate reimbursement“Reimbursement remains problematic. The time it takes to do a good job, while appreciated by the patient[ and/or] family, is not appreciated by administration. Without procedures, it is difficult to afford ancillary support.”
“[It is very] difficult to find a position [in which] I can both see Medicaid patients and stay in practice.”
“Much of the work involved is draining and not billable.”
 Not sustainable“[I am deeply] concerned about the sustainability of my subspecialty due to the tremendous clinical, nonbillable demands and the poor reimbursement for the work we do despite the overwhelming need for our services.”
“Low reimbursement for DBP services makes it nearly impossible to sustain a clinical practice and have adequate quality of life.”
 Undervalued“I love what I do, but I am exhausted and disheartened [by] the lack of valuation by academic institutions for the art of medicine [and] the human side of medicine.”
“There is real need for administrators and insurance companies to learn how valuable and how important it is.”
“To sum it up: overworked and undervalued.”
 Burnout“The complexity of our patients and the inability of our communities [and/or] systems to meet their needs make this job overwhelming. The expectations of academic medicine, which require productivity standards that do not include time for staffing, training, QI, or paperwork, are leading to burnout and frustration.”
“Something needs to change, or a generation of physicians will be retiring before we are 50 [y old] and seeking other careers with less stress and higher salaries.”
Potential solutions
 Changes in practice“Transition out straightforward cases to maintain access, limit to <18 y olds, and weed out true psychiatric referrals to reduce wait times.”
“New models of seeing patients for brief triage visits to plan who needs longer assessments.”
“Training to become more efficient with time.”
“We will be having more satellite clinics around the state.”
 Adding providers“NPs are underutilized in [DBP care]. This is a way to improve access for patients.”
 Increasing collaboration“More collaboration with community mental health, schools, and other community children’s agencies.”
“Greater support to primary-care [pediatricians] to allow them to take care of children with complex conditions.”
 Using telehealth“More telehealth services for rural areas of the state.”
  • ADHD, attention-deficit/hyperactivity disorder; OCD, obsessive-compulsive disorder; QI, quality improvement.