Retention In The Addiction Treatment Workforce
This is the third and (for now) final post in an impromptu series about working in addiction treatment. The first and second posts were on what I love about this job. This week we're looking at retention: why so many front-line workers leave the field, and what it would take for more of them to stay.
When I moved back to Maine in 2017 and started interviewing for jobs, people seemed unduly impressed with my background in substance use. Really, I thought? With just a masters field placement and one full-time job on my resume? I considered myself relatively new to addiction work.
Looking back on that time, I feel like I barely knew what I was doing– but I had already come further than most. 2 roles in 5 years is indeed considered lot of professional experience in a field with exodus-level turnover as a norm. From what I hear about peer support and harm reduction work, turnover is constant there as well. But I will focus on clinical staff and clinical settings since this is the world I know, and also the type of turnover most closely associated with problems in treatment access.
First I'll address organizational turnover, which refers to people quitting one treatment organization to take a similar job somewhere else. Patients are affected because they are then assigned new providers, having to "start over" in the counseling process with someone they don't know. The therapeutic alliance (relationship between clinician and client) has proven to be the single greatest determinant of treatment success. This means that even if an ideal replacement counselor is available immediately, patients' quality of care suffers as the alliance is reset to zero– which may happen again at any time due to further staff turnover. Some patients have told me they eventually gave up on agency counseling because, one after another, their providers kept leaving.
As to organizational turnover's impact on staff: our workplaces have very little institutional knowledge when everyone is always new. Mentorship is also hard to come by. Morale suffers. Theoretically, managers don't want organizational turnover either due to the costs of recruitment and training– but I'm not sure this is true on the ground (more below in Solution #1).
Then we have occupational turnover, in which people leave the field altogether. Occupational turnover can have many of the same effects as organizational, but from a policy perspective, I believe occupational turnover is a more important focus. Rather than asking, "How can we keep more staff in their treatment facility jobs?" I think we should ask, "How can we keep more providers accessible to patients?" There is no reason addiction treatment needs to take place in centralized clinics with professional management. In fact, most of my patients express this is specifically not where they prefer to be seen. One primary reason: everything in agency settings is done for maximized efficiency and in groups.
Rosalie Genova
So here are 3 steps I believe would help retain accessible providers.
1) Employers could address known drivers of turnover. As stated above, we shouldn't assume that treatment organizations are or should be the primary venue for care. But I'm taking up the "keeping staff in their jobs" goal anyway because a) for now, centralized facilities are usually the fastest way to access treatment, and b) we already know more than you'd think about how to retain their workers. Managers in addiction treatment claim staffing is their greatest challenge. But the causes of turnover have been studied in detail: lack of autonomy, unfair treatment, and poor supervision (or none at all) to name a few. These are matters of management discretion, yet managers act like there's nothing they can do.
I was told I was a highly valuable provider by my agency bosses, but I never saw much effort to address concerns I raised. I came to suspect they would rather be rid of a squeaky wheel– and even more so a potential ringleader who encouraged collective advocacy among the clinical staff. Why wasn't it worth the effort to retain me? Look back on the impacts of organizational turnover above, and you'll see that none of them directly affects management. Even loss of revenue seems to be acceptable. Reducing and canceling programs for lack of staff is normal, while meaningful effort to retain staff is rare.
I believe managers' real priority is to continue excluding clinical staff from all decision-making and to maintain the huge disparity in pay and tenures between us and them. This would explain why they have done so little to bring down organizational rates of turnover: they're more comfortable with the status quo. That brings us to what I think is the better goal: retaining accessible providers outside of professionally managed clinics.
2) Providers could form alternative work structures. I would love to see more group practices, networks of solo providers, or other worker-owned collaborative models offering addiction treatment that patients actually want. Such work structures could provide the autonomy, control, and clinical support that counselors don't get in agency settings– and thus, hopefully, more continuity in the patient experience.
Why isn't this more common? There's certainly the issue of providers not wanting to do substance use work in any setting. These are folks we probably can't retain no matter what we do. But for individuals and groups who are open to it, there may be ways to make it more feasible. First, we probably need subscription or membership models rather than fee-for-service payment. By this or other means, we need to pay clinicians for holding walk-in hours as well. This is because as of now, appointment no-shows are an existential threat. Providers who aren't on a salary are wary to take on patients who may not prove reliable. (This is the single greatest challenge I have in my own practice.) If "treatment on demand" is really the vision, it must be built around the reality that many of our people have chaotic lives and disorganized schedules.
Second, the administrative and clerical side of counseling is too much for a lot of practitioners. This is why so many are joining "practice management platforms" owned by the same insurance companies that providers struggle to deal with! A certain amount of desk work is inevitable, and provider collaboratives would either need to master it themselves or hire a dedicated professional. But this may not be realistic on a large scale without much greater transparency and accountability in...
3) Insurance: Stop the insanity. When I talk about "accessible providers," I generally mean providers who take insurance. Otherwise, "accessible" means charging very low out-of-pocket fees or seeing people for free, which few of us can afford to do full time. If you want to understand why so many clinicians only take private pay, and are thereby only accessible to wealthy people, read ProPublica's instant classic "Why I Left The Network." I cannot overstate how opaque and unaccountable insurance companies are as trading partners. It's not just the complicated credentialing process, low reimbursement rates, trying to pay us with gift cards, pretending not to have received claims, and having no way to contact them or get questions answered. They can also retract payments already made, as Harvard Pilgrim did to me. I'm lucky my "clawback" was only around $600– compared to amounts in the tens of thousands reported in the article– but I never got an explanation, nor did the patient affected. I gave up after my calls got cut off three times, at exactly the same point in the conversation. And then I left the network.
"Accessible" really means taking Medicaid as well. Very few counselors who work independently, even those who take insurance, are willing to deal with Medicaid's additional paperwork, and that too is understandable. I sincerely hope there's a way to lighten this burden in the interest of Medicaid members' access to mental health care. But as a MaineCare provider (our Medicaid) I'm actually seeing a lot of benefits to dealing with the state compared to private insurers! (Does anyone want a post on this?) The common denominator is that getting paid is too complicated and arbitrary. We probably won't have more accessible providers– regardless of work setting– until this is fixed. Medicare for all!
