‘Peer specialists’ emerge to support patients amid constrained mental health care access

When Alicia Doty was in a Shakopee prison for drug-related charges stemming from her methamphetamine addiction, volunteers who had once shared her experience visited during her 1 1/2-year sentence.

And while she did relapse after her 2017 release, she attributes that connection to helping her eventually achieve sobriety in May 2021.

Doty is now trying to pay it forward by helping people as a peer specialist, a growing profession that provides support based on personal experience with addiction, mental health or other emotional and social challenges. The traditional route for such treatment is usually through the health care system via licensed psychologists, therapists, social workers or other mental health professionals. But labor shortages in those fields, along with continued barriers to access, mean people can struggle to find help when they need it.

Doty, 33 of Mayer in Carver County, became a peer specialist in 2022 and has worked for St. Paul-based Minnesota Recovery Connection since July 2023.

“I can connect with people on a level that clinicians can’t,” Doty said, “because I have lived experience.”

As of mid-March, Minnesota had approximately 3,250 peer specialists, according to the Minnesota Department of Human Services, with more than 93% of working in the mental health or substance abuse fields. Family peer specialists, who work with families dealing with divorce or a child with a behavioral problem, for example, are less prolific.

In addition to a potentially quicker timetable, seeking a peer specialist could also be cheaper, especially with more health insurers beginning to cover them. But for all the potential benefits, there are still some drawbacks: Some say oversight is lacking, while others believe peer specialists are not a full replacement for professional mental health or medical care.

Shannah Mulvihill, executive director of Mental Health Minnesota, said the wait time for patients trying to book an appointment with mental health professionals can take “weeks or months.” That’s not always tenable in a time of crisis.

The reason behind these delays is a matter of supply and demand. Pew Research found at least 41% of U.S. adults experienced high levels of psychological distress during the COVID-19 pandemic. The U.S. Department of Health and Human Services estimated 122 million people live in areas with a shortage of mental health care, with more than 6,000 new providers required to meet the need. According to the Commonwealth Fund, in 2021 fewer than half of people with a mental illness could access care in a timely fashion, while those with substance issues found that even harder.

“We have a big workforce shortage in mental health,” Mulvihill said. “I think peers can play a really big role in mental health.”

A statewide survey of mental health providers this winter found challenges to the system like the inability to hire and retain staff; the closure and reduction of services; and increased staff burnout. The survey — from the Minnesota Association of Community Mental Health Programs and the Mental Health Providers Association of Minnesota — also showed those factors were driving a 41% increase in wait times, with average wait times being about four weeks for day treatment and 14 weeks for outpatient treatment.

North Memorial Health recently cut 103 jobs and eliminated mental health services at its anchor hospital in Robbinsdale. That will leave approximately 3,400 mental health patients without outpatient providers after Aug. 30.

A peer specialist could help ease the clinical labor shortage since it takes significantly less time to become one. Many licensed psychologists, for example, attend four-year colleges and spend an average of seven years in graduate education and training to prepare for counseling patients, per the American Psychological Association. Peer recovery specialists, which the Minnesota Certification Board certify at two experience levels, complete 46 hours of training and pass a certain exam for the first level.

The state certifies support or mental health peer specialists also at two experience levels and has been offering the service since 2009. It has a similar training-exam process, but the basic requirements are to be 21 years old, have a mental health diagnosis and to have received mental health services. Per the state website, peer specialists can “free up other mental health staff by running groups, reinforcing skills and helping the individuals develop their treatment plans.”

Peer specialists earn in the range of $20 to $25 an hour, with certification fees for two years costing $250 for peer recovery specialists, per the Minnesota Certification Board. People can connect with peer specialists through treatment centers, sober houses and nonprofits, but patients must first meet with an assessor who confirms their diagnosis and refers them to a peer.

“In the last several years, the number of recovery peers and recovery community organizations has grown exponentially,” the Minnesota Department of Human Services said.

Medicaid reimburses peer specialist services and is the largest payer of mental health services in most states in the U.S., including Minnesota. In 2019, Minnesota reimbursed slightly more than $51,000 for peer recovery services. That grew to more than $6.2 million in 2022.

As interest has grown in peer specialists, Blue Cross and Blue Shield of Minnesota started covering them at the beginning of this year. The insurer previously covered them within its Medicaid plan but has now added Medicare and commercial plans, meaning in-network peer specialists should have zero cost to members.

“We’ve expanded coverage,” said Lauren Foster, principal program manager of behavioral health at Blue Cross and Blue Shield. “All fully insured plans have access.”

Foster added that peer specialists can help take some stress off clinical staff. In a recent survey of its members, Foster said policyholders of color advocated for having more nonclinical care options.

Some Minnesota insurers, though, do not provide coverage for peer specialists or only do so for certain plans.

UCare covers peer specialists under its Medicaid plans but not in its individual, family or Medicare plans. HealthPartners covers peer specialists in its Medicare and MinnesotaCare products, while Medica only covers peer specialists in its Medicaid plans but is “evaluating coverage” for its other plans.

UnitedHealthcare covers peer specialists in states that certify peers.

“UnitedHealthcare has, for many years, recognized the important role peer support specialists can play in helping people successfully overcome mental health and substance use challenges,” said Dr. Donald Tavakoli, national medical director of behavioral health at UnitedHealthcare, in a statement.

Savings could also come beyond the individual level and in terms of lives as well as money. A report from the Minnesota Department of Health estimated excessive drinking cost the state $7.85 billion in 2019 and contributes to more than 2,000 deaths every year. The department also recorded 1,343 drug overdose deaths in the state in 2022, only 13 fewer than the year prior, with opioid-involved cases accounting for 75% of all drug overdose deaths.

Last year the legislature committed more than $200 million for addiction and recovery support over four years in a package that created the state’s first-ever addiction and recovery director position, which reports directly to the governor.

Justin McNeal spent many years fighting his drug addiction, which started with marijuana and became a meth and heroin habit. In his last years of using, he was in and out of jail. He became a peer recovery specialist in 2018 and has been sober more than seven years.

“I find it extremely effective,” McNeal said of peer specialists. “It’s a much cheaper route.”

Because this is an emerging field, there is still some wariness. Legislators are considering adding additional oversight for peer recovery specialists this session, with one representative calling the current situation “the wild, wild West.”

Marielle Demarais, chief of psychology at Hennepin Healthcare, said peer specialists still aren’t widely available in the state, so billing for them can be an issue because many insurers don’t cover peers, and Medicaid is only applicable in specific situations.

Demarais leads an interdisciplinary support team that includes a peer specialist who complements the work therapists are doing without working independently with patients. Licensed mental health professionals can conduct care like making clinical assessments and using cognitive and behavioral treatment strategies that peers cannot.

“They just provide really different services,” Demarais said.

In some cases, working with peers can be supplemental to other care, both medical and behavioral. Wendy Jones — executive director of St. Paul-based Minnesota Alliance of Recovery Community Organizations, which supports peer recovery specialists — said peer specialists “can be integrated into a lot of different settings.”

Kristin Nottingham, 62 of St. Paul, found it beneficial to work with peer recovery specialist Doty and has now been alcohol-free for two years and nine months. She’s now undergoing the training to become a peer specialist herself, a common theme for many who have used the service.

“I wouldn’t be at this point in my recovery without my peer recovery specialist,” she said.