Iowa faces shortage in psychiatrists, and resolving the problem won't be easy

March 08--During his 30-year career, Mercy Medical Center's Dr. Alan Whitters has seen the cracks in the state's mental health system slowly get bigger.

He's worked on the front lines, treating the area's chronically mentally ill, and he's watched as state and federal rules have made a larger mess of an already complex system. He's seen what happens when resources are cut and centers close.

And he's seen the state struggle to maintain the number of psychiatrists required to meet the population's needs.

"The result -- more people are being hospitalized, ending up in jail or a correctional facility," said Whitters, the director of behavioral services at Mercy.

And the recent closures of residential centers around the state, including the Abbe Center for Community Care in Cedar Rapids, and the pending closure of two of the state's mental health institutes are leaving communities with even more patients and not enough resources to adequately deal with them, he said.

"I'm not against shutting the mental health institutes down," Whitters said, adding the facilities are large and costly but don't necessarily offer many beds. "There's just no backup plan."

These cracks are leaving emergency rooms overburdened and the state's psychiatrists stretched thin, mental health experts said.

"We never had to board patients (in the ER) until about a year ago," he said. "Now we average about one person a day. We had nine last weekend."

But because the system is so complex, there is no easy fix.

Educating and retaining

Part of the challenge is that there are not enough psychiatrists to meet the state's needs, often forcing psychiatrists to limit the time they are able to spend with patients. The field requires significant training while it's generally one of the lowest paid medical specialties.

"We desperately need to double the number of (psychiatry) residents," said Nancy Hale, executive director of National Alliance of Mental Illness (NAMI) Iowa.

Gov. Terry Branstad has proposed investing state funds to create new residency positions, including in psychiatry. His budget would allocate $2 million toward the psychiatric residency program at Broadlawns Medical Center in Des Moines, said Jimmy Centers, the governor's spokesman.

But adding more psychiatry residencies isn't the only -- or the best -- solution, mental health experts say. Not if psychiatrists choose to practice outside the state once their training is complete.

That's why a group at the University of Iowa is looking for ways to better retain the physicians its medical school is educating. The Primary Care Task Force is using a three-year, $1 million state grant to come up with more long-term strategies to correct the state's family medicine and psychiatry shortfalls, said Greg Nelson, task force chairman.

The group -- made up of residents, medical students, medical professionals, residency program directors and mental health professionals -- has met a handful of times and has started to put a plan into place.

Among the initial projects the task force has completed is measuring the retention rate of residents -- which is around 60 percent -- to gain a better understanding of how many choose to stay in Iowa.

It's also compiling a list of different job opportunities to present to residents, and offering other job support services such as reviewing employment contracts.

"We want to make a difference and know there's a need for psychiatry and family medicine," said Nelson, who also is the director of the UI's office of statewide clinical education programs. "We're trying to look at the big picture."

Expanding access

But another huge challenge that the state faces is the concentrated distribution of psychiatrists in urban areas. According to a 2013 survey, the state's psychiatrists are clustered in the most populated parts of Iowa, with almost two-thirds practicing in Polk, Johnson and Linn counties.

Sixty-eight counties don't have a single practicing psychiatrist.

"It takes years to get someone trained and out there (practicing)," NAMI Iowa's Hale said. "It's even more difficult in Iowa when there is such a rural situation."

Telemedicine is one way to easily and efficiently expand access to patients with mental health issues. But many obstacles stand in the way, including lack of physician and patient familiarity, low insurance reimbursement rates and the need for better infrastructure.

Telemedicine allows psychiatrists to talk with patients via a web camera on their computer through a secure network.

Nelson's group at the UI has begun to work with other university staff members to expand its telemedicine training. Once finished, the comprehensive online course will teach residents how to apply the technology to a clinical setting, HIPAA compliance and how to properly bill, he said.

Some of the state's psychiatrists already are using this technology. However, in 2014 the state was given several failing grades for telemedicine adoption by the American Telemedicine Association, including Medicaid service coverage and parity laws -- legislation that requires insurance companies to offer comparable reimbursement rates to an in-person consultation.

The Iowa Psychiatric Society, which represents 210 psychiatrists from across the state, is pushing for higher reimbursement rates for telehealth services by both Medicaid and private insurers.

Mercy's Whitters said it can be a challenge to get insurance companies to approve new treatments because they are risk averse. Instead, they'll add limitations and restrictions, he said.

Insurance companies often will pay for portions of telehealth services, but it's not consistent and it's not comprehensive, said UI Hospital and Clinic's Dr. Patrick Brophy, medical director and assistant vice president for eHealth and eNovation Center, which delivers telehealth solutions across Iowa.

"Some (insurance companies) are good and some are waiting on the sidelines," he said.

Brophy said it makes sense for insurance companies to offer better payout rates to psychiatrists using this technology because it can result in fewer trips to the emergency room and therefore save money.

"We need to do this for our state, we need to do this for our people," he said.

Some steps forward

Better, more use of other health professionals for psychiatric care

By Chelsea Keenan, The Gazette

Iowa can stretch its mental health resources through more efficient use of psychiatrists by relying on other medical mental health professionals, experts say. Here are a few ways to do that:

l NAMI education expansion -- National Alliance of Mental Illness Iowa Executive Director Nancy Hale is working to expand an educational program that offers supplemental information to families and those diagnosed with a mental illness to help free up psychiatrists' time.

The program gives families more information about the disorder as well as walks them through treatment plans and prescribed medications, answering questions that a health care provider may not have the time to do.

Right now the group is involved with 12 affiliates throughout the state, which Hale said is not nearly enough. But it's working with the 15 regions created under the state's Mental Health and Disability Redesign to expand the program and is in the process of finalizing the contract with the East Central Region, which includes Linn, Johnson, Benton, Bremer, Buchanan, Delaware, Dubuque, Iowa and Jones counties.

l Primary care physicians training -- The Iowa Psychiatric Society wants to train family physicians, especially in rural areas, to help them in handling cases. Karen Loihl, executive director of the organization, which represents 210 psychiatrists in the state, said family doctors need to become more comfortable with assessing these patients, and should then bring in a psychiatrist for follow-up.

Mercy Medical Center's Dr. Alan Whitters, medical director of the hospital's behavioral health department, agreed. He believes psychiatrists should only be brought in to handle the worst cases.

"We need to use psychiatrists better," he said. The group is lobbying the state legislature for funds to create a pilot program.

l Better use of nurse practitioners -- Psychiatric nurse practitioners also can be used to a greater degree. Nurse practitioners can prescribe medication, and mental health experts say they are a way to help fill gaps.

"We could really start to move the state forward," NAMI Iowa's Hale said

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