Wait times for seeing psychiatrists or psychologists average 2-4 months, according to our poll 231 school counselors, PCPs, and hospital discharge planners in Iowa, but there is hope in a new program out of Broadlawns Medical Center. The hospital has a new psych residency program. 1,000 medical students applied for one of eight spots in the program. University of Iowa Hospitals had the only psych training program here until this one. Several Iowa hospitals closed their mental health units in recent years, not due to low demand but low supply, says Martin Kellogg, who struggled in handing recruiting for these hospitals. The state of Iowa is helping fund the effort, and Mercy Hospital here will also add its own psychiatric residency training program. There is limited federal funding for programs like these from predominantly rural states, Iowa hospital sources lamented. The PCPs or OBGYNs in our survey said they can treat mental health, ‘like the kids who come in with anxiety’ or ‘a mom with post-partum’ but ‘severe cases are outside of our comfort zone and scope of practice – it’s a disserve to the patients.’
There are almost 30,000 psychiatrists practicing nationally, more than a third in Texas, New York, California and Pennsylvania. States like Iowa are hard to recruit to, so it’s understandable that there’s so much interest among hospitals, healthcare investors and educators in trying to find solutions. Policymakers are beginning to do their part but solving the shortage and addressing demand likely takes more than funding. Innovation in delivery models has to emerge and it is beginning to. The advent of tele-psych is probably the most compelling trend, because it will at least allow for psych consults for patients in SNFs, homes and hospital EDs, but there are some barriers still, including licensing requirements and in some cases reimbursement. Still more, telepsych doesn’t address the shortage nor does it fix the problem of good psych care, says Susan Duffy, a psychiatrist at the University of Iowa. Duffy says there’s a tremendous gap in geriatric psych specialists so much so that she often does consults for patients many states away. On the flip side, there’s a trend in programs started by school counselors to address mental health in youth, and fill the gap in child psych specialists. Steve Boyle, a Connecticut school counselor for many years, has a program focused on sports, mindfulness, and exercise for kids to indirectly address anxiety and depression, and a counseling program called Dorm Room Coaching for young adults who’ve left for college where suicide rates are rising.
For investors, the interest in psych services is rising according to a BRG study of more than 130 senior leaders of private equity firms, but there are emerging challenges to consider with investment. For starters, demonstrating the medical necessity for ongoing psych services remains difficult, and managed care companies like New Directions and Beacon will continue to be tough on allowing visits. In the coming months, the BlueCross BlueShield health plan in Illinois begins to tighten the reigns on outpatient visits, allowing a max of 7 visits before they will require pre-approval.
What’s Past Is Prologue
These seem like reasonable steps from insurers given the growth and they are strangely familiar to 2011, when insurers starting requiring pre-approval for physical therapy and tightly managing visit allowances. OrthoNet led that charge and it created a new norm for PT groups – a constant fight for getting patients to their office and for many smaller PT practices led to diminished economics, and in some cases closures. PT has had a resurgence, so it will be interesting to see if outpatient psych therapy faces a similar fight with insurers. My hunch is yes. The two ‘therapies’ share the common challenge of trying to prove that ‘progress’ should mean more visits, not less. Interest on the higher acuity, inpatient side of psych may be less susceptible over time to insurer hassles, particularly because these patients are probably ‘in deep need’ for care at the level, be it for delusions, self-harm, or severe eating disorders.
The Next Battle
The trend in Iowa residency is encouraging but a sign of another battle ahead for the psych field and a wave of questions for psych operators, health systems and investors: which delivery model will be more attractive and which will gain favor with insurers, employers….and patients? The answer is probably it depends on the condition, the severity of it, the age of patient and interests of the professional. The age of the current psychiatrists is important too; about 59% are nearing retirement age, behind only oncology and pulmonology, according to a Merritt Hawkins analysis of AMA data. The new crop of residents in training will help, but where will they want to work – some are in their 30s and 40s and have families and may find telepsych more interesting and in some cases ‘just as rewarding,’ said 39 year old mom Pamela Nicols, who is applying for positions with companies like TalkSpace. That said, the advent of these residency programs and the emergence of both telepsych services and alternative models of addressing mental health conditions create a host of opportunities for the psych space.