There are parts of Minnesota where psychiatrists are as rare as tulips in February, where people must wait months and travel hundreds of miles to get treatment for their mental illnesses.
With the state’s aging psychiatry workforce, this is a problem that isn’t going away any time soon. Ask Teri Fritsma Mogen, senior research analyst for the Minnesota Department of Health Office of Rural Health and Primary Care. She and her colleagues track the number of mental health care providers in the state, and when Fritsma Mogen takes a closer look at the numbers, the news isn’t good, especially for folks living outside of the major metropolitan areas.
Minnesota has, Fritsma Mogen reported, some 600 board-certified psychiatrists. Of those 600, she explained, “We know that approximately 80 percent are employed in the seven-county metro area or in Olmsted County, where the Mayo Clinic is located.” The remaining 20 percent are elsewhere in the state, mostly in Duluth and St. Cloud.
“This leaves 48 of Minnesota’s 87 counties with no practicing psychiatrists,” Fritsma Mogen said. The counties without psychiatrists are — you guessed it — mostly rural. “That creates serious access issues for the people who live there and represents a severe shortage.”
The few psychiatrists who practice in care-shortage areas must travel long distances to see their patients in person. Increasingly this is rare. This adds up to oppressive waiting lists for in-person appointments.
“Absolutely there are long waits to see psychiatrists in many areas of the state,” Fristma Mogen said. “And this absolutely can be a barrier to care.”
The doctor is … online
One possible solution to this shortage may be telepsychiatry, where psychiatrists see patients remotely via video uplink, helping them manage their symptoms through the use of carefully monitored medications. These virtual appointments could take place in a patient’s home, or, more likely, in a dedicated space in their regular medical clinic.
Telepsychiatry seems as though it could be a workable option for many rural Minnesotans, Fristma Mogen said. Many of Minnesota’s rural communities have aging populations, making extended waits for treatment and long drives to appointments particularly onerous. If a patient could see a psychiatrist at a local clinic via dedicated telemedicine technology, some barriers to care could be overcome, she said.
Despite the potential benefits, telepsychiatry has been slow to catch on in Minnesota. Genoa Healthcare, a national provider of pharmacy services in mental health clinics with 20 in-clinic pharmacies based in the state, is in the process of establishing telepsychiatry services in several Minnesota mental health clinics, said Samir Malik, Genoa’s general manager of telepsychiatry. The company has operational centers in Eagan and Golden Valley.
About 100 Genoa Healthcare clinics nationwide offer telepsychiatry services to patients. In the Genoa clinics that offer telepsychiatry services, a private room is set up with video-conferencing equipment. Patients schedule video appointments with a psychiatrist who is licensed to practice in the state that the clinic is located in. When the patients are at the clinic for their psychiatry appointments, they can also update their prescriptions or meet with other health care providers.
While telepsychiatry can take place offsite in a patient’s home, all Genoa Healthcare telepsychiatry is done on-site, Malik said. This decision is intentional.
“Many of our patients have very complex psychiatric conditions and are severely disabled by them,” he explained. “They need the support on site in the clinic. We’re integrating [psychiatric care] into the existing services that are offered in the clinics.”
Does telepsychiatry help?
About four years ago, Genoa Healthcare began offering telepsychiatry services at some of clinic locations in response to patient requests. The shortage of psychiatrists is a nationwide problem: Patients served by Genoa pharmacies in other states complained of long waits for psychiatric care. While Genoa pharmacists could fill prescriptions, patients needed support and guidance to find the proper medications to treat their mental illnesses and to make sure that they were responding well to specific dosages. Long wait times to see psychiatrists affected the quality of care.
“In 2015, because we were hearing from so many patients that they didn’t have good access to psychiatrists,” Malik explained, “we bought a telepsychiatry business to help provide further support.”
As the program grew, Malik said that he and his colleagues began to observe that telepsychiatry was a good option for their patient population. Patients and providers reported feeling comfortable with the technology, and because video conferencing made it possible for one psychiatrist to see many patients in distant locations in one day, the program also appeared to increase efficiency of care delivery.
“We had been providing telepsychiatry services for seven years when we decided to put a study together,” Malik said. “While we had seen a lot of data that said that telepsychiatry was as effective as in-person services, we hadn’t seen data about its impact on improving access to care.”
Genoa Healthcare staff believed that telepsychiatry was making it easier for their patients to be seen by psychiatrists, but they wanted to have the numbers to back up that belief. So they conducted a study of Genoa patients at a mental health clinic in Missouri.
Malik explained that for the purposes of the study, Genoa worked with a research partner to look at Medicaid claims data for patients with access to telepsychiatry services compared to patients without access to telepsychiatry. “We wanted to peel back the onion and find out what was really happening,” Malik said. “We were seeing telepsychiatry move the needle on access for patients with the most need, and we wanted to confirm that our observations were accurate.”
What the study found was that at the Missouri clinic, telepsychiatry significantly improved patient access. “We saw that patients with access to telepsychiatry had access to care seven days sooner than those who didn’t,” Malik said.
The study also showed that individuals who established a relationship with a telepsychiatry provider were more likely to continue to seek mental health care in the future: “Patients who had access to telepsychiatry were 34 percent more likely to be seen monthly than patients who didn’t have access,” Malik said.
Another study finding was that most patients reported that the quality of telepsychiatry care was equal to in-person visits.
“From a study perspective we didn’t see anything that would demonstrate that patients got worse care or poorer outcomes with telepsychiatry than face-to-face treatment,” he said.
Results like these feel promising to Fritsma Mogen. If more Minnesotans with mental illnesses could see a psychiatrist sooner, they may find appropriate treatment methods and make progress toward recovery.
“I know that people with serious mental health issues really suffer,” Fritsma Mogen said. “A week makes a huge difference, so if telepsychiatry can shorten the wait by seven days, that could really change a person’s life.”
A telepsychiatrist speaks
Mehdi Qalbani became a psychiatrist because he wanted to improve the lives of people living with mental illnesses. As a psychiatrist practicing in New Orleans, he saw firsthand how many people diagnosed with serious and persistent mental illness struggled to get the care they needed to live healthy and happy lives.
Nationwide there is a shortage of psychiatrists in both rural and urban communities, and while Qalbani worked long hours serving patients in his private practice and through Assertive Community Treatment (ACT) teams, he always felt that there were more people who needed his help than he could reach.
In 2010, Qalbani was approached about providing telepsychiatry services to ACT patients in rural Louisiana. He jumped at the opportunity, because he felt it would allow him to see more people who desperately needed his care.
“I got into telepsychiatry because I was passionate about serving patients with serious and persistent mental illness,” Qalbani said. Without regular care from a psychiatrist, he explained, “Many of these patients would otherwise be incarcerated or institutionalized. Telepsychiatry allowed me to reach those patients.”
Today, about 50 percent of Qalbani’s patient interactions are via video uplink. He said that the technology has made him accessible to people who used to have no chance of seeing a psychiatrist. With his ACT patients, for instance, teams of social workers bring an iPad on their regular home visits. During those appointments, Qalbani can meet with the patient and assess their needs without ever having to leave his office.
Thanks to telepsychiatry, Qalbani said, “I can be more efficient, see more patients. Normally with my ACT teams, I’d see six to seven patients a day because I’d be driving across the state to their homes. Now, with my hybrid model, I can see 10, 11, sometimes 14 or 15 patients a day if need be.”
And telepsychiatry makes it possible for Qalbani to help a patient in acute mental health crisis. “When a social worker is seeing a patient who is having a crisis, they can get me on video chat and we can talk about the issue right away,” he said.
Though Qalbani still schedules in-person appointments with many of his patients, he also uses telepsychiatry in his private practice. His patients tell him that the technology makes it easier for them to schedule appointments at convenient times.
“I serve a lot of teachers in my private practice,” Qalbani said. “You can imagine how hard it is for a public school teacher to take off a half day to meet with their psychiatrist. With telepsychiatry, my patients can go to a nearby clinic or even to their car and have a session with me on their iPad. The reports I get from my patients are that they are satisfied with this kind of care.”
Qalbani said that most of his patients report feeling comfortable with these virtual appointments. Some even say they prefer it to an in-person meeting.
“Recently, one of my patients mentioned that it was easier for her to talk about really painful things during telepsychiatry sessions than it was in person because of that physical distance,” Qalbani said. “That little bit of barrier opens you up. It does not feel as intimate as being across the room from someone and telling them your personal stories.”
Whatever the reason, Qalbani said that he believes that telepsychiatry has significantly enhanced his ability to serve underserved patients, which has been his goal from very the beginning of his practice.
Telepsychiatry has improved access to mental health services, “a million, gazillion percent,” Qalbani said. And he believes that the technology also has the potential to draw more young physicians into the practice of psychiatry. “I think this kind of stuff is attracting people into the field, because we are going to be able to care for more patients. We may be in a crisis when it comes to providers these days, but I think technology will help us rebound.”
Making the case for telepsychiatry in Minnesota
It’s clear that something needs to be done to address the shortage of psychiatric care in Minnesota.
Fritsma Mogen explained that the numbers back up the scarcity argument.
“Job vacancy rates for an occupation is a leading indicator of shortage,” Fristma Mogen said. “A high vacancy rate means that there is difficulty filling the positions. In Minnesota, across all occupations, the job vacancy rate is 4.5 percent. For psychiatry, for the fourth quarter of 2018, we are looking at a vacancy rate of 11.6 percent. That’s more than double the average vacancy rate. It’s a strong indication of a shortage.”
In a climate of shortage, general practitioners often need to step in to provide mental health care for their patients.
“Another way to figure out if there is a shortage is to ask physicians how frequently they have to fill gaps in care because another specialist is not accessible,” Fritsma Mogen said. “More than half of rural physicians told us they fill gaps in mental health care frequently or all the time.”
While telepsychiatry or telemedicine might help lift some of the burden off the shoulders of medical providers, Fritsma Mogen said that her department’s research has shown that the technology has yet to take off in the state.
“We asked physicians how often they consult with patients using telemedicine. Roughly 72 percent said they never provide telemedicine services.” Fritsma Mogen compared those results to responses from a similar survey her department conducted in 2016. “The responses were exactly the same with pretty much identical breakdowns,” she said. “It seems like there’s room for growth here.”
Malik said that he and his colleagues know that they have tough row to hoe when it comes to convincing more Minnesota providers that telepsychiatry could help them serve patients who are clamoring for their care. But he’s confident that as more providers become aware of the benefits of the technology, more will get on board.
“Removing commutes and helping providers distribute their services in a more geographically agnostic manner is of interest,” Malik said. “If you are in St. Paul and you have a patient in Duluth, it would be cumbersome to make the commute to see that patient. Telepsychiatry allows a provider to sit in their office in St. Paul and treat patients all over the state.”
An expanded reach to the most needy patients gets at the heart of why psychiatrists went into the field in the first place, he said.
“Telepsychiatry allows providers to support the complex needs of the underserved,” Malik said. “That social impetus is driving more medical providers to work in telemedicine. Psychiatry is getting ready to take that important step.”