The last time they talked, the teen was primarily interested in Pokemon and video games. Since then, he’s grown up. He’s more into country-western music and fishing.
He also recently wrote a bomb threat at school.
Psychiatrist Jenna Saul often has long stretches between in-person visits with patients, such as this teen, because of overwhelming demand for her services. So Saul uses a webcam to talk with this patient and others because it allows her to reach outlying areas of the state where many counties don’t have any psychiatrists who work with children. She works from an old horse barn in Marshfield, refurbished with access to a broadband signal coming from a silo across the road.
“We had to really wrangle this system to make it work,” Saul said.
But make it work, she did.
This experimentation by Saul and others is part of an effort to address a severe shortage of mental health professionals. Wisconsin is estimated to need more new psychiatrists per capita than any other state. Telepsychiatry is a way to stretch the reach of the few psychiatrists who do work here.
Saul’s not alone in her trade. Randall Cullen, former medical director of Mendota Mental Health Institute, started using telepsychiatry after seeing immense need in rural areas of the state. He now does psychiatric evaluations remotely for mental health systems in more than 10 counties.
Indications show the practice is becoming more widely accepted. According to a survey of psychiatrists by UW-Madison researchers, about 8 percent of respondents said they used telemedicine.
But experts say there’s much room to grow telemedicine in Wisconsin, which has not embraced it in ways other pioneering states have.
Of the 130 child psychiatrists listed with the state’s licensing authority, more than half are in Milwaukee, Dane and Waukesha counties. Fifty-one counties don’t have any.
The shortage is nationwide. In high demand in nearly every corner of the country, child psychiatrists often have their pick of locations to set up shop, and many choose urban areas where they can be in a clinic with a vast support network.
“A lot of medical professionals want to stay in a bigger place with more colleagues and resources,” said child psychiatrist Gabriella Hangiandreou, president of the northern chapter of the Wisconsin Psychiatric Association. “It’s hard to lure people into rural areas.”
Noticing this trend several years ago in Illinois, the state Bureau of Child and Adolescent Services implemented a telepsychiatry program to reach children in areas of the state without practicing psychiatrists.
“It’s helped children and families receive a level of care they would have had to travel long distances for,” said Lisa Betz, associate deputy of the Bureau of Child and Adolescent Services.
The Illinois Department of Human Services provided the funds to install the technology and infrastructure to get the program running. The psychiatrist uses video conferencing to evaluate patients, manage medication and consult with a team of other professionals who can meet on-site with patients.
It’s similar to what Saul and Cullen do. But they’ve had to handle infrastructure on their own, and sometimes it’s problematic.
As Saul dialed into a video conference with a county clinic to talk to the boy who wrote the bomb threat, she struggled to connect as she talked to staff on the phone. “Not this again,” she sighed. The Internet can be slow and choppy.
Jennifer Miller, a spokeswoman for Wisconsin’s DHS, said the department has not made any financial investments in telepsychiatry, other than a consultation program through which psychiatrists advise primary-care doctors about mental health but do not provide direct care. She noted that counties can apply for grants from other sources to establish telepsychiatry lines.
With a sometimes spotty Internet connection, Saul said, she resents that state officials turned down $23 million in federal funds for broadband expansion in 2011. In the latest state budget, there is $1.5 million available in grants per year for broadband expansion projects.
In Hawaii, where health care access on the less-populated islands could be compared to Wisconsin’s rural counties, telepsychiatry has filled some gaps.
Combined with earlier identification, more children now can be treated for behavioral health needs on their home islands, said Michael Fukuda, from the Department of Psychiatry at the University of Hawaii’s John A. Burns School of Medicine.
Before telepsychiatry was more widely available, “they would present in the emergency room, but the emergency room didn’t have a child psychiatrist, either,” he said. “So what they would have to do is fly the child over to Oahu.”
According to the American Academy of Child and Adolescent Psychiatry, patients and providers have so far been satisfied with most telepsychiatry services. For adults, the academy said the research clearly shows telepsychiatry is just as effective as in-person treatment, while research about youth is starting to show the same results.
Before Saul started providing telepsychiatry in the public sector, she used it in her private practice. But she said reimbursement “wasn’t phenomenal.”
More than half of states in the U.S. have laws requiring private insurers to pay for telemedicine services the same way they would cover in-person services. Wisconsin is not among them.
Gov. Scott Walker signed a bill in 2014 that requires Medicaid to cover telehealth services, but the state does not have such a requirement for private insurers.
The American Telemedecine Association gave Wisconsin an “A” grade for having low barriers for telemedicine with its standards and licensing policies. But Wisconsin ranked among the lowest 15 states in terms of the ability for telemedicine professionals to get paid for their work.
Gary Capistrant, chief policy officer for the association, said laws requiring insurers to cover telemedicine services have made significant differences in other states.
Psychiatrist Jenna Saul uses a webcam to talk with Kim Bain, a nurse at CHAPS day treatment program. (Photo: T’xer Zhon Kha, USA TODAY NETWORK-Wisconsin)
“Without parity, providers won’t organize to provide it,” Capistrant said, referring to telemedicine. “We are all used to teleconferencing in our daily lives, but somehow when it comes to patient care we still want the patient to jump in the car and drive to the care.”
Jerry Halverson, president of the Wisconsin Medical Society and former president of the Wisconsin Psychiatric Association, said payment is a significant barrier for telepsychiatry.
Halverson said telepsychiatry has the potential to expand services in rural areas by tapping into the more plentiful resources of urban areas. He said Madison and some parts of Milwaukee are fully staffed by mental health professionals and he expected some providers in those regions would be open to helping in rural areas if payment were more reliable.
“We do need more psychiatrists, but really the biggest issue is having psychiatrists in the right areas,” Halverson said. “There’s a maldistribution of the psychiatric resource, and certainly telepsychiatry is a way to help correct that.”
Halverson said while ideally insurers would opt to cover telemedicine services, Wisconsin may need to consider requiring it by law.
“You hate to have to do that, but it may be something we have to look at in our state,” Halverson said. “It’s pretty clear there’s a need for telepsychiatry.”