Conference of Allegheny Providers

Conference of Allegheny Providers

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White Paper

Leveraging Telehealth Technology in Allegheny County

April 2017

Introduction:

“Telepsychiatry, or telemedicine, is a specifically defined form of video conferencing that can provide psychiatric services to patients living in remote locations or otherwise underserved. Traditionally, underserved areas are usually thought of as rural areas with few psychiatrists but now with the diminished number of psychiatrists in practice urban areas with high concentrations of mental health consumers are also underserved due to the large number of psychiatric vacancies that results in limited access. (In Allegheny County of quick search of the recruiting website Indeed returns 57 positions for psychiatrists). It can connect patients, psychiatrists, physicians, and other healthcare professionals through the use of television cameras and microphones. Telemedicine currently provides an array of services, including but not limited to diagnosis and assessment; medication management; and individual and group therapy. It also provides an opportunity for consultative services between psychiatrists, primary care physicians and other healthcare providers.

Telepsychiatry is also being used to provide patients with second opinions in areas where only one psychiatrist is available. Telepsychiatry has been shown to improve collaborative services between professionals. Studies indicate that healthcare professionals feel telepsychiatry has given them an opportunity to work more effectively as a team. Patients surveyed say they felt that the communication between their physicians had improved their outcomes.

There are a few barriers to providing telepsychiatry services. Reimbursement is still difficult to receive, especially through third-party payers, and licensure can be difficult to obtain. Overall, telepsychiatry provides increased access to services and has helped enhance the provision of services to families with children and other patients who are homebound. Patients participating in telepsychiatry say they are satisfied with the care they are receiving and that they feel telepsychiatry is a reliable form of practice.” (American Psychiatric Association).

Currently in Pennsylvania there are significant cultural as well as regulatory and reimbursement issues that impact and restrict the use of telepsychiatry. The PA Services Bulletin of 3/18/14 defines the scope of services in the public sector and allows only psychiatrists and psychologists to provide psychiatric services via telepsychiatry with the approval of OMHSAS. The requirement that the telepsychiatry services be provided only when in-person services are difficult to access serve to restrict the use and approval of telepsychiatry service to rural areas where consumers are still required to expend resources traveling to local CMHC’s to receive services.

In contrast to the APA position telepsychiatry, the state services bulletin describes telepsychiatry as inferior to and not a permanent replacement for in person services. It further requires informed consent from the consumer but does not allow the consumer the choice of receiving services in their home which would place much less burden on consumers and would increase the likelihood of actually receiving services.

There are approximately 200 publications addressing telepsychiatry, about 150 with adult populations and 50 with child and adolescent populations and a few meta-analyses. These studies are uniform in their conclusion that telepsychiatry services are comparable to in person services. In quality projects over the past five years we have data that strongly supports consumer comfort with telepsychiatry services. Consumer empowerment and choice is at the core of recovery principles and part of consumer choice should be a decision about how, when and where an individual chooses to receive services.

The state of the art in providing telepsychiatry has changed substantially over the past few years, moving from barely mobile carts to the current web based HIPAA compliant platforms that can be delivered with low speed internet connection on virtually any hand held device, tablet, laptop or desktop. Recent research indicates, “Telepsychiatry,i.e., the use of information and communication technologies to provide psychiatric services from a distance, has been around for more than half a century now. Research over this period has shown that videoconferencing-based telepsychiatry is an enabling and empowering form of service delivery, which promotes equality of access, and high levels of satisfaction among patients.”Usefulness of telepsychiatry: A critical evaluation of videoconferencing-based approaches; Subho Chakrabarti, World Journal of Psychiatry, 2015, Sept, 22; 5 (3); 286-304.

In addition to producing guidelines the Commonwealth of PA requires a waver form be completed and reviewed before approval is given to provide services. The behavioral health MCO and the County mental health program where services are provided are also required to provide approval before services are provided. From a regulatory perspective it is neither necessary nor efficient for the, behavioral health MCO, County MHMR or Commonwealth of PA to approve telepsychiatry. The necessary guidelines could be added to existing guidelines outlining standards of care and monitored within the existing review process. Telepsychiatry also opens access to behavioral health services to nontraditional venues such as primary care offices, schools and other community locations. Bringing services to consumers in preferred locations can be navigated for even a limited number of consumers and these services could still be brokered through licensed CMHC’s.

In May of 2017 Senate bill s.1016 Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2017 was introduced by a bipartisan group of Senators. The Connect bill allows for the waiver or elimination of telehealth restrictions in Medicare in certain conditions, effective Jan. 1, 2018. Mental health services are considered a qualified circumstance for exemption.Restrictions that can be waived include that the originating site be located in a rural health professional shortage area or non-metropolitan statistical area. Another restriction that can be waived under this bill is the limitation on the type of health care providers furnishing services and the limitations on codes described as telehealth services.

In summary technology has the ability to transform how behavioral health services are delivered. By bringing services to consumers in a preferred location, be that a licensed mental health center, primary care office, school orhome, we will be able to reach more consumers with higher quality service and increase the likelihood that the consumers will actually receive the services, resulting in better outcomes and use of the most appropriate levels of care.

Statement of the Problem:

Recruitment and retention of psychiatrists in Allegheny County has become a full time focus for providers. The chronic shortage of psychiatrists and CRNP’s impacts access to timely psychiatric services and ongoing continued care. Wait time for a psychiatric appointment can as long as 90 days. The Conference of Allegheny Providers queried local providers and found the following patterns emerge:

The majority of providers were experiencing at least 1-3 physician vacancy at any given time.
Long term psychiatrists were beginning to retire.
Newer/younger psychiatrists were interested in creating a more satisfying work experience by engaging in varied work experiences vs. full time clinic work.
New psychiatrists have a higher salary requirement because of tremendous burden of student loans.
Physician vacancies on average take 6 months to 1 year to fill, therefore having a significant impact on consumer access to psychiatric services.
The cost of using a physician recruitment firm ranges from $30,000 to $50,000 per placement and does not guarantee goodness of fit or long term employment of the physicians.
Licensing interpretation of the PA 5200 regulations does not allow for using CRNPs to their fullest licensing capacity. CRNPs are difficult to recruit and hire in Allegheny County and also take 1 year or more to hire.
Locum tenens services provide stop gap support but at a significant cost financially and in quality and consistency. Locum assignments are intended to be temporary assignments but often extend 3-6 month time frames.Given the shortage of psychiatrists even using locum tenens companies can take several months to find a temporary psychiatrist. Some managed care companies are now not covering services retroactively after the credentialing processes are complete (Medicare, PROMISE, MCO) which means service provision with no reimbursement.

The National Council Medical Director Institute recently published The Psychiatric Shortage Causes and Solutions in March of 2017. This document supports our local experience related to the challenges of access. “ The pool of psychiatrists working in the public sector and insured populations declined by 10% for 2003-2013.” The National Council completed environmental scans and offered solutions to the problem, one of which was the use of telehealth.

Proposal

The Conference of Allegheny Providers is proposing that Allegheny County offer support for the use of tele-psychiatry in Allegheny for children and adults. The focused areas for the use of tele-psychiatry are outpatient; IOP and partial hospital levels of care. The Conference of Allegheny Providers is requesting support for the application process with OMHSAS and payment with the local MCOs.

In Allegheny County, providers can leverage the use of telepsychiatry as they manage vacant positions either on a short term basis until a permanent physician is found or as a permanent treatment team member with a caseload. Telepsychiatry can also be leveraged to provide second opinion consultations/evaluations.

Local providers are committed to providing the service and supports necessary to make the use of tele-psychiatry a successful modality.

Acknowledgements:

The Conference of Allegheny Providers wishes to acknowledge the contributions of Jack Cahalane, PhD, Director of the Telepsychiatry program at Western Psychiatric and Clinic of UPMC and Jon Evans, CEO Innova Tel Telepsychiatry for their contributions to this white paper.