Until recently, when the North Dakota human services agency had an opening for a mental health provider, months might go by before a single application came in.
But that’s started to change as the state boosts telemedicine as an option for mental health care. The department has started allowing providers who serve patients through its health centers to live in some of the state’s bigger cities — or even move out of state — and deliver mental health care to rural areas through video calls. The University of North Dakota’s medical school has started training its psychiatry residents to treat rural patients by computer.
“Telepsychiatry really is integral to our ability to provide that equitable access to psychiatric services across the state, regardless of rural and urban environment,” said Dr. Laura Kroetsch, a psychiatrist who works as the field medical director of the human services department.
In mostly rural states like North Dakota, the nationwide shortage of psychiatrists feels particularly acute.
“We’re desperately short throughout the state,” said Dr. Robert Olson, a psychiatry professor at the University of North Dakota. Recent research suggests that providers who are based in rural areas are more likely to provide telepsychiatry than those in urban areas, with North Dakota psychiatrists most likely to provide care via video chat.
Expanding telemedicine has given North Dakota a way to reach more patients — and convince more psychiatrists to practice in the state. Anecdotally, health officials say that it has helped to curb wait times for patients to see a mental health provider who can prescribe medication. It’s also helped them reach more patients in rural areas and those who can’t travel far for mental health care, including the elderly.
“If they just get to their little town clinic and we can beam them in, it makes a huge difference,” said Olson. He added that telemedicine even makes it easier for patients to get care in the face of one of North Dakota’s most infamous obstacles: winter snowstorms.
“The telebeaming just goes right on out, whether its 20 degrees below or 70 above,” Olson said.
Telemedicine use is uneven across U.S.
Research suggests that a telepsychiatry appointment is just as effective as an in-person visit for many situations. The American Psychiatric Association says that there’s a “substantial” evidence base for telepsychiatry, and that satisfaction rates are high among both patients and providers. But the practice hasn’t gained traction in some parts of the country.
A study published this month in JAMA Psychiatry found wide variations from one state to the next in the percentage of psychiatrists who provide telemedicine. The study used data from providers who take Medicare fee-for-service payments, which means it doesn’t capture the experiences of many psychiatrists in the U.S.
Nationwide, roughly 5 percent of the more than 28,000 psychiatrists in the study delivered a telemental health visit. In North Dakota, the state with the highest rate, nearly 25 percent of psychiatrists saw patients by video, compared to less than 1 percent of psychiatrists in Massachusetts, where providers were the least likely to provide care via video chat.
Percent of psychiatrists who provided at least one telemedicine appointment, 2014-2016
“When I talk to psychiatrists in big cities, it seems outside the norm. But in certain communities, this is becoming the norm,” said Dr. Ateev Mehrotra, an author of the study and a health care policy researcher at Harvard Medical School.
Not all states regulate telemedicine the same way. Dozens of states have enacted what are known as a pay parity laws, which require private payers to cover telemedicine appointments. Some of those explicitly require payers to pay the same amount for a medical appointment that’s conducted over video chat as for one that takes place in person. But the laws have also sparked a debate about whether in-person and video visits should cost the same amount, given that telehealth providers may be working from home or in lower-cost facilities.
Mehrotra said that while it’s not clear what’s driving the state-by-state disparities, part of it might be due to the differences in the perceived need for telemedicine to deliver mental health care.
“If you are a psychiatrist in North Dakota, the need might be very clear to you. So you might be more apt to try new ways to provide care. While if you’re a psychiatrist in Boston, it may not seem necessary to move in this direction,” Mehrotra said.
But as telepsychiatry continues to move toward the mainstream, more states might start looking like North Dakota.
“For our state, it’s so crucial,” Olson said. “And frankly, it’s where the future is going.”
‘Eye-opening experience’ for psychiatrists
Dr. Lori Esprit was born and raised in North Dakota and, as a psychiatrist, is passionate about providing mental health care to its citizens. She spent years providing in-person care at a Fargo clinic run by the human services department. Last fall, when her family decided to move to Maryland to be closer to relatives, she jumped at the offer to keep her job and provide telemedicine instead of in-person visits. She wanted to keep working with the patients she’d built relationships with and serving the communities she cares about.
Now, she sees patients via video chat and communicates with other health workers using email and notes in health records. Esprit said that her routine hasn’t changed much since shifting to full-time telepsychiatry.
“The main difference is that I don’t have to put shoes and socks on. I can wear my house slippers all day long,” she said.
And while that might sound like a small benefit, being able to retain more mental health providers who might otherwise move is a big deal for a state that has had difficulty attracting psychiatrists.
“We’ve definitely seen a significant impact on that recruitment and retention,” said Kroetsch, of the North Dakota human services department. There are 22 psychiatrists who provide telemedicine care through the department’s eight clinics. Another three psychiatrists live out of state and provide telemedicine to those health centers. In December 2018, the department’s psychiatrists carried out nearly 500 telemedicine appointments — more than 150 of which were provided by psychiatrists who live out of state.
The state is also trying to prepare the next generation of psychiatrists to provide telemedicine to underserved areas. Once a week, psychiatry residents training at the University of North Dakota treat rural residents across the state by video chat. And once a month, they drive out to the rural clinics to see patients in person, talk with staff, and get to know the community.
“We wanted them to learn the skills of telemedicine, but we also wanted them to be somewhat attached to their community,” said Olson, who also serves as the director of the medical school’s psychiatry residency program.
“It’s really been an eye-opening experience,” said Dr. Lisa Schock, chief resident in the program. Schock and others who offer telemedicine say they have to tweak their practice slightly, like learning how to work with a slight delay in the video chat or leaning more on clinic staff to observe potential changes in patients’’ demeanor or grooming, which might signal a shift in their wellbeing.
There are still challenges with fitting telemedicine into a psychiatrist’s workflow, particularly among providers who split their time between video and in-person appointments. And because many telehealth appointments take place in a medical office, patients still might have to travel a long way to get to the nearest health center.
“We still have patients driving hundreds of miles for a telehealth encounter,” Schock said.