talking to a psychiatrist over the web while in the emergency department, telehealth
An emergency department patient talks with a psychiatrist via a secure network. Photo courtesy of Albemarle Hospital. Photo credit: Richard Muldez.

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<p>The Centers for Medicare & Medicaid Services now reimburses more telepsychiatry services, potentially increasing access to psychiatric services, but experts say more can be done with telehealth to extend health care.

By Hyun Namkoong

The Internet lets people to do all sorts of things online: order wine, fall in love and post pictures of cats.

The Internet and technology have crossed over to the medical world too. Technology has dramatically changed health care delivery and services from electronic health records to telemedicine.

An emergency department patient talks with a psychiatrist via a secure network. Photo courtesy of Albemarle Hospital. Photographer: Richard Muldez.

Telemedicine delivers health care services to patients through videoconferencing. A psychiatrist based in Raleigh can observe, diagnose and prescribe medication for a patient in an ED in Carteret County, or a doctor in Winston-Salem can diagnose and order treatments for a patient having a stroke in the mountains.

In some places in the U.S., like Alaska, doctors have been using telemedicine to treat patients in remote locations for years. But now it’s become easier: A stable Internet connection, a video screen and a microphone can be used to care for patients miles away. And the practice is finally starting to take off in North Carolina.

But even as telemedicine and telepsychiatry hold promise, there are still substantial barriers to more patients and doctors meeting online. Concerns that Big Brother or worse might hack the chat and listen to an intimate conversation about someone’s mental health means that not every doctor or patient is ready to log in and pour out their heart on the worldwide web. And then there’s the problem of getting paid for a virtual visit.

Telepsychiatry in NC

In many counties in North Carolina, there’s no psychiatrist and in many others there might be only one or two.

A statewide shortage of psychiatrists led to the collaboration between the Office of Rural Health and Community Care, East Carolina University’s Center for Telepsychiatry and the General Assembly to provide telepsychiatry services in emergency departments through the North Carolina Statewide Telepsychiatry Program, called NC-STeP.

Data analysis from the Carolina Center for Health Informatics at UNC-Chapel Hill shows that between 2008 and 2010 nearly one in 10 emergency room visits were associated with a mental health disorder.

“If you have a patient who doesn’t get appropriate or adequate care, when they are in crisis they end up in the emergency department,” said Sy Saeed, a psychiatrist and director of NC-STeP.

According to the Centers for Disease Control and Prevention, around a quarter of American adults have a mental illness and nearly half of all adults will develop a mental illness in their lifetime.

Although the correlation between mental illness and ER visits is strong, North Carolina barely meets federal guidelines for the recommended psychiatrist-to-population ratio.

On top of that, psychiatrists cluster around more urban areas while large swaths of the state have no psychiatrists at all.

In fiscal year 2013-14, the North Carolina General Assembly appropriated $2 million for NC-STeP and another $2 million in 2014-15. The Duke Endowment also awarded a grant of $1.5 million to fund the expansion of NC-STeP.

Psychiatrist full-time Equivalents per 10,000 population, North Carolina, 2004. Data: UNC-Chapel-Hill Sheps Center

According to Saeed, more than 6,000 patients in North Carolina were seen via telepsychiatry in the first eight months of the program, and NC-STeP projects a total of 24,000 patients by the end of the year.

The majority of the hospitals in North Carolina already have telepsychiatry in their emergency departments. By July 2015, NC-STeP should be available in every hospital.

Saeed believes the state will save $6 million to $8 million annually from NC-STeP.

Evaluation data on patient outcomes in a hospital-based telepsychiatry program in the northeastern part of the state found that telepsychiatry reduced the average emergency room length of stay by more than 50 percent. Readmissions to psychiatric hospitals for patients with persistent or severe mental illnesses also decreased.

According to the state Department of Health and Human Services, cost-effectiveness data analysis shows that NC-STeP has already saved North Carolina an estimated $1.1 million in fiscal year 2013-14 from reductions in involuntary commitments alone.

Great results, not such great money

But just because telepsychiatry is showing results in North Carolina doesn’t mean it’s being fully embraced, and that’s because there’s a problem with payment.

A report from the American Hospital Association shows that Medicare patients are often sicker and have more complex, chronic conditions, driving up the number of ER visits. From 2006 to 2010, behavioral-health related emergency visits among Medicare patients increased by 22 percent.

According to DHHS, almost 20 percent of patients who received a telepsychiatry assessment were Medicare enrollees in 2013-14.

Saeed said that although the federal Centers for Medicare and Medicaid Services has been a leader in funding telemedicine, funding remains inadequate to cover all of the costs for telepsychiatry.

Psychologists per 10,000 population, North Carolina, 2012. Data: UNC-Chapel-Hill Sheps Center

Reimbursements don’t fund the cost of implementing care, so start-up costs such as the tech equipment and setting up broadband aren’t covered.

Saeed said that inadequate reimbursements from Medicaid and Medicare dollars are the reason why so many psychiatrists in private practices don’t accept those patients.

“If your patient base was nothing but Medicare or Medicaid and you employ a psychiatrist to take care of those patients, at the end of the day would you be able to pay the costs of employing that psychiatrist?” Saeed asked.

“The answer is no.”

He said that’s why state allocations, a mix of third-party payers and research grants are important to balancing the equation for keeping clinics afloat.

And while CMS already reimburses the types of telepsychiatry assessments that NC-STeP provides, proposed increases in federal reimbursement of psychoanalysis and family psychotherapy may allow NC-STeP to expand its services, according to DHHS.

Quality of care

While NC-STeP has been received with enthusiasm, the N.C. Medical Board and the N.C. Academy of Physicians have voiced concerns about the quality of care provided through a screen.

“Because [telehealth] is evolving so rapidly, nobody knows for sure where this is going to lead to and what the outcomes are going to be,” said Scott Kirby, medical director of the N.C. Medical Board.

He said that the board has concerns that the quality of care delivered via video, text messaging or phone calls is not as good as face to face, but that the board has an open mind that technology, in some instances, may provide equivalent care.

Greg Griggs, executive vice president of the N.C. Academy of Family Physicians, echoed similar concerns.

He emphasized the importance of a physician-patient relationship and a face-to-face visit for taking blood pressure or temperature for diagnosing illnesses.

But because NC-STeP is implemented in hospital emergency rooms, the patient is always surrounded by health care workers who can take vitals.

“It may not always be a nurse, but the presence of another person is typically required, especially in acute visits,” Saeed said.

A literature review of 68 articles from academic peer-reviewed journals found that in general patients are satisfied with the care they receive from telepsychiatry, but patients who are from rural settings or with limited access to care report evern higher levels of satisfaction.

The same study found that clinical outcomes from telepsychiatry are just as good as the old-fashioned way of seeing the doctor.

“Mental health treatment has never been as effective as it is now,” Saeed said.

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Hyun Namkoong

Hyun graduated from the UNC-Chapel Hill Gillings Global School of Public Health in the health behavior department and she worked as the NC Health News intern from Jan-Aug 2014.