TMA Testimony by Andrew Harper, MD
TMA and Federation of Texas Psychiatry Comments for Texas Select Committee on Health Care Education & Training
On behalf of more than 47,000 physician and medical student members of the Texas Medical Association and the Federation of Texas Psychiatry, I wish to respectfully submit comments for the select committee’s consideration. We applaud Speaker Joe Strauss and our House leaders for creating a committee to focus on our state’s health care education and training needs — a topic of critical importance to Texas and for Texans.
As you are well aware, our state has a great need for more health care professionals, but nowhere is the need more acute than in the area of psychiatric physicians. When Texas ratios of physicians per 100,000 people, by specialty, are compared with U.S. totals, Texas outranks the United States in only four major specialties: aerospace medicine, medical genetics, transplant surgery, and colon and rectal surgery. Meanwhile, Texas ranks below the Unites States for the other 36 out of 40 medical specialties, with psychiatry having the lowest rate at only 58.2 percent of the U.S. ratio. Child/adolescent psychiatry is also near the bottom of the rankings, at 68.7 percent of the U.S. ratio.
Shortage of Psychiatric Physicians
Any meaningful effort to improve the recruitment of workforce is contingent upon adequate reimbursement and a culture that promotes appropriate roles, communication, and values mental health treatment. Currently, mental illness, and to a large degree, mental health treatment are too often seen as derogatory, stigmatizing, and coercive from both the patient and provider perspectives. Undue regulation of the practice of psychiatry and mental health services adds additional costs and decreases the availability of services. This is especially true in government and institutional settings as evidenced by chronic staffing challenges in State hospitals and the Veterans Administration.
Policymakers should be aware that while mental health parity is improving third party payment for mental health services, a growing number of psychiatrists are opting out of networks and instead using a cash model for their practices. In our view, Medicaid reimbursement rates are a deterrent for participation by behavioral health providers, and it would be immensely beneficial for this committee to give policy guidance to the legislature to improve the situation. Absent meaningfully increasing reimbursement rates for providers at all levels, efforts to increase the mental health workforce are going to be effective only in the margins, and not at addressing the heart of the problem.
Expansion of Medical Education
Graduate medical education (GME) remains an important part of the answer to improve our health care workforce. In 2003 and 2011, Texas endured state funding cuts for psychiatric residencies in state hospitals and funding cuts to GME. This has meant fewer residency-training slots for graduates who want to specialize in psychiatry, forcing them to move to other states for this training, where they most likely remain to practice. Thus, for the past decade, Texas has been investing in the expense of medical education of students who ultimately will live and practice in another state.
The 83rd Texas Legislature recognized the need to ensure more Texas medical school graduates have a fair chance to complete residency training in the state, and had the foresight to establish new grant programs with the specific goal of expanding GME capacity in the state. These programs received relatively modest funding, $14.25 million and are in the early stages of implementation. Given the tremendous need for psychiatrists in the state, it is critically important that psychiatry residency programs have the resources they need to provide high-quality training, in order to compete with other medical specialties.
Loan repayment programs are an innovative and effective way to recruit and retain mental health providers. At a time when so many physicians are carrying high levels of education-related debt, loan forgiveness programs can not only encourage students to join the mental health provider workforce, but also improve geographic disparities in mental health services by incentivizing providers to practice in underserved areas and facilities.
Establishing educational loan repayment programs for psychologists, LPCs, and LCSWs as well will help produce a broader pool of practicing mental health providers, better addressing Texas’ acute mental health provider shortage.
Telemedicine is likely to improve access for some services when sufficient telecommunications infrastructure is in place. State policy and regulations will need refinement to address privacy, liability, record keeping, and payment.
Recently, a significant challenge to the practice of telepsychiatry, so serious that it threatens its availability in large areas of the state, emerged about which this committee should be aware. Several medical providers in Texas have expressed concern with the Drug Enforcement Administration’s (DEA’s) enforcement of the Ryan Haight Online Pharmacy Consumer Protection Act, a federal law enacted in 2008.
Generally, no controlled substance that is a prescription drug may be delivered, distributed, or dispensed by means of the Internet without an in-person medical evaluation of the patient. This subsection of the statute, however, is not applicable to “the practice of telemedicine.” Under federal law, the “practice of telemedicine” includes a relatively narrow set of telemedicine practices, and as a result, a telemedicine practice that is permissible under Texas law may not meet the federal definition of the “practice of telemedicine” in the DEA rule and the related statute.
In East Texas, regional agents of the DEA have strictly enforced provisions of the Ryan Haight Act against telemedicine providers. Specifically, the DEA has taken the position that a practitioner must conduct an in-person medical evaluation before prescribing a controlled substance via telemedicine, despite the fact that the Act does not apply to telemedicine if the telemedicine requirements are being met.
Additionally, the DEA has taken the position that during the telemedicine encounter, the patient must be in the physical presence of a practitioner with a DEA registration or physically located in a hospital or clinic with a DEA registration. If the patient is not in this setting, the telemedicine practitioner may not prescribe the patient a controlled substance. Although the affected Texas providers would concede that the Act does require registration of the site, many sites where telemedicine is currently being practiced are not able to obtain DEA registrations. Furthermore, because the DEA has not established the special registration process permitted by statute or identified additional permissible telemedicine practices in rule, telemedicine providers of legitimate services are left without a means to meet patient and community medical needs.
The current DEA position is significantly impacting initial access to care, disrupting continuity of care, and is imposing a barrier to provide services to both vulnerable and underserved populations by a variety of medical disciplines across the state of Texas. The Health and Human Service Commission, TMA, the Federation, the Texas Council, and other stakeholders are presently engaging with the DEA to resolve the problem, but the committee should be aware that until a mutually agreeable resolution is reached, the practice of telemedicine in Texas is very much in jeopardy.
Lack of Diversity
The state should work with higher education and accreditation bodies to build the skills and capacity of the emerging mental health workforce – including primary care providers -to provide culturally appropriate and trauma informed services, and to be able to work collaboratively with families and other systems.
The Joint Admission Medical Program (JAMP) is a special program to support and encourage highly qualified, economically disadvantaged Texas-resident students pursuing a medical education. Since 2001, JAMP has been providing scholarships and summer stipends, mentoring and personal assistance to prepare for medical school, and hands-on experience through summer internships.
Funded through the Texas Higher Education Coordinating Board (THECB), JAMP is coordinated between all Texas medical schools and sixty-five undergraduate institutions. The program offers guaranteed admission to a Texas medical school if all requirements are met. Program funding has been cut in recent years due to budget constraints. However, thanks to improvements in the economy and legislative support, JAMP funding was restored but remains flat. There has not been sufficient funding to allow for the planned growth in the program.
Insufficient Data to Inform Workforce Planning
There is currently an insufficient quantity and quality of data at the state and national level to fully inform workforce-planning initiatives. Utilization of active licensees from several licensing boards can be helpful, but does not define who is doing what – for example, which practitioners are in direct patient services versus administrative or business or academic practice. The state licensing boards should be urged to collect and update practice information in accordance with established minimum-data-set standards and to make that information available to the state’s Health Professions Resource Center for analysis. The Committee should consider defining what “acceptable” geographic access would look like. In our view, merely reporting data by county or per capita does not adequately illustrate access issues.
Additionally, workforce planning must consider the need for physicians with expertise in serving specialized populations, including very young children; the elderly; individuals with co-occurring substance abuse and mental disorders; co-occurring intellectual or developmental disabilities and mental disorders; and veterans.
Child & Adolescent Mental Health, and Early Intervention
The state’s juvenile population has unique mental illness needs, and identifying this population and adopting early intervention methodologies to address their issues deserves serious discussion in any policymaking effort regarding mental health workforce shortages.
Half of chronic mental disorders begin to manifest by age 14, but currently, treatment may be delayed until years after the initial onset of symptoms, allowing problems to become more entrenched and difficult and costly to treat. School counselors and nurses are strategically positioned to identify and address concerns in students early, reducing the number of children and youth who would otherwise require more specialized and costly mental health services if early interventions had not taken place.
Texas schools cite counseling as the most successful strategy to support students’ mental health, but high counselor-to-student ratios and assignment of non-counseling related tasks severely limit their ability to provide prevention and early intervention services to students. For example, in 2004, Texas elementary school counselors spent less than a third of their time on behavioral health counseling; high school counselors spent only 12 percent of time on it (despite that risk for mental illness and suicide spike in adolescence). Moreover, districts are required to have but one school counselor for every 500 elementary school students, while the ratio recommended by the Texas Education Agency is at least one counselor for every 350 students.
1115 Waiver Process
At present, the only way in which some areas of the state have mental health and/or substance abuse services are through the opportunities provided by the 1115 waiver. Due to the mental health and substance abuse workforce shortage in Texas, in each of the 20 Regional Healthcare Partnerships (RHPs) there are Delivery System Reform Incentive Payment (DSRIP) projects specifically seeking to increase the number of behavioral health providers in order to increase capacity and access in their regions. Many RHPs, especially in the rural areas of Texas, are exploring the use of telemedicine to bring psychiatry services to the area regularly.
Emphasis on Public vs. Private System
Too often, the maldistribution of the mental health workforce is described primarily with respect to underserved populations defined in terms of gender and ethnicity, as well as communities defined by their location, density and per-capita workers. However, the committee should also consider the distinctions between the public and private mental health workforces. It is our view that these are disparate workforces, each facing their own challenges and opportunities, and should not be considered in tandem.
The Texas Legislature is already taking steps to address the current inequities between the public and private mental health care systems in this state. House Bill 3793 requires DSHS to develop a plan to allocate outpatient mental health services and beds in state hospitals more equitably between civil and criminal patients. The bill provides for an advisory panel to assist the department in developing the plan, which has been meeting for several months, and has produced an initial plan to reduce the involvement of the criminal justice system in managing adults with the mental health disorders, and make additional beds available for civil commitments.
The committee should also be aware that the Health & Human Services Commission is poised to release a report mandated by the Legislature in 2013, due to the enactment of H.B. 1023. That legislation charged HHSC to research and analyze the state’s mental health workforce shortage, solicit comments from stakeholders, and review the causes and identify potential solutions to those shortages. While our organizations have some reservations about the report as a whole, we appreciate the agency’s continued efforts to communicate with the physician community to improve the current situation and we look forward to reviewing the final report when it is released.
Thank you for the opportunity to provide comments for the select committee’s consideration. TMA and the Federation wish you great success in fulfilling the committee’s charge, and we stand ready to assist you in the coming months.
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