Interim Testimony Presented by Thomas J. Kim, MD, MPH
House Select Committee on Mental Health
April 27, 2016
Good afternoon, Chairman Price and members of the committee. My name is Dr. Thomas Kim. I’m an internist and psychiatrist here in Austin who develops and evaluates solutions, and practices telehealth care. Today I’m testifying on behalf of the Texas Medical Association (TMA), representing more than 49,000 physicians and medical students across our state. My hope is to offer you some insight into my daily practice experience as a telehealth physician for people in need of psychiatric care.
So what is a psychiatrist? Psychiatrists are medical doctors who treat disorders of the brain, ranging from depression to bipolar disorder and schizophrenia to substance abuse disorders. While psychiatry is often associated with Freud and talk therapy — important aspects of our profession — it is based on the science and chemistry of the brain, our knowledge of which is growing exponentially each year.
Like most practicing physicians, psychiatrists tend to practice in solo or small group practices. These are small businesses. As such, overhead costs — staffing, record keeping, buying and maintaining an electronic health record system, and billing and collections — are a considerable concern. And until recently, psychiatrists faced practice barriers other specialties did not. For example, many health plans “carved out” mental health services, meaning they subcontracted with another insurer to manage a patient’s behavioral health needs. So psychiatrists who also needed to obtain treatment for a patient’s physical ailments often would have to deal with two different entities. But some illnesses, like dementia, are not clearly physical or behavioral, so carve-outs just added to the complexity. Thankfully, the mounting evidence in favor of integrating physical and behavioral health treatment has resulted in more plans ditching these awkward carve-out arrangements.
There has also been greater scrutiny of the profession because of misbegotten and antiquated knowledge about psychiatry, and thus less generous benefits. But with the enforcement of mental health parity and gains in insurance coverage, it is easier to provide behavioral health care.
Still, physician payment for mental health, through both public programs like Medicare and Medicaid and private insurance, is a great concern. For many psychiatrists, inadequate payments, combined with payment hassles, have contributed to their reluctant decision to drop participation in private and public insurance programs. Efforts in Texas to eliminate Medicaid red tape may help improve in-network psychiatric services. But it will become increasingly difficult for public programs like Medicaid to attract psychiatric practices — as small businesses — to participate unless payment becomes more competitive. With up to one-quarter of the Texas adult population experiencing a mental disorder, cost and insurance barriers to care will continue to increase demand on the public mental health system, particularly for severe mental illness. This will continue to challenge our system.
But psychiatrists must also be able to provide an environment that supports a strong and healthy relationship with the patient. We must protect patient confidentiality, which is a unique issue for many seeking care for a mental illness. We also may be more likely to see diverse patients with difficult and complicated backgrounds; for example, some may be in the criminal justice system. Psychiatrists’ work with them can involve dealing with competency and other legal issues.
While there are multiple entry points to the mental health system — including physician referral, an insurance provider list, Veterans Affairs, or local mental health authorities (LMHAs) — mental health services in Texas can be described as fragmented, with a lack of coordination among multiple funding silos. While many policy and legislative reforms have been implemented, meeting the ever-increasing demand for mental health services is still a struggle across Texas.
Ideally, a patient should be able to talk to his or her primary care physician about a mental health concern and receive a referral to a psychiatrist. But with an estimated 4.2 million Texans relying on Medicaid for acute and long-term services each month, the system is not able to meet the demand. Limited access to community and preventive mental health services can result in patients’ mental health needs inadequately addressed in our hospital emergency departments, adult or juvenile criminal justice facilities, or schools, or through child protective services agencies.
Suggestions for Improvements to the Mental Health Delivery System
Physicians share with you a vision of a health care system that delivers on the promise of timely, cost-effective, high-quality health care, and it is essential that this vision includes care for Texans with mental illness. Primary care physicians and psychiatrists frequently discuss the barriers and potential improvements in the mental health care delivery system for our patients. We identify several here that show promise for improving the delivery system.
Evidence-Based Treatment of Substance Use Disorders. While both mental illness and substance abuse are prevalent in Texas, substance use disorders, or SUDs, are more costly to the individual, our community, and our state. More than 8 percent of Texas’ adults are dependent on alcohol or other illicit substances. It makes sense to ensure our state prevention and treatment efforts address SUDs directly, using services that are proven to be effective. This means we need to move towards evidence-based, patient-centered care. This includes providing a person with a SUD a health home with case management to help with housing or other support, to enable the person to focus on his or her treatment plan. Additional medical care for this individual should not focus solely on detoxification, but should target the appropriate patient-centered treatment with pharmacology as needed.
Dependence on illicit drugs leads to impairment of the brain, and over time will affect functioning and behavior. SUD patients often use tobacco and have poor nutrition, which lead to the development of significant chronic diseases such as diabetes, heart disease, and infectious diseases like HIV and viral hepatitis. While national data indicate almost 70 percent of those with a mental disorder have at least one other chronic condition, many have multiple conditions that require treatment. Having a medical home presents the best opportunity for individuals to access all of the medical care they need. This may be more costly but it will allow an individual to achieve and maintain sobriety so he or she can function and contribute to the community.
Overdose Prevention. We were pleased that the legislature passed Senate Bill 1462 last session, allowing physicians to prescribe an opioid antagonist for individuals, family members, friends, or organizations to aid those at high risk for an overdose. This is a key step in reducing preventable overdoses in our state. We ask that you identify and address barriers to the provision of naloxone and consider other effective overdose prevention activities. A comprehensive overdose prevention strategy will ensure our public and private health system — and the public — is informed, and that communities can take appropriate action.
Mental Health Workforce. We appreciate your continued attention to addressing concerns for accessing mental health care services. Psychiatrists interact with medical and mental health professionals to care for patients with psychiatric symptoms. Due to the complexity of diagnoses and assessments, multidisciplinary teams often coordinate to enhance and improve care. These multidisciplinary teams of varying specialists organize efforts to diagnose, treat, and plan to provide the best patient care. Depending on the patient’s needs, a psychiatrist might participate on such a multidisciplinary team with other physicians, psychologists, social workers, nurses, occupational and rehabilitation therapists, and counselors. Our association is continuing to assess barriers and identify strategies for Texas to increase the psychiatric workforce. With targeted efforts to stimulate medical student interest in psychiatry training, and your continued support for psychiatric residency programs, we can begin to address the mental health professional shortages.
Telehealth. I hope you will excuse my preferred use of the term telehealth as being synonymous with telemedicine. Ten years ago, telehealth was largely a service found only in a handful of institutions serving vulnerable populations such as the incarcerated or military personnel. Caring for these people typically required expensive hardware setups and internet circuits that cost thousands of dollars per month. I trained in Louisiana which, like Texas, embraces telehealth as a way to address the unacceptable access-to-care challenges facing too many of its citizens. From the moment I began caring for incarcerated juveniles without the hassle of travel or concern for my safety, I knew I would devote my professional life to becoming good at telehealth so that I could care for those in need.
When my wife and I moved to Georgia so that she could pursue her fellowship, I was confronted
with a question. … How do I keep caring for my Louisiana patients? Six months of effort led to my successfully transferring my practice to Georgia. Soon after, my wife and I secured our first jobs in the state of Maryland. During this time hurricanes Katrina and Rita ravaged the Gulf Coast, and I was fortunate to work with a wonderful team seeking to rebuild lost capacity — through telehealth. Finally, when my son was born, we wanted to raise him in Texas, so we got here as quickly as we could. Using telehealth, I’ve continued to care for my patients in other states to this day.
This personal highlight reel illustrates how I came to understand what telehealth represents to a physician. Only after persisting through challenge after challenge did I come to realize what telehealth was. At the risk of retraumatizing any of you with less-than-positive memories of high school physics … telehealth exhibits a paradox similar to light being both a particle and a wave. Telehealth is both a skill to be mastered as well as a system to be optimized. Recognizing these distinct properties allows us to more easily unpack some of the challenges facing telehealth today. Some of these challenges are connectivity, licensure, and payment.
Connectivity — The single technologic element fundamentally essential to society is access to broadband internet. While many people believe internet access facilitates the freedoms of expression, assembly, and education, access to health care can easily be counted as another notable value of broadband connectivity. I am not suggesting that the United States is anywhere close to making a similar declaration, but fiber optic broadband represents far better bandwidth with even greater opportunities for potential applications. Encouraging continued expansion of broadband availability as a system resource, particularly to communities still struggling with access to care challenges, is vital.
Licensure — I have practiced in four states to date and have firsthand experience with how medical license requirements vary. For telehealth physicians practicing across state lines, the current recommendation is to secure a license in any state that either the physician or the patient lives in. This is a requirement that I am happy to meet in order to continue to care for my military patients out of Fort Hood, my at-risk juveniles in Louisiana, and a displaced Katrina survivor in Maryland. But the challenge is fairly clear if I wanted to care for folks in states in which I am not currently licensed. At some point, multiple licenses become prohibitive for a skilled telehealth physician seeking to care for patients in need. Fortunately, there is active discussion around the merits of a national licensure versus establishing a compact of expedited portability. TMA supports an interstate compact for licensure and thanks Representative Zerwas for his efforts last session in favor of this. I am confident that a better pathway will emerge in time, despite some who continue to oppose these efforts. To these critics I highlight telehealth as a skill set. During residency, doctors are trained to work in a hospital, clinic, and emergency department. Not all 49,000 TMA physicians and medical students will master telehealth care, but for those who do pursue telehealth as a career, a supportive licensure pathway is key to realizing the maximum benefit from these specialized doctors to better respond to growing clinical needs, both here in Texas and elsewhere.
Payment — I do not believe telehealth care is an equivalent or proxy for conventional care. It is a unique environment that requires a unique skill set to be mastered. That said, both TMA and I believe in telehealth payment parity. Historically, telehealth has succeeded in places with the highest need, namely rural America. As such, payment for telehealth care is restricted to areas that are both nonmetropolitan statistical areas and health provider shortage areas. The logic supporting this requirement made sense at the time it was drafted, but proper payment should be reconsidered as an access issue given the growing numbers of Texans in need — both 600 miles and six blocks from where we stand.
You have taken substantial steps to address mental health. In addition to the supplemental state funding that has been provided, it is equally important that your efforts and concern have brought together public agencies, mental health professionals, and organizations from multiple disciplines and interests to focus on mental health. We are better informed about our roles and responsibilities. But the science of mental illness and substance use disorders continues to evolve, and professionals and our health and public systems must also evolve to directly address these chronic conditions in our state. For example, we are studying the effects of childhood trauma and other adverse events that can affect our resilience — leading to health problems and our ability to recover from a health event. The landmark Felitti study on adverse childhood experiences and recent resiliency studies are influencing how we will assess individual health and the care we provide for many of our patients. With this additional knowledge, we can provide more comprehensive, culturally competent, and empathetic treatment for our patients, and contribute to that vision of high-quality care.
As Dr. David Lakey, the former Texas commissioner of health, told TMA: “(T)here is no greater challenge to the health and well-being of Texans than mental illness and substance abuse.” Our suggestions are opportunities for you to support and encourage the continued growth and maturation of evidence-based mental health care and telehealth in Texas. Additional challenges do remain, largely limited by our current inability to know exactly how best to proceed. Technology innovates at a blazing pace, creating devices and services with enormous potential every day. As a doctor dedicated to figuring out how best to use technology, even I am sometimes captivated by the latest and greatest. Ultimately, I support care models that strike the balance between innovative improvements and maintaining standards of care.
In closing, I wish to thank Chairman Price and this committee for convening this gathering, as I hope the result is that Texas remains a leader in the field of health care for adults with mental illness, including seizing the opportunities presented by telehealth care and evidence-based approaches to addressing mental health disorders.
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