How does psychiatry access differ among patients, and how should it become individualized?
Among the many hurdles a mentally ill patients faces toward proper care, actual care access may be among the most dimensional. The diversity in payer plans does not always really the individual needs of patients.
In an interview with MD Magazine® while at the Advancing Mental Health Policy: BetterTogether forum in Washington, DC, Ken Duckworth, MD, medical director of the National Alliance on Mental Illness, explained the burdens of mental health care access, and shared perspective on telehealth and individualized treatment pathways.
MD Mag: How does care access disparity manifest in psychiatry?
Duckworth: I think primary care doctors face a lot of challenges, because when they identify someone with a mental disability—anxiety, depression, substance use disorder would be the most common—they're often challenged to find a way to get them care.
And because we have multiple payers, and not all providers are on every payer panel, and not every provider is taking patients, this quickly becomes a challenge for the primary care doc. And I think that we do a disservice to the patients if we can't figure out how to get them care.
You have a cardiac vulnerability, you can typically find a cardiologist for them if you need a consult. And in the mental health side, we are a more fragmented system. We haven't done as well.
MD Mag: What are the burdens of initiating telehealth in psychiatry?
Duckworth: Telehealth is a good idea and an interesting idea. But you have to get people to do it—integrate it into their practice, figure out how that connects to their health record, and then you have to get patients to take it up and believe that it's okay.
So I think just introducing the technology itself doesn't really change the equation, the way smartphones did. On smart phones, you could do anything on your phone, very quickly—you can actually do telehealth through your smart phone. But someone has to take the time to get a HIPAA compliant platform to integrate this into their care process, and to also deal with the complexities that'll happen with telehealth that they weren't necessarily trained for.
We know telehealth is as good as in-person care. We know that. The question is how do we make it happen to improve access because the efficiency of providers can be increased if people aren't driving and parking, and if the practitioners can work in the evenings after they put their kids to bed, and if you can see patients on Saturday morning on a snowy day in Boston, like where I live. I think that you can make a case that this will increase access.
MD Mag: How do we better diversify the construct of psychiatric healthcare?
Duckworth: I think it's difficult to know the best approach to an individual person unless you've done a comprehensive evaluation. So I tell people that I would start with anybody who has an independent license—social worker, psychologist, psychiatrist, clinical nurse, specialist—and get an assessment.
Some people only need psychotherapy. Some people need a very specific kind of psychotherapy—exposure response prevention for OCD, for example, is a completely different kind of psychotherapy than you would give somebody who's trying to identify patterns and their bipolar disorder. So after an evaluation, you and the patient would agree with the treatment plan.
Some people only want to take meds, and for most conditions meds plus other interventions like psychotherapy produce better outcomes, but some people don't have the time or resources for psychotherapy, and some people can't find somebody in psychotherapy.
I encourage people to contact their health plan. For the people who are lucky enough to have insurance in America, the health plan has an obligation to give you someone. If you can't find someone call the number on the back your health plan card and say, “I want a psychologist for this OCD problem I have.”
Exposure response prevention is a very specific kind of psychotherapy. Typically, if the health plan can't find it for you, they will pay for somebody to do it out of their network. And if you don't ask the health plan, you're missing an opportunity.
The other question which I think we're trying to figure out in the field is how do you extend the limited supply of practitioners with a peer workforce. It's a good question and it's an important question. I do think interest in using peers to extend the reach of care is happening, but it's important to remember they are not clinicians, they are not trained to do clinical work, and they don't want to do clinical work they have mastered or they're in recovery with their condition.
They want to be that resource to a person, to go alongside someone in their journey—not to replace a mental health practitioner.