Access to mental health care in Western NC only partially helped by telehealth (reprint)
Reprint notice: This article was originally published by Carolina Public Press, and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.
Access to mental health care in Western NC only partially helped by telehealth
When Kara Nash learned her psychiatrist was retiring, she had six months’ notice to find another doctor. Living in Buncombe County as a nurse turned private mental health case manager, Nash has enough trouble finding local psychiatrists for her patients, who — like her — have autism. Since she cannot see psychiatrists with whom she has a working relationship, telehealth appointments with a doctor elsewhere in the state is her best option.
Even knowing about the serious shortage of mental health professionals in Western North Carolina, Nash was surprised to find only three or four providers in the entire state qualified to treat her condition.
She waited six weeks for a telehealth appointment, only for that provider to tell Nash that her case was too complex. In July she scheduled an appointment, but couldn't get anything sooner than the week after Thanksgiving.
While that appointment went well, Nash will soon be transferred to Medicaid due to the state expansion. Most psychiatrists — including the one Nash liked — do not accept Medicaid.
“Finding a psychiatrist is hard. Finding one that takes Medicaid is even more challenging,” Nash wrote in a follow-up message..
According to the nonprofit advocacy group Mental Health America, North Carolina ranks 39th in the nation for access to mental health care. Four million state residents — two in every five North Carolinians — live in an area with a mental health professional shortage, according to research from the University of North Carolina at Chapel Hill.
The situation is worse in rural counties, which have only 0.58 psychiatrists to every 10,000 people, compared to 1.79 per 10,000 in urban ones.
To address the problem, the state legislature has earmarked hundreds of millions of dollars for it in the most recent budget, using both pandemic funds and the $1.4 billion Medicaid expansion signing bonus. Some of that money will be directed toward telehealth, including $20 million for equipment for rural providers.
According to the American Psychiatric Association, telehealth has been used for mental health care in the United States since 1959, when the Nebraska Psychiatric Institute used videoconferencing for consults, group therapy and training at the state hospital in Norfolk.
Though the practice increased with improved technology in the 2000s, it has especially taken off since the pandemic, thanks in part to federal laws establishing pay parity with in-person appointments and many states authorizing Medicaid reimbursement for telehealth.
While the APA indicates that telehealth can be especially effective for depression, ADHD, and PTSD, not all mental health conditions are equally suited for telehealth.
“Autism is a social disorder," said Nash, 48. "The only time some of my people see another human is when they go to therapy.
"If social skills is a part of your brain that is underwired, then not using it just allows it to to get more and more underwired.”
With such a severe mental health provider shortage in the region, however, she and her patients — especially those in rural Western North Carolina — have to rely on telehealth, provided they have sufficient internet access.
“Having some support is better than no support,” Nash said. “Sometimes.”
The pandemic and rural psychiatric telehealth
Nash worked as a nurse in Western North Carolina from 2002 until 2023, when she left to set up her private case management business.
She first encountered telehealth around 2012 as a regional hospital liaison, a job that required her to visit rural WNC critical care facilities like Transylvania Regional Hospital in Brevard and Haywood Regional Medical Center in Clyde.
These facilities function as triage hospitals, equipped to address lower-level situations like childbirth and heart stents and to stabilize more seriously ill patients for transfer to Mission Hospital in Asheville.
While Transylvania Regional has lost at least 15 physicians in recent years. Former board members have accused the hospital of providing substandard care since the Mission Health System was acquired by HCA in 2019. Even so, the hospital is still listed as a critical care facility.
While Nash was at Transylvania Regional, whenever a patient arrived with psychiatric conditions the staff felt unprepared to manage, they would call what Nash called “doctor on a stick” — a pre-Zoom era form of telehealth.
“It's harder to do a cardiac appointment telehealth because you want an EKG, you want a stress test,” she said. “With mental health, it's easier to talk to someone. You're getting mostly subjective information.”
Nash began her career right after the General Assembly passed a major bill in 2001 restructuring mental health care in the state. At the time, counties ran their own mental health centers and had case managers meet patients where they lived.
However, budget shortfalls meant that the state owed the federal government for its Medicaid spending, and its psychiatric hospitals required as much as $250 million in repairs.
The move from public facilities to private companies, however, had its own problems. Over the last two decades, the population has increased by 2 million, while the number of available psychiatric beds has been halved, from 1,572 in 2000 to 894 currently.
Many patients end up homeless or incarcerated. A 2008 report by the News & Observer found that these private companies wasted up to $400 million on initiatives that ultimately failed.
A more recent concern has been the consolidation of the limited management entities and managed care models (LME-MCOs) that replaced the community health centers from 39 area authorities in 2001 to just seven by 2016.
Critics say this model has resulted in lower quality of care and let patients fall through the cracks.
Rural areas are impacted most. In 2022, only 15.5% of the state’s psychologists were located in rural areas. According to data provided by the Mountain Area Health Education Center, eight counties in WNC do not have a general psychiatrist, even though rural areas have above-average numbers of behavioral health disorders.
“It seems like rural people would benefit the most from telehealth,” said Steve Buie, chair of psychiatry at MAHEC. “But because of the lack of broadband access, many people in rural settings can't use telehealth.”
Before he worked at MAHEC full time, Buie split his time between MAHEC and the Pisgah Institute, where they used Zoom occasionally prior to the pandemic. “But really COVID transformed the landscape as far as telemedicine goes,” he said.
During the first two years of the pandemic, MAHEC’s Center for Psychiatry and Mental Wellness had to conduct all of its appointments online. Rural patients in particular struggled to connect, Buie said. Many drove to school or fire station parking lots to have their appointments, Buie said.
Today, MAHEC encourages its patients to come in-person whenever possible. “Sitting in the room with a person, you can see their entire body,” said Buie, noting that “antipsychotic medications can cause subtle movement disorders that you might not be able to pick up on a monitor.”
However, many of MAHEC’s rural patients still prefer telehealth because it can take half a day for them to drive to the clinic in Asheville. “They can just go out into the parking lot at work,” said Buie.
A mental health caste system
Even when rural residents can access telehealth, they face economic barriers to effective psychiatric and psychological care. Increasingly, Nash has seen a rise in concierge psychiatry, or private practices that accept no insurance and can charge as much as $300 an hour.
In a region where the median income is almost $10,000 lower than the state average, those rates are widely unaffordable. “It's just creating this medical caste system,” Nash said.
Buie said psychiatrists charge so much because insurance companies regularly violate the 1996 Mental Health Parity and Addiction Equity Act, which requires private insurance companies to reimburse mental and physical care at equal rates.
Since MAHEC is a federally qualified health center, Buie said, “the government pays much higher rates for Medicare and Medicaid patients. So we can actually afford to see (them). But people who are in private practice aren't getting those enhanced rates.”
For example, he said Blue Cross Blue Shield North Carolina usually reimburses primary care physicians 130% over Medicare rates. For psychiatry, though, they only reimburse 60% of Medicare rates. In the 26 years Buie worked at Pisgah Institute, BCBS only increased its reimbursement rates once.
“They basically discriminate against mental health providers,” he said. Unfortunately, physicians cannot sue insurance companies, and when Buie complained to the then-Commissioner of Insurance Wayne Goodwin, he was told it was a contracting issue.
When asked to comment on reimbursement rates, BCBS NC spokesperson Darcie Dearth did not address the issue directly. Instead, she pointed to a 2022 press release announcing that the company would expand its coverage of telehealth services, including behavioral health services, in 2023.
Buie speculates that this reimbursement gap is one reason that physicians elect not to specialize in psychiatry.
Nevertheless, MAHEC has been working to actively recruit psychiatrists to the region. Since 2017, they have run a clinical psychiatry residency. Of the 12 graduates, Buie said, eight have stayed in the region: seven in Asheville and one in Cherokee County.
Addressing the needs of children
One area where Asheville in particular has less of a shortage than other areas of the state, according to Buie, is in child psychiatry.
Off-hand he could name at least two physicians at MAHEC, two at Pisgah Institute, and three with private practices. In fact, Buncombe County has 19 child or adolescent psychiatrists, according to the American Academy of Child & Adolescent Psychiatry.
That places Buncombe County as fifth in the state for the most psychiatrists, behind Durham, Orange, Mecklenburg and Wake counties. Even so, Buie acknowledges that it’s not nearly enough, since those physicians serve not only Buncombe County but the rest of Western North Carolina.
According to data from the American Academy of Child and Adolescent Psychiatry, only four child or adolescent psychiatrists serve the counties west of Buncombe: two in Haywood County and one each in Jackson and Macon.
It’s especially hard for Nash to find psychiatrists for her child and adolescent clients, whose cases are the most difficult. “With an adult, you find something that works and they're probably going to maintain about their same hormone levels and about their same size," she said.
"With a child, you're constantly having to adjust meds.”
As a result, child psychiatrists rarely discharge an under-18 patient from their list. That makes it very difficult for new patients to come onboard.
The wait to be seen can be agonizing for children and their families. One of Nash’s newest patients, an adolescent, is currently taking multiple medications that give significant side effects. Nash has attempted to find a child psychiatrist for this patient, but two local providers have said the adolescent’s needs are too complex for them to treat with confidence.
Nash is currently trying to find a provider in Charlotte. In the meantime, the patient continues to take the medications, suffering side effects that put strain on them, their parents, and their siblings. “Six months, that's a long time to be uncomfortable” for a teenager, Nash said.
The need has grown even greater since the pandemic, as mental health conditions in both children and adolescents have grown significantly. As a result, some organizations are trying to step into the gap to provide whatever services they can. This includes the Center for Rural Health Innovation, which runs the Health-e-Schools telehealth initiative.
This program provides school nurses with telehealth equipment so that they can work with a remote nurse practitioner when a child presents with a problem.
A 2023 study by the Center for the Analysis of Longitudinal Data in Education Research found that this program lowered absenteeism for elementary and middle school students from 2012 to 2018, especially for students with chronic health issues.
In the beginning, Health-e-Schools avoided behavioral health, mostly because it’s not reimbursed.
“If I was going to hire a therapist, it would have to be entirely grant-funded with no hope of ever billing for those services,” said CRHI executive director Amanda Martin North.
The most they felt able to do, she said, was work with students who already had mental health diagnoses. This year, however, they hired a psychiatric mental health nurse practitioner who has the power to diagnose children because they are seeing younger children present with conditions for the first time now that they have entered school.
“They didn't go to pre-K, they didn't go to daycare, they didn't socialize” during the lockdown, North said.
“More importantly, they weren't screened appropriately and adequately for stuff like autism.”
While North says it’s been a bumpy road in the program’s early days, the Health-e-Schools initiative is trying to make it work. “We know there's an unmet need,” she said.
Nevertheless, telehealth remains an imperfect mental health care tool for most children, according to Buie. “A lot of therapy with children is play therapy,” he said. “You certainly benefit from being able to see them” in person.
When telehealth, social services don’t mix
“I'd say about a quarter of my caseload is coming in through telehealth at this point,” said Garrett Lagan, a licensed clinical social worker and licensed clinical addiction specialist with Blue Ridge Health.
While his office is located in Sylva in Jackson County, he also sees patients from Swain County, as well as a few people from across the 10 counties that Blue Ridge serves. The greatest factor he has found that determines whether his patients use telehealth is their ability to access transport.
“We don't have a lot of really affordable, reliable public transportation in the communities around here,” he said.
“If you have to call Swain County Transit a week in advance to schedule a ride, and then it also costs you $5, you might be more inclined to use telehealth.”
However, he often struggles to connect to his patients due to his internet connection, provided by a local provider, BalsamWest.
“There have been times where I've had to pack things up and head into town to find public Wi Fi in order to be able to do what I'm doing,” he said.
While talking over Zoom with Carolina Public Press, he measured his internet speed as 6.8 megabits per second for downloading and 2.5 mbps for uploads — far below the 25 mbps download and 3 mbps upload speed deemed the lowest threshold for high-speed internet by the Federal Communications Commission.
Dropping a call can derail a successful appointment, according to Lagan: “How many times am I going to ask somebody to repeat the same traumatic story because the signal broke up a little bit, you know?”
His patients can also have issues connecting. “A lot of people are using their phones, and the cell service around here is pitiful,” Lagan said.
This difficulty connecting is especially true with some of his most vulnerable clients facing issues like homelessness. The 2001 mental health reform bill greatly reduced the amount of enhanced services available for state residents, such as at-home visits or inpatient and outpatient rehab.
“A lot of our social service systems are built around how things show up in urban communities,” Lagan said.
“In our rural communities, you're gonna see a lot more couch surfing and camping than what you're going to see in the homeless population in Charlotte or in Raleigh,” he said.
Telehealth can not only be a greater challenge for these patients, but it can also be inadequate for their needs. As just one example, Lagan frequently helps homeless clients with mental illness apply for services. Often, this entails driving them to county records offices to get birth certificates to verify their identity.
“It can be tricky to get connected with the people who most need my service via telehealth,” he said. “You're going to be spending all of your energy making sure you've got a place to stay before you can focus on, ‘How do I get enough cell signal to talk to Garrett about why I'm upset about not having a place to stay?’”
One area where Lagan has found telehealth very helpful is Spanish-language interpreters for the Spanish-speaking clients he has. While Lagan meets in-person with the patient, an interpreter translates through a tablet.
“Getting an interpreter into a therapy session with telehealth is so much easier than grabbing somebody in the office,” he said. All the same, he said he prefers seeing patients in-person whenever possible.
Incremental change
Nash believes that one reason Western North Carolina has such a pronounced shortage of mental health professionals is that, unlike other areas of the state, the region does not have a teaching hospital or a four-year medical school.
“It's not to say we don't get great doctors — we do. But they have to already have this lean towards community health and underserved populations in order for them to want to come here,” she said.
Buie is encouraged by the growth of MAHEC’s clinical psychiatry residency, as well as its new Rural Integrated Behavioral Psychology Fellowship that began this September.
However, he cautions that it’s important to recognize that change will come incrementally. “Even at graduating six people per year and two fellows per year, it's going to take a long time to really meet the need,” he said.
“We have to see this as a 10- or 15-year project.”
This article first appeared on Carolina Public Press and is republished here under a Creative Commons license.
