The exodus of NHSC physicians from rural areas stems from various factors. Those psychiatrists interested in establishing a private practice find they may not generate adequate incomes unless their patients toil at companies that offer employees comprehensive third-party benefits. Generally these companies are located closer to larger cities or urban areas. Those who do choose rural practice are apt to remain salaried employees of organized systems, such as community mental health centers. Salaries offered to psychiatrists by rural clinics are generally less than those offered by their urban counterparts. However, the lesser pay is commonly offset by the lower cost of living in a rural locale. Additionally, adjusting to a rural social culture as well as facing the inevitable professional isolation encountered in working in these distant areas has deterred many psychiatrists from embarking on or sustaining a rural career.
The chronic difficulties in recruiting rural psychiatrists have begun to ameliorate. Graduate medical education programs in psychiatry have begun to consider decreasing the number of trainees graduating from their residencies. This continued supply of young psychiatrists, coupled with the general downsizing in psychiatric services as a consequence of managed care penetration in the private as well as the public sectors, has led to increasing competition for fewer positions in urban areas. The national movement to curb health care spending has limited the amount of service delivered and has, in turn, reduced the need for a variety of physicians in heavily populated areas. For the first time ever, urban psychiatrists are feeling the uncomfortable sting of underemployment. As a consequence, upon completion of residency training, many more graduates are investigating rural practice opportunities.
More importantly many states, such as New Hampshire, Virginia, Oregon and Louisiana, have developed elaborate State University Collaboration projects to give psychiatry residents a closely supervised experience in rural and frontier psychiatry in the hopes of luring graduates to those locales. Through active mentoring during residency training as well as sustained professional support once the psychiatrist is employed, these initiatives have offered valuable preparation for rural practice and have helped to curb the professional isolation that often leads to a limited tenure in these positions.
One antidote for psychiatrist undersupply may now be emerging as the nemesis of psychiatric employment: using paraprofessionals such as nurse practitioners and physician assistants to diagnose psychiatric illness and prescribe medication in rural areas. Oregon, Utah and Colorado have allowed the use of these physician-extenders, which coincidentally reduces the cost of service delivery. Many of these programs have the potential to work quite well and expand access to important services, provided there is adequate training as well as physician backup and supervision for challenging cases.
The pressure to control health care spending has certainly disproportionately affected the subsidy of mental health services, whether urban or rural, which unfortunately tend to be viewed as optional or expendable by some. Now, in an effort to contain health care costs, state governments and departments of mental health are beginning to look to managed care companies and health maintenance organizations to allocate and monitor the use of resources.
This transition has certainly been smoother in those states already heavily populated by health maintenance organizations and where capitation is a known entity for both patients and practitioners. In Oregon, for example, these private companies have chosen to contract, both via capitated and fee-for-service arrangements, with the existing mental health systems in rural areas, particularly for services such as psychosocial rehabilitation for the chronically mentally ill. Each recipient is entitled to a basic medical benefit with an additional subcapitated, subcontracted benefit for needed services for the severely and persistently mentally ill (SPMI), such as case management and housing.
It appears that the state has attempted to protect and preserve the existing system of delivery. Without ongoing financial support of some kind, the rural clinics might not have survived on their own and it is unclear whether a market of private providers would have emerged. This continuity, while protecting existing provider-patient relationships, also allows that most, if not all, patients in need will have access to psychiatric services in their area. However, according to David Cutler, M.D., director of the Public Psychiatry Training Program at Oregon Health Sciences University, psychiatrists employed in rural and urban areas are generally thought to be working harder with decreasing pay.
In Tennessee, this transition is following a divergent course. According to Clifton Tennison, M.D., medical director of the Helen Ross McNabb Center in Knoxville, the infiltration of managed care in the public sector via TennCare has occurred with less regard for the preservation of the previously existing relationships between the state and community mental health centers (CMHCs) and between the CMHCs and their collaborating agencies. Through TennCare, private provider networks have been slow to emerge. Control of the market has remained in the hands of the managed care organizations, leading to delays, denials and the absence of care in some cases.
Despite the original promise of a consequent increase in choice and quality with the fostering of competition, no private provider networks have emerged to take control of the market and, unfortunately, many psychiatric patients end up on long waiting lists or going without care. CMHCs now burdened to continue operating without guaranteed contracts or grants are struggling to downsize to survive, leading to a perpetually deteriorating quality of service where patients must either wait for months to be served or accept services from clinicians with ever-declining qualifications.
However, there may be a hopeful development in the very near future for psychiatric services in rural Tennessee. A mental health carveout from TennCare, called TennCare Partners, is scheduled to come to fruition this summer. With this plan, rural areas are slated to receive a windfall of dollars, which will ironically be shifted away from urban areas, where services are more ubiquitous and costly. The current plan is to capitate providers within their catchment areas based not on level of severity of illness or dysfunction, but on the number of TennCare recipients in that catchment area.
Because SPMI adults and severely emotionally disturbed children tend to be concentrated in urban areas, as are the tertiary care services, urban providers and patients will most assuredly suffer. Although the prior arrangement of Medicaid plus state grants was not perfect by any means, the traditional systems of interagency collaboration, enfranchisement to care for a given area and the guarantee of resources to provide care have given way to competition and distrust among providers who paradoxically must partner with one another to survive.
Although there has been pressure to downsize the budgets for public mental health services throughout the country, some states have yet to experience a dramatic change in the distribution and control of these monies. Richard Lippincott, M.D., assistant secretary of the Louisiana Office of Mental Health and Hospitals, reports that Louisiana continues to struggle with the traditional methods of rural mental health delivery. With minimal HMO or managed care penetration in the state, the department of mental health continues to maintain the traditional model of rural psychiatric funding through grants and fee-for-service methods. However, in Louisiana more costly services such as an inpatient stay or a psychosocial rehabilitation program now require authorization, which is a concerted effort to contain costs. There is a single point of entry system and a cap on the amount of uncompensated care reimbursement that can be expended.
Lippincott suggests that if the entry of managed mental health care entities into the arena of public psychiatric services is accomplished in a well-organized and thoughtful manner, the end result has the potential to be an exciting boon to rural mental health care delivery. Conversely, the temptation for companies to take advantage of these vulnerable systems through collecting revenue and denying care is an ever-present danger as well. As a result, departments of mental health must themselves be extremely savvy buyers in the new health care marketplace.
Thus, competition for employment and managed care infiltration into private and public sector service delivery, though commonplace in urban psychiatric markets, are now beginning to affect the future of rural psychiatric practice as well. Certainly, despite these inescapable forces, the rewards of rural living, such as a lower cost of living and a slower pace of life, will continue to draw more and more psychiatrists to rural work as the urban opportunities diminish.
