Loan Forgiveness and Telepsychiatry

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i61164

i61164

Polar Bear, MD
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A psychiatrist was recently telling me that you can serve an underserved population via telepsychiatry and qualify for loan forgiveness. He mentioned that you can get more than 100K of loans forgiven. Has anybody else heard anything about this or have any details?
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Loan forgiveness for telepsychiatry for underserved areas would be great. I would also be interested to know more about telepscyhiatry for private practice psychiatrists and their patients who are not in underserved areas. This would open up a lot of flexibility for travel, living abroad and working from home.

Here's a scenario: A practice consisting entirely of patients who are willing to do a significant proportion of their sessions via telepsychiatry. This would include psychopharmacology as well as most forms of psychotherapy. The intake and most other sessions would be done in person, but a pre-determined number of sessions during a specific time (e.g. June through August) would be done over the internet. They would have to agree to this and have the necessary computers/internet access in order to be accepted into the practice. Prescribing would be done over the phone for these sessions. They would pay whatever they would normally pay for in-person sessions.

A number of questions arise from this scenario:
1) Would patients be willing to do this, especially if they have access to psychiatrists who are available in person all the time?

2) What are the considerations in terms of reimbursement, malpractice insurance?

3) Is the technology that is available to the average person at a low cost advanced enough to enable this? Do free programs such as Skype, SightSpeed and iChat have sufficient video resolution and speed to make a psychotherapy session meaningful?

4) How is the quality of care affected?

5) Does this system act to limit care to only those who have access to high-speed internet? Isn't this pretty much most people who have insurance/can pay full fee?

Any ideas? Any other questions that others might have?
 
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Update: The program he was telling me about is for North Carolina (maybe this phenomenon will spread?). Here is a website with some info: http://www.ncruralhealth.org/services.html#inc1 It doesn't mention psychiatry or telemedicine on the webpage, so I guess this is sort of unofficial. The chair of my department says that he has received a verbal commitment that telepsychiatry is elegible for this program. It mentions $70,000 for 4 years and according to my source, they also pay the taxes on that so the actual value is greater. So theoretically, you can receive this loan repayment deal while also receiving the benefits of a professorship at an academic center. Double dipping.
 
psychotherapy via tele-link = reduced efficacy.

A mostly gut call on this one, but I think a safe one.
 
masterofmonkeys said:
psychotherapy via tele-link = reduced efficacy.

A mostly gut call on this one, but I think a safe one.
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What does the literature say? I doubt several programs are doing telepsychiatry now just because it seemed like a good idea and they had an extra web cam on hand.
 
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wolfvgang22 said:
What does the literature say?
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I have seen exactly ONE RCT on telepsychiatry vs in person psychotherapy and that was for 8 sessions of CBT over 24 weeks. Which is an oddball frequency and although you can do 8 session CBT I think it's generally longer. (12-16 week?)

For consults and med management I'm sure it's fine. But psychotherapy is about interpersonal connection and there's a heck of a lot more to that than can be transmitted across a tv.

I doubt several programs are doing telepsychiatry now just because it seemed like a good idea and they had an extra web cam on hand.
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In related news, abilify has just been FDA approved for the treatment of hangnails, pneumonia, and GERD.
 
masterofmonkeys said:
In related news, abilify has just been FDA approved for the treatment of hangnails, pneumonia, and GERD.
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Ooo--time to repost this link!😀

"Pugh warned that Zoloft use may cause side effects such as agitation, erratic behavior, restlessness, difficulty speaking, or shaking of hands and fingers. He added that Zoloft can help those suffering from agitation, erratic behavior, restlessness, difficulty speaking, and shaking of hands and fingers."
 
masterofmonkeys said:
psychotherapy via tele-link = reduced efficacy.
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Where's the psychotherapy come in? I wouldn't imagine psychotherapy would be high on the hit-list of telepsych, but I could see a lot of other services rendered long distance pretty handily.
 
Bumping an old thread because I wanted to see if anyone has any more info on this type of thing?

Also, what is involved in setting up a tele psych practice? Do you just need Skype and a webcam, or are there special equipment/programs required? For the record, I'm not interested in being a lazy work-at-the-beach bum...I'm seriously interested in using tele psych to reach underserved populations.
 
digitlnoize said:
Bumping an old thread because I wanted to see if anyone has any more info on this type of thing?

Also, what is involved in setting up a tele psych practice? Do you just need Skype and a webcam, or are there special equipment/programs required? For the record, I'm not interested in being a lazy work-at-the-beach bum...I'm seriously interested in using tele psych to reach underserved populations.
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Who cares if some boney blue-fingered puritan thinks you might be a lazy work-at-the-beach bum for asking a legitimate business question?
I'm also interested in the answer. 😀

Anyway, I suspect telepsychiatry might be harder than it sounds and would appreciate any insights into it.

Thanks.
 
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i61164 said:
Update: The program he was telling me about is for North Carolina (maybe this phenomenon will spread?). Here is a website with some info: http://www.ncruralhealth.org/services.html#inc1 It doesn't mention psychiatry or telemedicine on the webpage, so I guess this is sort of unofficial. The chair of my department says that he has received a verbal commitment that telepsychiatry is elegible for this program. It mentions $70,000 for 4 years and according to my source, they also pay the taxes on that so the actual value is greater. So theoretically, you can receive this loan repayment deal while also receiving the benefits of a professorship at an academic center. Double dipping.
Click to expand...

yeah, I'm responding to an old post, but working out in Boone actually sounds kind of nice... tele or not.
 
I don't know much about telepsych. It was used at my residency program but only for involuntary commitment of patients. Actually IMHO that was a great reason to use it because it didn't involve treatment thus avoiding the legal pitfall of not reaching the standard of care.

A good place to start looking is Nighthawk. Nighthawk is a corporation that sets up radiology scans to be viewed by radiologists in Australia late at night. They have telepsychiatry franchises they will be willing to assist to set up at least last time I checked about 2-3 years ago.

I found this after a websearch.

http://www.tmhguide.org/

I've read that it's being used in prisons and that to me is not surprising since in that scenario too you can avoid the legal pitfall of not meeting the standard of care. I'm not kidding. It turns out, and this went up all the way to the Supreme Court, prison physicians only have to provide some type of care. It doesn't have to be the standard of care type of care. (A reason why several correctional institutions only have tricyclics and typical antipsychotics).

As for loan forgiveness, plenty of places offer it. A great thing about it is in many places it is given tax free. E.g. a place I work at now, I get an extra few hundred dollars tacked onto my paycheck and that money is not taxed. It's supposed to go into my loans but if I didn't put it into it I'd still get the money anyways. Too bad I don't have too much in loans (<$10,000). If I knew about loan forgiveness before I did residency, I would've intentionally got much more in loans. Seriously. I could've put more money into the day-trading and internet merchandising I did during that year off of medschool where I got most of my student debt paid off.
 
Sounds good. When you are finished watching someone self harm or threaten to complete the act of suicide you can just change channels and watch back how you handled it (along with the rest of the world) on youtube.

This would be a great prank in someones mind.

This will happen and it could be lucky old you.
 
For the reasons you mentioned, it is important that telepsychiatry be done in limited conditions. There are several stating that it does not meet the standard of care in many areas. One could create an argument that if a locality has no psychiatrists, then the standard of care is so low that telepsychiatry would not violate that criteria of malpractice. Remember the standard of care is defined by the local practice. If everyone got a PET scan in one locality, then that becomes the standard of care for that locality. If there's no child psychiatrists in an area, a general psychiatrist treating a minor could very comfortably argue in court that the standard of care does not include child psychiatry training.

Telepsychiatry certainly has it's limitations. For those of you gung ho about it, remember those limitations and the context it is being used.
 
What about using it in combo with extender personnel? For example, set up a very small rural office staffed by a social worker or nurse. This would help eliminate the issues of on camera suicide, weight checks, BP checks, etc. The only difference being that the physician doesn't have to live in BFE.
 
Ibid said:
Sounds good. When you are finished watching someone self harm or threaten to complete the act of suicide you can just change channels and watch back how you handled it (along with the rest of the world) on youtube.

This would be a great prank in someones mind.

This will happen and it could be lucky old you.
Click to expand...

Never would have thought of that--i.e. someone recording it and putting it on youtube. I wonder if there are ways to prevent recordings from happening? Regardless of the recording issue, I suppose anyone could self-harm during an appointment. You would have to just be prepared to call 911 or have some other safety procedure in place prior to setting up a practice.
 
What about using it in combo with extender personnel?
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That would help you out, but guess what? There's also the captain of the ship policy. You could be held responsible if your crew is incompetent because as the "captain" you have responsibility over your crew.

(There are ways to legally sidestep the captain of the ship policy but that's another topic unto itself).

Let's all admit to the truth that is not PC talk in treatment teams. Some staff members (including the physicians!) are just terrible and incompetent. If you're doing telepsych, you're going to have even a harder time figuring out if the staff on the other end of the TV screen are competent.

Never would have thought of that--i.e. someone recording it and putting it on youtube. I wonder if there are ways to prevent recordings from happening?
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There are including closed line connections and encrypted data feeds. For that reason, if you do telepsych, do it with someone who knows what they're doing. Don't just simply do it over SKYPE. There's a reason why some places are franchising it and doctors are willling to have these businesses handle the compter-geek end. Some companies handle all the technical stuff and you sign a contract where if anything is leaked out, it's the franchise's fault, not yours.
 
Whooper

Luckily where I am we have socialised medicine so the "standard" is mandated by government. These national service frameworks in mental health at least have had a huge impact on reducing regional variation and inequalities with regard to what is provided. Of course this means that the government also has to establish quasiautonomous nongovernmental organizations to encourage innovation in that context, but thats socialism for you.

Edit: Crossed posts: Encription: If its on the screen you can grab it. (hint: just record the screen with another camera if all else fails)

Chimed

Joking apart, fear of these sorts of potentially events being reported in a salacious way need not hinder their use. I would simply make sure an official and complete recording of every encounter was made, then there is nothing to fear. One wouldn't want to stop a patient bringing a notebook and pen into a ward round or even making a sound recording of an outpatient appointment if it helped them remember what was said. A video record is just a natural extension of that in my view.

Self harm during an appointment? As long as they use fresh glass or clean razor blades and tidy themselves up afterwards. As you know most people who self harm are experts and know just how to cut with out causing anything more than superficial damage. In my experience putting people in control of when and how they cut lessens its incidence in the long run. Not an approach that goes down well with the general public or even some staff groups though, so video evidence of that approach could cause problems.

99 times out of 100, 911 for self harm by cutting is overkill in my experience. People who self harm by cutting get very very good at it. Just my opinion and very much a case of d.y.o.r.
 
This discussion seems to visualize telepsychiatry as a psychiatrist at home on his computer delivering care to a patient at home on his computer.

That's a pretty skewed view of how telepsychiatry is customarily practiced, at least from what I've seen. Our psych program has done a lot of work and research in telepsychiatry and the context is a provider delivering care to a patient that is in a doctor's office in the patient's area. Telepsychiatry in this context is a specialist coming in on a case as requested by another physician. You have someone with a meat-time relationship with the patient, someone monitoring the patient's physical condition, and no concerns about your care being surreptitiously videotaped or recorded by the patient.

I think it probably makes more sense to visualize and discuss telepsychiatry in that view than picturing doing therapy with Some Dude on his dial-up at home.
 
notdeadyet said:
This discussion seems to visualize telepsychiatry as a psychiatrist at home on his computer delivering care to a patient at home on his computer.

That's a pretty skewed view of how telepsychiatry is customarily practiced, at least from what I've seen. Our psych program has done a lot of work and research in telepsychiatry and the context is a provider delivering care to a patient that is in a doctor's office in the patient's area. Telepsychiatry in this context is a specialist coming in on a case as requested by another physician. You have someone with a meat-time relationship with the patient, someone monitoring the patient's physical condition, and no concerns about your care being surreptitiously videotaped or recorded by the patient.

I think it probably makes more sense to visualize and discuss telepsychiatry in that view than picturing doing therapy with Some Dude on his dial-up at home.
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Yeah, that makes a lot more sense the way you described it.
 
Notdeadyet

Interesting, of course that rather negates one of the potential advantages. Seeing a person in their usual surroundings would be so much more useful than just having a sterile clinic/consulting room as a back ground.

A natural habitat as a back drop could provide info on everything from how well they may be coping in general as well as all sorts of visual clues about what thier life is really like. This extra information on top of what they report could be really useful and provide a much richer context for management desicions than might usually be afforded.

Just my opinion.
 
Ibid said:
Interesting, of course that rather negates one of the potential advantages. Seeing a person in their usual surroundings would be so much more useful than just having a sterile clinic/consulting room as a back ground.

A natural habitat as a back drop could provide info on everything from how well they may be coping in general as well as all sorts of visual clues about what thier life is really like. This extra information on top of what they report could be really useful and provide a much richer context for management desicions than might usually be afforded.
Click to expand...
Personally, I think making assumptions based on what you see over a patient's shoulder is risky at best. Are they dialing in from their home or do they use a friends? Is the decor/cleanliness reflective of them or their spouse? If you see a blank wall over the patient's shoulder is it because they have no passion/imagination or is it because he and his wife use it on which to project home movies from their courtship or is it because their computer with the webcam is in a hallway? Etc. etc. etc.

Regardless, the benefit from any assumptions you want to make based on the background of a webcam session is far outweighed by the fact that you're delivering therapy to someone you've never met, who is not monitored by a physician, and who may be recording/broadcasting your sessions for who knows what purpose.

I don't believe webcam-based treatment delivered from a physician's home to a patient's home is yet standard-of-care for telepsychiatry. Trying to run before we walk in this modality seem like bad medicine.
 
I dont disagree. What you are saying is just commonsense.

Seeing someone where they live, in their own home, standard of care or not is always going to yield more information than a consultation in an office. The closer you can get to that the better, I was just trying to be positive about something that could easily be abused from either end of the line for different reasons.

Dampwallpaper, screaming children, endless traffic noise, a televison that is never turned off, early era K-mart furniture, unemptied ash trays, stacks of uanswered letters, emaciated pets, a mattress on the floor out of place, all these sorts of things tell a story and you wont get them in your consulting room.
 
FWIW, I met a doc last night who does some telepsych, skype style. He says he selects patients who only need that level of care (I.e. Stable, established patients), and also makes sure he is familiar with the services available in their area, so he can access them if the need does arise. He also agreed when I suggested that the patients themselves will somewhat self select for the theapy as well. If you're non comfortable skyping, you probably don't seek out a doc who does it.
 
masterofmonkeys said:
psychotherapy via tele-link = reduced efficacy.

A mostly gut call on this one, but I think a safe one.
Click to expand...

perhaps you should check up on your sources before making claims like this. I know for a fact that this is untrue. =)

cheers
 
bumping a old thread.

the VA has recently done a large study on telepsych and found it to be efficacious

i know a lot of places that have a hard time finding psych coverage.

it's too bad this isnt used more

in terms of loan forgiveness id be very careful with programs like the natl health service corp. who knows if the govt will be solvent enuf to pay yr loans?
 
GroverPsychMD said:
in terms of loan forgiveness id be very careful with programs like the natl health service corp. who knows if the govt will be solvent enuf to pay yr loans?
Click to expand...

I'm of the opinion that if the gov't isn't solvent enough to pay the loans, then we've got much bigger problems, and my loans probably wouldn't be worth anything anyways. If this ever happens, we'd likely have runaway inflation, making my 200k in loans, much much less than that in this hypothetical future.

Is it bad to wish for runaway inflation? I'd love for my total student debt to equal the cost of one Pepsi! 😀
 
Solvency is never an issue for a country that issues its own currency.
 
digitlnoize said:
What about using it in combo with extender personnel? For example, set up a very small rural office staffed by a social worker or nurse. This would help eliminate the issues of on camera suicide, weight checks, BP checks, etc. The only difference being that the physician doesn't have to live in BFE.
Click to expand...

I know I am responding to a year old post but when I was an MS-IV doing a child psychiatry rotation at UVa this is the solution they used. They connected remotely to community sites where an NP or PCP could handle the medical screen and staff members were nearby if anything went wrong. The camera equipment and screen was pretty high quality.

It had a different feel to it for sure. Despite having good equipment it was tough to pick up on subtle facial cues, shifts in posture, and the "feel" of the room that you can get when the person is face to face with you. It felt more impersonal and I became bored much quicker than I did with in person interviews and found it was tougher to sustain attention. It is useful as a last option (a heck of a lot better than those people having no access to care) and it could be fun to vary things up with a day of telepsych each week but it isn't something I would want to do full time.
 
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