The Honorable Gus Bilirakis: Title X of H.R. 3717 provides medical malpractice protections to providers that volunteer at Community Health Centers. Will you talk about the challenges that Community Health Centers have in finding qualified staff and getting fully staffed? How would this provision meet that need?
Dr. Michael Welner: Psychiatry features numerous subspecialty disciplines. The skills and technical knowledge unique to child psychiatry, substance abuse psychiatry, forensic psychiatry, psychopharmacology, and various psychotherapy protocols demonstrate how these and other subspecialties are distinct.
Updating knowledge is always a pressure, because new discoveries in the brain and behavior and excellent research impacts diagnostics and therapeutics. Only last year, the American Psychiatric Association released it’s the fifth version of its diagnostic handbook. In order for me to demonstrate the qualifications of psychopharmacology for board certification, I needed to sit for examination every five years.
Reimbursement is poor relative to other specialties, and it is easier to make a more prosperous living in almost every other medical discipline. Psychiatry suffers a lack of prestige from its origins as iconoclastic, theoretical, and not science-based. The field has matured dramatically into an evidence-based discipline, but psychiatry’s lower prestige has lagged. Contrast psychiatry’s assessment and therapeutics of the brain – exactly the domain of neurosurgery. Neurosurgery enjoys all of the intrigue of its focus in the brain, and all of the prestige of the life-saving surgery. Psychiatry, on the other hand, is denigrated and even lampooned.
Many shortages exist in subspecialty talent. The same lacking incentives that disadvantage psychiatry from out-competing other medical disciplines impact subspecialty talent as well. As for child psychiatry, the gap between needs and staffing is so substantial that positions in many areas are already overtaxed.
Community mental health centers are limited in their resources. A general psychiatrist or counseling psychologist may be responsible for the gamut of services. This is akin to a general practitioner being responsible for all medical needs, and for all ages. It may be adequate for many community residents, but the special emotional problems of some children, those of all ages with chemical dependency, those in crisis, and the recently incarcerated with risk reduction issues call upon very different knowledge and clinical skills.
Shortages of mental health professionals in underserved localities carry more serious consequences than medical shortages. The public health system remedies the absence of available acute and emergent medical needs with airlifting and ambulances. There is no airlifting a person in mental health crisis. The medical crisis patient seeks help and will travel where need be for vital care. The person in mental health crisis may be at particular risk for suicide or violence because that individual denies a problem and refuses to seek center-based help. Mental health crisis response approaches, involving counselors, physicians, other allied professionals, and other community supports must be refined in underserved areas.
HR 3717 attaches eligibility for block grants to the community mental health center’s success in attracting appropriate staff to provide the range of subspecialty services needed. These also include staffing community mental health centers with staff with cross-cultural literacy. Funding for community mental health centers can only account for some needs, however. Crisis intervention and other counseling can especially be aided by professional volunteers whose skills become force extenders in underserved areas.
Mental health crises may be a life threatening suicide risk or family emergency. Or, community safety may be in play. The human, medical, and material costs of mental health crises may draw liability interest because the outcomes can be devastating. The American public is best served when doctors make room in their careers for crisis mental health and for dealing with the unpredictable course of the seriously mentally ill. A prudent vision from this Congress and from mental health leadership would be to draw those with the best skills to meet the acute needs of the seriously mentally ill and those in crisis.
Patients in crisis need more attention and follow-up. Doctors may not necessarily be reimbursed for more frequent or more lengthy contact. This is unacceptable. The importance of heavier outpatient services during crisis must be respected in reimbursement. Otherwise, our government is not treating crisis and acute illness with the same urgency as public safety and homeland security issues.
Given the potential risks, these professionals are comparable to those who perform high risk obstetrics, or neurosurgery. For this reason, liability exposure is also a strong deterrent to potential crisis mental health providers. Bad outcomes, especially suicides and enduring injuries, threaten treaters regardless of the excellence of their effort. Naturally, doctors who can make decisions about how to apportion their time would be dissuaded from working with those who need it most.
Something has to give. Either we create conditions (be they tax advantages, liability protections, tuition reimbursement, specialized training, better reimbursement, for example) that incentivize the best mental health professionals to practice with the serious mentally ill and those in crisis, or we are not respecting serious mental illness seriously enough. We will the keep learning the hard way from tragedies that could have been interrupted, even as we allocate monies or direct them properly. At the end of it all, the toughest patients have to be seeing the best talent. This includes alleviating the reality that conditions for assuming care for the crisis and serious mentally ill patients are too thankless and driving their doctors away. The dialogue within the Energy and Commerce committee has proven that this reality is unsustainable.
In order to advance, therefore, individual constituencies will have to accept the need for adjustments. Trial lawyers, for example, resist any liability immunity discussions for those tasked with the most volatile and high risk. Their position clearly sacrifices remedies to attract top talent to defuse crises in order to protect revenue streams. Congress needs to set limits with selfish resistance that places the needs of a select few over crisis management. Would we not protect our military from liability suits of those hurt or killed while our Navy Seals or Army Rangers or Marines are exercising public service? Are there not qualified immunities for first responders and SWAT law enforcement who likewise put themselves in harm’s way? Why would crisis mental health professionals be any different?
America has already witnessed the byproduct of this liability industry overfishing in the decimation of high risk obstetrics. So unapproachable is liability protection that doctors have simply stopped practicing, and those with special medical needs become unserved in conditions that are more third world. So, too, have neurosurgeons become endangered species with predation.
The gaps in community mental health and crisis mental health that have prompted these hearings and have inspired HR 3717 mandate that we protect professionals performing lifesaving work in the national interest at least as much as we protect spotted owls from rapacious profiteering. And if liability protection to those working with the most seriously mentally ill cannot be compromised, how would our national health needs realistically attract volunteers to underserved community mental health centers?
I strongly recommend to the Subcommittee on Health, and to Congressman Murphy, to respond to the national dialogue that has inspired HR 3717 by creating a range of conditions that attract the best and the brightest to crisis mental health. Our nation will owe a great debt to you all, as will those you have a hand in saving.
