Combatting the Psychiatrist Shortage in

Wisconsin: Policy Recommendations for

Increasing the Psychiatry Workforce and
Access to Mental Health Services
Prepared for the Wisconsin Medical Society by Josh Cruz, Ian Korpel, Stephanie
Murray, Morgan Pair, and Sangeetha Shreedaran
 2018 Board of Regents of the University of Wisconsin System
All rights reserved.

For an online copy, see

http://www.lafollette.wisc.edu/outreach-public-service/workshops-in-public-affairs
publications@lafollette.wisc.edu

The Robert M. La Follette School of Public Affairs is a teaching and research department of the University
of Wisconsin-Madison. The school takes no stand on policy issues;
opinions expressed in these pages reflect the views of the authors.

The University of Wisconsin-Madison is an equal opportunity and affirmative-action educator and employer.
We promote excellent through diversity in all programs.

ii
 Table of Contents

Foreword.................................................................................................................................... 1
Acknowledgements ..................................................................................................................... 2
Executive Summary .................................................................................................................... 3
Introduction: Overview of Psychiatrist Shortage in Wisconsin...................................................... 4
Existing Efforts to Alleviate Shortage .......................................................................................... 6
Goals and Impact Categories....................................................................................................... 7
Methodology ............................................................................................................................... 8
Analysis of Potential Policy Solutions........................................................................................... 9
Telemedicine ........................................................................................................................... 9
Telepsychiatry ...................................................................................................................... 9
Part-Time Retirement...........................................................................................................14
Integrated Care and Nonprofit Contracting ............................................................................15
Integrated Care ...................................................................................................................15
Nonprofit Contracting ..........................................................................................................20
Loan Assistance......................................................................................................................22
Designate Loan Assistance Awards for Psychiatrists ...............................................................23
Increase the Loan Assistance Award for Psychiatrists .............................................................26
Residency and Recruitment Programs.....................................................................................27
Expand Residency Programs ................................................................................................28
Recruit Medical Students into Psychiatry ...............................................................................30
Reimbursement and Parity Enforcement.................................................................................32
Reimbursement ...................................................................................................................32
Parity Enforcement ..............................................................................................................34
Conclusion and Recommendation ...............................................................................................36
1. Expand Residency Programs ...............................................................................................37
2. Integrated Care .................................................................................................................37
3. Telepsychiatry ....................................................................................................................37
4. Parity Enforcement.............................................................................................................37
5. Recruitment into Psychiatry ................................................................................................37
Appendices ................................................................................................................................38
Appendix A: Goals Matrix ......................................................................................................38
Appendix B: Economic Impact Analysis of a Psychiatrist .........................................................39
Appendix C: North Carolina Telepsychiatry Program Model ..................................................41

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Foreword
This report is the result of a collaboration between the La Follette School of Public Affairs at the
University of Wisconsin–Madison and the Wisconsin Medical Society. Our objective is to
provide graduate students at the La Follette School with the opportunity to apply their policy
analysis skills while providing WMS with an analysis of policies and programs designed to
increase the number and reach of psychiatrists practicing in the state of Wisconsin.

The La Follette School offers a two-year graduate program leading to a master’s degree in public
affairs. Students study policy analysis and public management, and they can choose to pursue a
concentration in a policy focus area. They spend the first year and a half of the program taking
courses in which they develop the expertise needed to analyze public policies. The authors of this
report all are in the final semester of their degree program and are enrolled in Public Affairs 869
Workshop in Public Affairs. Although learning a set of skills in the classroom is important, there
is no substitute for doing actual policy analysis as a means of developing these abilities. Public
Affairs 869 gives graduate students that opportunity.

This year, workshop students were divided into eleven teams. Other teams completed projects
for the U.S. Department of the Treasury, Environmental Protection Agency (Region 5),
Wisconsin Department of Public Instruction, Wisconsin Bureau of Assisted Living, Wisconsin
Department of Health-Division of Medicaid Services, B-Local Wisconsin/Always B Sustaining
LLC, National Council on Crime and Delinquency, UNICEF, the Moravian Church, and
Daayitwa (Nepal).

Wisconsin has too few practicing psychiatrists—a discrepancy that is expected to worsen in
coming years. This shortage is most acute in rural parts of the state where there is substantial
unmet need in mental health services. This report provides a detailed examination of policies and
programs designed to both increase the number of psychiatrists practicing in the state and
increase their presence in underserved communities. From increasing the number of psychiatric
training slots at medical residency programs in the state to implementing a comprehensive
telemedicine program, the ideas in this report provide state and local policymakers a robust set of
options for helping ensure every Wisconsin resident has access to high quality mental health
care.

Rourke O’Brien
Assistant Professor of Public Affairs
May 2018
Madison, Wisconsin

1
Acknowledgements

The authors would like to thank Wisconsin Medical Society for the opportunity to engage in this
project on the psychiatrist shortage in Wisconsin. Thank you to HJ Waukau and Dr. Martha Rolli
from the Wisconsin Medical Society for offering their time and resources to help guide and
coordinate our work with their organization. Thank you to all those who shared information with
us about their organizations and allowed us to interview them: Pamela Guthman, Indianhead
Community Action Agency; Kathleen O’Brien, Walden Sierra Inc.; Dr. Jennifer Beyer, St. Croix
Regional Medical Center; Debra Morrison, University of Washington AIMS Center; Dr. Art
Waleszek, University of Wisconsin–Madison Department of Psychiatry; and John Eich and
Kevin Jacobson, Wisconsin Office of Rural Health. Thank you to Professor Rourke O’Brien for
his continued insight, support, and guidance throughout the progress of this report. All the
aforementioned partners and stakeholders contributed to the quality and completion of this report
in all its stages.

2
Executive Summary
Wisconsin faces a growing shortage of psychiatrists, and access to mental health services in the
state is low. In this report, we analyze several policy alternatives for increasing the psychiatrist workforce,
improving access to care, and boosting efficiency, while emphasizing high quality care and reducing
stigma. Based on our findings, we recommend a broad array of approaches that involve several groups
within Wisconsin, including the State Legislature, hospitals, health systems, universities, insurers, and
nonprofit organizations. To better utilize and support the existing psychiatrist workforce, we recommend
the utilization of telemedicine and integrated care models, as well as improved enforcement of mental
health parity. To directly address the shortage of psychiatrists in Wisconsin, we also recommend
expanding psychiatry residency training programs and increasing efforts to recruit medical students into
psychiatry. Our analysis identifies these as the most effective ways Wisconsin can utilize its resources to
increase the number of psychiatrists working in the state.
Wisconsin ranks fourth nationally in prevalence of mental illness. Nearly 1.45 million people in
the state live with a mental or behavioral health issue, ranging from anxiety and depression to
schizophrenia, addiction, and substance abuse. Unfortunately, many Wisconsinites suffering from mental
health issues struggle to find care when they most need it; 49 percent of Wisconsin residents with a
mental illness do not receive care. Lack of access to mental health services strains not only the individual,
but also his or her family, coworkers, caretakers, and the community. It is estimated that costs associated
with mental illness have a $9 billion impact on Wisconsin’s economy due to lost productivity, public
assistance, and crime.
Access to mental health services is especially scarce in low-income urban areas and rural
communities. Unless specific efforts are made to improve access in these areas, it is expected to worsen
over the next decade, as a large portion of Wisconsin’s psychiatrist workforce is expected to retire. Nearly
half of Wisconsin psychiatrists are older than 55; one-quarter are older than 65.
Historically, psychiatry has struggled to recruit medical students into the field due to societal and
professional stigma associated with mental illness and the perceived lack of effective treatments. Even
more challenging is placing those who choose psychiatry to practice in rural or underserved areas.
In this analysis, we rely on a combination of literature reviews, data analysis, and personal
interviews to evaluate a number of policy options for addressing these challenges. Utilizing existing
efforts to address these challenges, we consider the impact of increasing Medicaid reimbursement rates
for psychiatry services, improving enforcement of mental health parity, and expanding loan assistance,
and residency and recruitment programs. We also explore alternative models of patient care, such as
telemedicine, integrated care, and nonprofit contracting.
This report provides several perspectives on how the state of Wisconsin can introduce policies
that build and maintain a sustainable psychiatrist workforce and increase access to mental health services,
while reducing the stigma of psychiatry and mental illness, maintaining or improving quality of care, and
maximizing efficiency. Ultimately, we identify the expansion of graduate medical education opportunities
through increasing psychiatry residency class sizes or creating rural psychiatry residency programs as
having the greatest potential to achieve these goals. We also recommend the utilization of telemedicine
and integrated care models, improved enforcement of mental health parity, and the expansion of programs
designed to recruit medical students to train and practice as psychiatrists in Wisconsin.

3
Introduction: Overview of Psychiatrist Shortage in Wisconsin
Psychiatrists are in increasingly short supply throughout the country. Between 2003 and 2013, the
number of physicians has increased by 14.2 percent; however, the number of psychiatrists declined
slightly (-0.2 percent). As a result, the average number of practicing psychiatrists per 100,000 residents in
hospital referral regions (populations served by common major referral centers) fell by 9 percent over this
period. 1 An estimated 60 percent of U.S. counties do not have a single psychiatrist. 2 A study
commissioned by the U.S. Department of Health and Human Services estimates that the current
psychiatric workforce would need to increase by 6.4 percent to meet demand; the shortfall is expected to
rise to 12 percent by 2025. 3 An aging workforce exacerbates this shortage; an estimated 59 percent of
psychiatrists are 55 or older, making it the third oldest specialty. 4 The shortfall of psychiatrists contributes
to the significant gap in treatment for those with mental illnesses; of the 44 million adults who experience
mental illness in a given year, 60 percent will have received no mental health services in the previous
year. 5
Wisconsin is not immune to these challenges. Statewide, Wisconsin has roughly 1.5 psychiatrists
for every 10,000 residents. However, the ratio varies significantly across the state; 75 percent of
Wisconsin counties have a “significant shortage” of psychiatrists, defined as having fewer than one
psychiatrist for every 10,000 residents. 6 Another 43.1 percent (31 of 72 counties) have fewer than one
psychiatrist for 30,000 residents, the threshold used to define federally designated Mental Health
Professional Shortage Areas (HPSA). 7 Twelve Wisconsin counties have no psychiatrists; another 11 have
less than one full-time psychiatrist. Figure 1 shows that the most severe shortages are concentrated in the
northern half of the state. Figure 2, a map of the population-to-psychiatrist ratio by county produced by
the American Medical Association’s (AMA) Health Workforce mapper, tells a similar story. Similar to
nationwide trends, these shortages are exacerbated by Wisconsin’s aging workforce, 25.6 percent of
Wisconsin’s psychiatrists are 65 or older; 48.8 percent are 55 or older. Of those younger than 55, nearly
70 percent practice in Dane, Milwaukee, and Waukesha counties.
These shortages contribute to Wisconsin’s high mental health treatment gap; 49 percent of
Wisconsin residents with a mental illness do not receive care.8 The gap among adults is higher (54
percent), and among children is lower (36 percent). However, these statewide figures mask regional

1
Bishop, Tara F., Joanna K. Seirup, Harold Alan Pincus, and Joseph S. Ross. “Population of US practicing
psychiatrists declined, 2003–13, which may help explain poor access to mental health care.” Health Affairs 35, no. 7
(2016): 1271-1277.
2
New American Economy, “The Silent Shortage: How Immigration Can Help Address the Large and Growing
Psychiatrist Shortage in The United States.” New American Economy: Healthcare (October 2017).
3
National Council Medical Director Institute, “The Psychiatric Shortage: Causes and Solutions.” National Council
for Behavioral Health (March 28, 2017).
4
Merritt Hawkins, “The Silent Shortage: A White Paper Examining Supply, Demand and Recruitment Trends in
Psychiatry.” Merritt Hawkins White Paper Series (2018).
5
ibid
6
Data provided by the Wisconsin Medical Society, 2018.
7
“First Quarter of Fiscal Year 2018 Designated HPSA Quarterly Summary.” n.d. Bureau of Health Workforce
Health Resources and Services Administration (HRSA) U.S. Department of Health & Human Services
8
State of Wisconsin Department of Health Services Division of Mental Health and Substance Abuse Services,
“Wisconsin Mental Health and Substance Abuse Needs Assessment Update.” State of Wisconsin Department of
Health Services (February 2016).

4
variation. The adult mental health treatment gap ranges from 5 percent in Dane County to 80 percent in
Calumet County and is most severe in the northwestern and southwestern parts of the state.
Figure 1: Figure 2:
Counties Below HPSA Designation Threshold Population-to-Psychiatrist Ratio by County

43.1 percent (31 of 72 counties) have fewer than one psychiatrist The population-to-psychiatrist ratio varies widely by county, from less
per 30,000 residents. than 7,000 residents per psychiatrist to more than 60,000.
Source: Wisconsin Medical Society data 9 Source: American Medical Association health workforce data 10

Alleviating widespread shortages of psychiatrists will provide benefits that extend well beyond
their patients. Psychiatrists have a positive economic impact on the state through the generation and
support of jobs, output (medical revenues generated in the course of patient care), tax revenue, and the
alleviation of the social costs of mental illness. A study prepared for the AMA estimated the state-specific
economic impact of patient care physicians in all 50 states, across four vital economic barometers: output,
jobs, wages and benefits, and state and local tax revenue. 11 In addition, the study evaluated the impact of
10 specialties, including psychiatry. Accounting for varying state economies and healthcare
environments, these estimates include direct and indirect impacts.
Direct benefits capture the medical revenues generated in the course of patient care, the jobs
within the physician industry, wages and benefits of physicians and employees who are hired to support
the delivery of patient care, and the taxes that are paid by physicians and the positions that they create.
Indirect benefits are those economic activities generated by the industries that are supported by
physicians. These “business-to-business” effects include the “supplies/equipment purchased by
physicians, practice administrative services, cleaning/property maintenance services, and clinical and
laboratory services.” 12 Additional indirect benefits arise when the employees of physicians and vendors
spend their earnings to support local businesses, which pay their employees and pay taxes.
The AMA study found that in 2015, each psychiatrist in Wisconsin generated an average of $1.4
million in output and supported 7.5 jobs, which paid $709,248 in wages and benefits. Adjusting for
inflation (CPI), these figures translate to $1.47 million in output and $743,258 in wages and benefits in
2018. In total, Wisconsin’s 852 psychiatrists generate $1.25 billion in output and $633 million in wages

9
Data provided by the Wisconsin Medical Society, 2018
10
“Health Workforce Mapper | AMA.” accessed April 13, 2018, https://www.ama-assn.org
11
IQVIA, “The Economic Impact of Physicians in Wisconsin: State Report.” The American Medical Association
(January 2018).
12
ibid.

5
and benefits annually. Because of the lack of psychiatrists, some counties are getting none of this value.
For more information about the study, see Appendix A.
Though useful, these figures underestimate the true impact of psychiatrists on Wisconsin’s
economy. In addition to generating output and supporting jobs and wages, psychiatrists help alleviate the
social costs of mental illness. Although the social costs of mental illness are difficult to quantify,
estimates suggest binge drinking and unaddressed substance abuse each cost Wisconsin an estimated $3
billion annually. 13,14,15 Opioid misuse, which has increased significantly in recent years, cost Wisconsin
$1 billion in 2009. 16 Alcohol-related motor vehicle crashes cost Wisconsin $1.1 billion in 2015. 17
Depression and schizophrenia cost Wisconsin $800 million and $1 billion each year, respectively. 18,19 In
addition to the costs associated with public assistance and crime, Wisconsin’s Department of Health
Services (DHS) estimates that the total cost of mental illness in the state at nearly $9 billion annually.
Given the severity of the psychiatrist shortage as well as the economic and social benefits
psychiatrists provide, Wisconsin policymakers and leaders are seeking ways to support and expand the
state’s psychiatric workforce. In this report, we analyze a series of potential policy options for doing so.
First, we describe the explicit goals of the analysis and the metrics by which policy options will be
evaluated. Next, we analyze and score each policy according to those goals and metrics. Finally, we
recommend a series of the most promising policy options based on our findings.

Existing Efforts to Alleviate Shortage

There are a number of existing programs in Wisconsin aimed at drawing psychiatrists and other
physicians to underserved parts of the state. For example, there are three loan assistance programs
available to Wisconsin psychiatrists: the Health Professions Loan Assistance Program (HPLAP), the
Rural Physician Loan Assistance Program (RPLAP), and the National Health Service Corps (NHSC). The
HPLAP allows physicians, psychiatrists, dentists, dental hygienists, physician assistants, nurse
practitioners, certified nurse midwives, and other health professionals to receive up to $50,000 in
education loan assistance. In return, eligible health professionals must agree to work full-time in a
federally designated urban or rural HPSA for three years.
The second major loan assistance program is the RPLAP. Established in 2010, the RPLAP grants
physicians practicing in a rural community up to $50,000 in loan assistance funds. Physicians practicing
in rural communities qualify for this funding whether or not the worksite is located in a HPSA. Physicians
practicing in a rural HPSA can apply for both the HPLAP and RPLAP and receive up to $100,000 for a
three-year commitment.

13
“Wisconsin Mental Health and Substance Abuse Needs Assessment Update.” State of Wisconsin Department of
Health Services (February 2014).
14
Harwood, Henrick. “Updating estimates of the economic costs of alcohol abuse in the United States: Estimates,
update methods, and data.” the National Institute on Alcohol Abuse and Alcoholism, 2000 (2000).
15
Bouchery, Ellen E., Henrick J. Harwood, Jeffrey J. Sacks, Carol J. Simon, and Robert D. Brewer. “Economic costs
of excessive alcohol consumption in the US, 2006.” American journal of preventive medicine 41, no. 5 (2011): 516-
524.
16
Birnbaum, Howard G., Alan G. White, Matt Schiller, Tracy Waldman, Jody M. Cleveland, and Carl L. Roland.
“Societal costs of prescription opioid abuse, dependence, and misuse in the United States.” Pain Medicine 12, no. 4
(2011): 657-667.
17
Bigelow, Wayne. “Injuries, deaths and costs related to motor vehicle crashes in which alcohol was a factor,
Wisconsin, 2015.” Center for Health Systems Research and Analysis University of Wisconsin–Madison.
18
Stewart, Walter F., Judith A. Ricci, Elsbeth Chee, Steven R. Hahn, and David Morganstein. Cost of lost
productive work time among US workers with depression." JAMA 289, no. 23 (2003): 3135-3144.
19
McEvoy, Joseph P. "The costs of schizophrenia." The Journal of clinical psychiatry 68 (2007): 4-7.

6
 A third loan assistance program, which operates through the NHSC, awards up to $50,000 in
education loan repayment funds for health care professionals who agree to work for two years in a HPSA.
This program is similar to Wisconsin’s HPLAP and is open to physicians, dentists, advance practice nurse
practitioners, physician assistants, certified nurse midwives, dental hygienists, and mental health
professionals.
In addition to loan assistance, The Primary Care and Psychiatry Shortage Grant (2013 Act 128)
was created to encourage primary care physicians (PCPs) and psychiatrists to practice in underserved
areas of the state. Under this program, up to 12 PCPs and 12 psychiatrists can receive a financial
assistance award of at least $20,800 a year for up to three years.
Other opportunities include the Wisconsin Conrad Waiver program. This program allows foreign-
trained physicians to seek medical residency or fellowship training in the United States. A J-1 visa waiver
expedites the immigration process in return for providing primary care or general mental health care in
federally designated rural and urban communities that have shortages of PCPs or psychiatrists. Finally,
2017 Assembly Bill 556 introduced in the Assembly in October 2017 proposed an individual income tax
deduction for up to $200,000 of income earned in this state by a psychiatrist. However, the law was never
passed.
Despite these efforts, Wisconsin’s prominent and growing shortage of psychiatrists affects mental
health outcomes in the state. Below, we explore a series of policy options intended to build upon existing
efforts to address this issue.

Goals and Impact Categories

Below, we consider several policy options for alleviating Wisconsin’s shortage of psychiatrists.
We evaluate each policy by considering five broad goals: Workforce, Access, Efficiency, Quality, and
Stigma. (See Goals Matrix in Appendix A) Within each of these goals, we identified specific impact
categories by which to evaluate our policy options. We rated policy options according to each impact
category on a scale from -2 to +2, with -2 representing the least favorable outcome and +2 representing
the most favorable outcome (see Table 1). Each policy option’s overall ranking represents the weighted
sum of these individual scores. We assigned weights to each goal (and corresponding impact categories)
contingent on its priority. We determined workforce and access as the most important goals, so scores
within these goals received a 2-point weight. Efficiency and quality were considered secondary goals and
received a 1-point weight. Stigma, which has an indirect impact on the psychiatrist shortage, was a
tertiary goal and received a weigh of .5.

Table 1: Goals Matrix Analysis Scale

POLICY OUTCOME Score

Positive Effect 2

Moderate Positive Effect 1

No impact 0

Moderate Negative Effect -1

Negative Effect -2

7
Workforce: Increasing the total number of psychiatrists living and working in Wisconsin.
Impact Categories
● Within State: increase the total number of students pursuing training in psychiatry in Wisconsin.
● Recruiting: increase the number of psychiatrists recruited from out of state to work in Wisconsin
(measured in full-time equivalent hours worked).

Access: Helping people command appropriate mental health care resources to preserve or improve their
health.
Impact Categories
● Rural Access: increase the number of Wisconsin residents with a psychiatrist within a 45-mile
radius of the home.
● Equity of Access: increase the number of psychiatrists who accept insurance/Medicaid, ensure
that psychiatric services are available to all people regardless of socioeconomic status, and
minimize existing barriers.
● Underserved Area Access: increase the number of counties with normal or high access (i.e. more
than one psychiatrists per 30,000 people) and reduce the number of HPSA designated counties.

Efficiency: Achieving maximum productivity with minimum wasted effort or expense.

Impact Categories
● Cost of Operation: potential increased operating costs for clinics and hospitals.
● Ease of Implementation: the people and administrative resources necessary to enact the solution
(including one-time fixed costs).
● Political Feasibility: the political climate in Wisconsin and the potential level of opposition.

Quality of Care: Maintaining baseline quality of psychiatric care. The WHO says “the extent to which
health care services provided to individuals and patient populations improve desired health outcomes. In
order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-
centered.” 20

Stigma: Improving associations with the field of psychiatry.

Impact Categories
● Professional Stigma: the negative perception of standing within the medical field
● Societal Stigma: the negative perception of those needing psychiatric services. 21

Scores for each policy can be found in Appendix A, the goals matrix analysis.

Methodology
To evaluate policy alternatives, we relied on a combination of literature reviews, data analysis,
and personal interviews. A key component was to look at similar states already implementing these types

20
“What Is Quality of Care and Why Is It Important?” 2017. World Health Organization. World Health
Organization. February 16. http://www.who.int
21
Polaha, Jodi, Stacey L. Williams, Craig Anne Heflinger, and Christina R. Studts. “The perceived stigma of mental
health services among rural parents of children with psychosocial concerns.” Journal of pediatric psychology 40, no.
10 (2015): 1095-1104.

8
of programs and learn from their program designs. Our methodologies are outlined in the discussions of
each policy recommendation below.

Analysis of Potential Policy Solutions

Telemedicine
Telemedicine is a rapidly expanding strategy for increased saturation of health services. It seeks
to decrease administrative burdens, increase access for patients, and provide specialty services for
underserved areas. There are many differing definitions of telehealth. Wisconsin State law defines
telemedicine as:

“The practice of medicine when patient care, treatment, or services are provided through the use of
medical information exchanged from one site to another via electronic communications. Telemedicine
does not include the provision of health care services only through an audio-only telephone, email
messages, text messages, facsimile transmission, mail or parcel service, or any combination thereof.” 22

Whereas, the Federal Health Resources Service Administration (HRSA) says:

“The use of electronic information and telecommunications technologies to support long-distance clinical
health care, patient and professional health-related education, public health and health
administration.” 23

For this analysis, we separated telemedicine into two key policy options. The first is the more
well-known solution of telepsychiatry. The American Psychiatric Association (APA) is a strong
proponent of telepsychiatry and in 2015 created a committee on telepsychiatry that was tasked with
developing resources for educational materials specifically related to practice, research, and policy
implications. 24
The second policy proposal takes some of the chief problems identified through our research into
telepsychiatry and attempts to adjust the program to meet specific workforce needs designated by the
Wisconsin Medical Society. The chief component of the proposal is that the state of Wisconsin provide
resources for newly retired psychiatrists to continue to practice on a part-time basis via telepsychiatry.

Telepsychiatry
Though telemedicine is defined above, telepsychiatry is slightly different. The APA defines it as:

“Telepsychiatry, a subset of telemedicine, can involve providing a range of services including psychiatric
evaluations, therapy (individual therapy, group therapy, family therapy), patient education and
medication management... It also encompasses psychiatrists supporting primary care providers with
mental health care consultation and expertise. Mental health care can be delivered in a live, interactive

22
Telemedicine, Wisconsin State Statute, Register May 2017 No. 737, Med 24-02.
23
“What is Telehealth?” Center for Connected Health Policy, 2018, accessed March 20, 2018,
http://www.cchpca.org/what-is-telehealth.
24
“Telepsychiatry.” 2018. American Psychiatric Association. https://www.psychiatry.org

9
communication. It can also involve recording medical information (images, videos, etc.) and sending this
to a distant site for later review.” 25

Most telepsychiatry models still involve patients physically going to clinics and utilizing the
clinic’s equipment to initiate the meeting. However, in-home services are becoming more popular,
especially for elderly or physically restricted patients. It is important to note that administrative models
can differ greatly while still being considered telepsychiatry. The first model presented is a typical model
as supported by most telepsychiatry agencies. 26 The second is from Dr. Martha L. Rolli, the Wisconsin
Medical Society’s president and chair of its Mental Behavioral Health (MBH) Task Force. The final
model is a case study of the University of Arizona and St. Elizabeth Hospital.
The typical telepsychiatry model is relatively straightforward and an excellent starting place for
new programs. Patients often travel to clinics at set blocks of time and begin a telepsychiatry session with
an off-site specialist, who is able to do almost anything an on-site provider could do (i.e. medication
management, assessment, and treatment team meetings). It is important that a consistent off-site provider
collaborate with the on-site team. One benefit of telepsychiatry is that the model can be shifted depending
on need. For instance, models are available for crisis management, consultation, phone, integrated care,
asynchronous, in-home, and combinations of these. 27
In our interview with Dr. Rolli, a psychiatrist, the chair of the Mental Behavioral Task Force and
the Wisconsin Medical Society President-Elect, she emphasized two key points. First, that telepsychiatry
is a powerful tool when utilized properly and professionally. Specifically, the reputations and
qualifications of the practicing psychiatrists are what make some systems excel and others perform
poorly. Dr. Rolli’s chief concern is that low overhead costs make telepsychiatry particularly desirable for
less reputable providers seeking to profit from the booming market. She notes that, “as the shortage gets
worse, the more inadequately trained operators will appear.” 28 The best way to prevent undertrained
service provision is to ensure that participating psychiatrists have strong reputations and are already
experienced in in-person care. Her model dictates the need for strong centralized leadership with a well-
trained and self-managed system of experienced psychiatrists. This has the effect of keeping costs
internal, especially when utilizing in-house software licenses to implement the services.
The University of Arizona and St. Elizabeth Hospital used telepsychiatry for treating depression
in an underserved Hispanic population. The key takeaways to the program are as follows:

Benefits
1. Limited IT users have demonstrated acceptance of computer technology.
2. Telepsychiatry can improve access to and acceptability of mental health services.
3. Stakeholders report improvement in health outcomes and quality of care.

Barriers
1. Time and resource constraints can limit patient participation (similar to overall mental health
barriers, such as time off work).

25
“What Is Telepsychiatry?” 2017. What Is Telepsychiatry? American Psychiatric Association.
https://www.psychiatry.org/patients-families/what-is-telepsychiatry.
26
Morris, Chad and Varrell, James R. “Creating a Successful Telepsychiatry Program Best Practices for Designing
and Implementing Telebehavioral Health.” Tennessee Association of Mental Health Organizations (2014).
27
ibid
28
Dr. Martha Rolli, personal interview, March 29, 2018

10
How to Integrate
1. Partnerships can provide functional support.
2. A state’s reimbursement environment drives sustainability.
3. IT integration into a clinic’s broader system is necessary for sustainability. 29

Another state-level example is North Carolina, which provides 70 percent of the funding for the
program. The remaining 30 percent comes from the Duke Endowment. The program has been widely
successful at providing long-term cost savings; it has noted approximately $2.7 million in total return on
investment. The program has five core segments: Site development assistance, community development
assistance, contract development assistance, clinic/staff assistance, and other activities. It includes 42
hospitals, with 15 hospitals in development, and seven provider hubs (saturation map in Appendix C). 30
Similar systems have been implemented in Tennessee, San Diego, Georgia, and Kansas, and at
Penn State Hershey Medical Center. 31

Workforce
Within State: Dr. Art Walaszek, residency training director for the University of Wisconsin–
Madison’s Department of Psychiatry, said that telepsychiatry “solves geographic distance, not
capacity.” 32 A telemedicine model may lead to time-savings by reducing transportation costs. This is a
notable advantage of the program and we note its effects in analysis of the access goal. To have any
effect on the workforce, a telepsychiatry model would have to increase effective psychiatric hours, the
total number of hours Wisconsin psychiatrists spend with their patients. By decreasing the time
psychiatrists spend commuting to see their patients, telepsychiatry could have this effect. However, most
psychiatrists do not offer this service; therefore, we judge this potential time-saving to be minimal. The
overall analysis of this impact category designates no impact.
Recruiting: As telemedicine has expanded, powerful organizations are taking notice and
implementing their own programs. The Federal Government provides a clear example: “In 2010, the
Veterans Health Administration (VHA) established a National Telemental Health Center, and, in 2013,
that Center facilitated nearly 3,000 videoconference encounters to 1,000 patients at 53 sites in 24
states.” 33 Thus, we believe telepsychiatry can slightly increase the number of psychiatrist serving
Wisconsin from out of state, although the field is expanding and may become more prevalent within the
next decade. That said, according to the Wisconsin Statutes, “a physician who uses telemedicine in the
diagnosis and treatment of a patient located in this state shall be licensed to practice medicine and surgery
by the medical examining board.” 34 This requirement limits the out-of-state workforce potential; most of
Wisconsin’s import comes from neighboring states. Other psychiatrists note that, “Telemedicine is nifty.

29
NORC at the University of Chicago. “Case Study Report: University of Arizona and St. Elizabeth’s Health Center
Telepsychiatry Depression Treatment Program – Using Telepsychiatry for the Treatment of Depression in
Underserved Hispanics.” Prepared for U.S Dept. of Health and Human Services (2012)
30
“Statewide Telepsychiatry Program.” 2018. NC DHHS. North Carolina Dept. of Health and Human Services.
Accessed April 18. https://www.ncdhhs.gov/providers/provider-info/health-care/statewide-telepsychiatry-program.
31
“Telemedicine Case Studies.” 2018. Telemedicine Case Studies - The Source. American Telemedicine
Association. Accessed April 13. http://hub.americantelemed.org/resources/telemedicine-case-studies.
32
Dr. Walascek, Residency Director, University of Wisconsin Madison Psychiatry Program, personal interview,
2/16/18.
33
A. Darkins, Telehealth Services in the United States Department of Veterans Affairs (VA), Veterans Health
Admin. (2014)
34
Telemedicine, Wisconsin State Statute, Register May 2017 No. 737, Med 24-04.

11
But if you have a shortage, spreading people thinner with televideo conferencing doesn’t really cover
that.” 35

Access
Rural Access: This impact category is judged based on proximity to psychiatric services. We
consider a psychiatrist available by video call an effective psychiatrist—that is, telepsychiatry can
increase access to psychiatrists in an area without changing the number physically serving there. Thus,
telepsychiatry would increase access among traditionally underserved populations. This solution also
positively effects the rural access category, as it does not require psychiatrists to live in rural
communities, which is difficult to incentivize. 36
Equity of Access: In many cases, underserved populations are in low-income rural districts.
Wisconsin is no exception. Telepsychiatry provides consumers with lower administrative costs, such as
transportation. These fiscal and logistical barriers often limit equity of access. Depending on the details of
the program, this solution has the potential to increase equity of access to psychiatric services.
Additionally, through Wisconsin ForwardHealth, Medicaid reimbursements are available for
synchronous or live video conferencing. Many other telemedicine services such as remote patient
monitoring or phone calls are not currently covered under Wisconsin law. 37 Though there are options for
increasing access, many of those solutions would be categorized under Medicaid reimbursement
increases. Therefore, we believe telepsychiatry would have a significant positive impact on this category.
Equity could further be improved if coordinators provided options for patients without access to
technology. This would depend on the strategy implemented and whether it is a private system with
governmental support, or a government-run agency empowering social service coordinators.
Underserved Area Access: Because we consider psychiatrists available through telepsychiatry as
effective psychiatrists, overall access is also positively affected. Expansion of telepsychiatry services has
the potential to improve spread and saturation of psychiatric expertise across most of Wisconsin.

Efficiency
Cost of Operation: The costs of operating such a system are substantial. Social services
employees would require continual training in the software available, assuming the State opts to
implement a government run organization. Additionally, maintaining the technology and managing
system updates would also require oversight. However, the cost would not be particularly debilitating if
agencies coordinate with current private partners to improve telepsychiatry services and increase
saturation and trust among practicing providers.
Ease of Implementation: This impact category is broken up into two components, as the score
relates heavily to the scale of the implementation. Initiating this program at a full clinic level requires
application development, workforce development and training, adaptation of existing clinics, and
technology. The platform for teleconferencing would also need to be HIPPA compliant. As of right now,
there are not many large-scale providers, though there are numerous smaller companies that offer services
of varying quality. This is largely due to the youth in the field.

35
An Anonymous Psychiatrist in Wisconsin, personal interview, March 2018.
36
Kevin Jacobson, Rural Communities Initiatives Program Manager at the Wisconsin Office of Rural Health,
personal interview, February 23, 2018.
37
Forward Health, “New and Clarified Telehealth Policy.” Forward Health No. 2017-25 (August 2017).

12
 However, many organizations and practitioners are implementing their own systems. By this
approach, ease of implementation is high. Though there is an initial startup cost, it is minimal relative to
average psychiatrist salaries and the costs of alternative programs. 38
Psychiatrist Dr. Jennifer Beyer of the St. Croix Regional Medical Center stated that her
experience with a third party telepsychiatry provider led her to discontinue practicing via telemedicine.
Her core complaints were that the telepsychiatry provider and her clinic used different systems, which
complicated prescriptions and coordination, increased missed appointments, made it difficult for patients
to access her between appointments, and led her to feel dissatisfied with the quality of her work. Each of
these concerns can reasonably be attached to another impact category. For example, an increase in missed
appointments could be tied to access concerns, and a decrease in satisfaction with one’s work could be
tied to quality. However, Dr. Beyer attributed much of her distress with the method to the third-party
company she was working with to administer telepsychiatry. She noted the potential of the concept and
said that her response would be different if there was a full-time telemedicine provider, an in-clinic
system, or an alternative provider. For these reasons, we put these critiques of telepsychiatry into the
implementation section, specifically under the administrative costs component. 39
Overall ease of implementation is difficult to analyze due to variability in scale and program
design. Given the range of possible outcomes, we assign a neutral score on this impact category. More
important than the simple numeric value we assign here, however, are the lessons covered in the analysis.
It is key to note that a program could be administered cheaply through a State grant. A strong first step to
implementing a program should be to support practitioners with the resources and training needed to
begin practicing telepsychiatry, study the process, and expand to larger clinic-based settings over time.
However, this analysis is not intended to design a telepsychiatry program for the state of Wisconsin, and
ground-level experts may find alternative administrative solutions as the process unfolds.
Political Feasibility: This variable is scored neutrally. There is a cost component to this proposal
along with psychological change aversion. Alternatively, the support base for telemedicine systems is
growing rapidly and gaining massive traction in the healthcare field. The opioid epidemic also opens a
policy window, which could increase support for this proposal.

Quality
Perhaps controversially, we give telepsychiatry a neutral score on the quality of care impact
category. As noted, Dr. Beyer felt that utilizing telepsychiatry threatened the quality of her work.
However, the APA passionately argues the merits of telepsychiatry 40,41 even going so far as to identify
particular groups that could uniquely benefit from telepsychiatry services, such as geriatric patients with
physical limitations. 42,43 Though the APA’s research is extensive, we cannot discount Dr. Beyer’s
negative experience with telepsychiatry, though much of it was attributed to the method of provision.

38
Dr. Martha Rolli, personal interview.
39
Dr. Jennifer Beyer, rural psychiatrist in Wisconsin, personal interview, March 2018.
40
Myers et al. “Effectiveness of a telehealth service delivery model for treating attention-deficit/hyperactivity
disorder: a community-based randomized controlled trial.” Journal of the American Academy of Child & Adolescent
Psychiatry 54, no. 4 (2015): 263-274.
41
Hilty et al. “Telepsychiatry: effective, evidence-based, and at a tipping point in health care delivery?” Psychiatric
Clinics 38, no. 3 (2015): 559-592.
42
Yellowlees et al. “Global/World Wide Telehealth: International Perspectives of Telepsychiatry and the Future.”
Key Issues in e-Mental Health, (2015): 233-250.
43
Hilty et al. “The effectiveness of telemental health: a 2013 review.” Telemedicine and e-Health 19, no. 6 (2013):
444-454.

13
Incorporating both of these viewpoints, we estimate that telepsychiatry would have no net impact on
quality of care. 44

Stigma
Professional Stigma: Similar to its ease of implementation, telepsychiatry’s impact on
professional stigma is not certain. Telepsychiatry could exaggerate the current stereotype of psychiatrists
as simply providing medication. Other professionals may perceive telepsychiatrists as uninterested in
personal contact with their patients. However, societal stigma regarding the field of psychiatry is
decreasing, which may reduce professional stigma as well.45 Additionally, as telemedicine becomes more
prevalent in healthcare overall, the legitimacy of the technique will increase.
Societal Stigma: Societal stigma is a driver of professional stigma, so these variables are closely
related. The increased saturation level of psychiatry within traditionally underserved populations would
have a positive influence on societal stigma. The increased visibility of this service would reduce many
existing cultural biases centered around psychiatrists and psychiatric patients. However, there is also a
risk of increasing stigma regarding psychiatry. If administered poorly, 46 the field could be viewed in a
negative light.
Lastly, telepsychiatry has the interesting effect of protecting patients from the stigma associated
with visiting a mental health facility. 47 This benefit would only be captured if the telepsychiatry model
does not require patients to physically visit a facility. Though it is very dependent on the administrative
model utilized, a stigma reduction here would affect access.

Part-Time Retirement
The policy proposal was developed internally for this analysis. The intent is to utilize
telepsychiatry to score highly in both the access category (as it already does) as well as the workforce
category. We propose that retired psychiatrists would be given the option and resources to work remotely
from home on a part-time basis. This could be designed any number of ways, but the simplest solution
would be a telepsychiatry grant as suggested above. The simplest way to begin such a program would be
to administer this service through social service programs that coordinate the administrative duties tied to
traditional psychiatry services. A cheaper policy option would be to develop training programs that allow
psychiatrists to work through administrative barriers themselves.
The success of this program can vary greatly depending on enthusiasm from psychiatrists,
resources of social service agencies, and political feasibility. However, since it is simply a subset of the
broad telepsychiatry option, it scores similarly on many impact categories.

Workforce
Within State: Part-time retirement could substantially increase the psychiatrist workforce by
slowing the retirement of Wisconsin’s aging workforce. If the system performs as we have designed it,
the state’s expected psychiatric capacity would increase. Though many participating individuals would
work part-time, this policy option increases capacity without the need for long-term educational expenses.
If we assume that 10 percent of psychiatrists participate in the program at 5 hours a week, effective

44
“Telepsychiatry,” American Psychiatric Association.
45
Polaha et al (2015). “The perceived stigma of mental health services among rural parents of children with
psychosocial concerns.”
46
Dr. Jennifer Beyer, March 2018.
47
Aboujaoude, Elias, Wael Salame, and Lama Naim. “Telemental Health: A Status Update.” World Psychiatry 14,
no. 2 (June 2015): 223–30.

14
psychiatric hours would increase by approximately 384 hours a week. 48 This is equivalent to about 9.5
full-time psychiatrists.
Recruiting: This category had no impact. We found it unlikely that psychiatrists working in other
states would choose to retire in Wisconsin for the purpose of working part-time via telepsychiatry
services. Though there may be some individuals that would take advantage of this program after choosing
to retire in Wisconsin, it is unlikely that the existence of such a program would induce meaningful
workforce increases.

Access
All metrics of access are scored identically to overall telepsychiatry.

Efficiency
Cost of Operation: Cost is scored slightly lower than general telepsychiatry as part-time
retirement would require a centralized management system and support staff to help administer and
troubleshoot technology. Additionally, since this program is administered on a large scale by design, costs
would increase accordingly. Key cost components are strongly tied to the overall design of the program.
This is different from telepsychiatry, as in that system, models can often be built on existing hospital
infrastructure.
Ease of Implementation: This was scored lower than telepsychiatry. The neutral rating of
telepsychiatry stems from both positive and negative influences. Since the scale of the part-time
retirement system is significantly larger, beginning a program is more complex than telepsychiatry,
making this recommendation harder to implement.
Political Feasibility: The option is less politically feasible than telepsychiatry chiefly because of
potential cost and implementation pushback associated with beginning a new program of this magnitude.

Quality
Quality is scored identically to overall telepsychiatry.

Stigma
Both metrics of stigma are scored identically to overall telepsychiatry.

Integrated Care and Nonprofit Contracting

Integrated Care
In an integrated care model, psychiatrists are part of a care team in an existing general practice or
family physician office. Integrated care is the systematic coordination of general and behavioral
healthcare. According to the Health Resources and Services Administration (HRSA), integrating mental
health care, substance abuse, and primary care services produce the best outcomes, and are proven the
most effective approach to caring for people with multiple healthcare needs.49 There are multiple models
of integrated care, but the Advancing Integrated Mental Health Solutions (AIMS) Center in Seattle
Washington, a national leader in Integrated Health, cites the Collaborative Care model as the most
evidence-based model of integrated care. According to the AIMS Center:

48
“Number of active physicians in Wisconsin in 2017, by specialty area.” Statista.
https://www.statista.com/statistics/211120/number-of-active-physicians-in-wisconsin-by-specialty-area/.
49
“Integrated Care Models.” 2018. Integrated Care Models / SAMHSA-HRSA. SAMHSA. Accessed March 20.
https://www.integration.samhsa.gov/integrated-care-models.

15
“Based on principles of effective chronic illness care, Collaborative Care focuses on defined patient
populations tracked in a registry, measurement-based practice and treatment to target. Trained primary
care providers and embedded behavioral health professionals provide evidence-based medication or
psychosocial treatments, supported by regular psychiatric case consultation and treatment adjustment for
patients who are not improving as expected.” 50

The Collaborative Care model of integrated care was developed through a research collaboration
between the state of Washington and the AIMS Center and has been tested in over 80 randomized control
trials in the US and abroad. According to the AIMS Center, “Several recent meta-analyses make it clear
that Collaborative Care consistently improves on care as usual. It leads to better patient outcomes, better
patient and provider satisfaction, improved functioning, and reductions in health care costs, achieving the
Triple Aim of health care reform.” According to AIMS, Senior Project Manager and Practice Coach at the
University of Washington AIMS Center shared what the AIMS Center has experienced through its
utilization of the Collaborative Care model in a phone interview. The information gathered from her
interview will be used to evaluate the integrated care policy option. In comparing the Collaborative Care
model to other models of integrated care, Ms. Morrison explicitly stated that the Collaborative Care
model is best suited to alleviate the psychiatrist shortage. Based on randomized controlled trials and the
application of the model throughout the state of Washington, there are six benefits to using this model:

• The Collaborative Care model directly addresses the shortage of psychiatry providers.
• The model meets previously unmet need for behavioral health care.
• The model helps patients get better, faster.
• The model encourages all behavioral health care professionals to perform at the top of their
licensure because it asks more of their skills.
• The model recognizes that primary care providers face many behavioral health needs, increases
their understanding of those needs, and helps them better manage behavioral health concerns.
• The model dramatically increases primary care job satisfaction. 51

It is important to note that the APA also advocates for the Collaborative Care model of integrated
52
Care. Thus, the Collaborative Care model is the most well-supported model of integrated care.

Workforce
Within State: It is difficult to assert that integrated care would lead to a within state workforce
increase. If the incorporation of integrated care models of psychiatry in Wisconsin proves to be a
desirable model of practice over current systems, it has the potential to attract medical students who are
already interested in psychiatry to practice within the state. However, such an impact is likely to be
minimal. According to James Knickman, in order to achieve more efficient team-based approaches such
as integrated care, it is important to leverage technology, invest in strategies and programs to expand,
improve, and diversify the clinical workforce, and develop incentives to improve service in underserved

50
“Collaborative Care.” 2018. Collaborative Care | University of Washington AIMS Center. AIMS Center. Accessed
April 13. https://aims.uw.edu/collaborative-care.
51
Debra Morrison, personal interview
52
“What Is the Collaborative Care Model?” 2018. Collaborative Care Model. American Psychiatric Association.
https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/get-trained/about-
collaborative-care.

16
areas. 53 Thus, while integrated care models may not directly increase the psychiatrist workforce, they
more effectively utilize the existing workforce to improve psychiatric care delivery.
Recruiting: It is more realistic to say that integrated care would help to recruit out-of-state
psychiatrists to Wisconsin. According to a report entitled The Role of the Integrated Care Psychiatrist in
Community Settings: A Survey of Psychiatrists’ Perspectives, 52 U.S. psychiatrists reported that the
quality of practice under integrated care models were overwhelmingly positive.54 Additionally, when
asked in an interview about her experiences with the integrated care approach, Dr. Jennifer Beyer
commented that:

“I prefer being in a setting like that, where there’s multi-specialty and primary care. It’s nice for my
patients and to have the collaboration with the other doctors. I prefer that. I know some people might
prefer to be in their own private practice.” 55

Considering the positive response to integrated care from practicing psychiatrists, it is reasonable
to believe that the establishment of additional integrated care clinics would help to recruit psychiatrists to
the state.
The AIMS Center has noted that the APA has invested a lot of attention in the Collaborative Care
model and the two organizations have worked together to create modules for practicing psychiatrists and
psychiatric nurses. The Collaborative Care model directly addresses the psychiatrist shortage; the goal is to
train people in the existing workforce throughout the country to implement this model in primary care
settings. 56

Access
According to the AMA, access to existing mental health services is severely limited, and unlikely
to improve if the system continues to rely on traditional referral methods.57 Currently, the reigning norm
for accessing psychiatric services is referral to a psychiatrist’s office. By improving upon traditional referral
methods, integrated care proves to be a promising method of increasing access to psychiatrists.
Rural Access: Depending on the type of integrated care model established, this alternative can
improve access to psychiatric services in rural areas. For example, the Collaborative Care model of
integrated care demonstrates effective and efficient integration in terms of controlling costs, improving
access, improving clinical outcomes, and increasing patient satisfaction in a variety of primary care
settings – rural, urban, and among veterans. 58 If integrated care clinics are strategically designed and
placed throughout the state of Wisconsin, they could increase the number of residents with a psychiatrist
within a 45-mile radius of their home, consequently improving rural access. The AIMS Center in
Washington has helped spread the Collaborative Care model throughout the state, including rural areas
that previously did not have psychiatrists for hundreds of miles. 59 Psychiatrists who lived and worked in

53
Knickman, James, K. et al. Improving Access to Effective Care for People Who Have Mental Health and
Substance Use Disorders. Discussion Paper, Vital Directions for Health and Health Care Series. National Academy
of Medicine, Washington, DC. https://nam.edu/
54
Norfleet et al. “The role of the integrated care psychiatrist in community settings: a survey of psychiatrists’
perspectives.” Psychiatric Services 67, no. 3 (2015): 346-349.
55
Dr. Jennifer Beyer, personal interview.
56
Debra Morrison, personal interview.
57
“Frequently Asked Questions.” 2018. FAQ. American Psychiatric Association. Accessed March 20.
https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/learn/faq.
58
“What is the Collaborative Care Model?” 2018. Collaborative Care Model. American Psychiatric Association.
59
Personal interview, Debra Morrison

17
Seattle could provide consultation to patients in rural areas. Thus, expansion of the Collaborative Care
model dramatically increased rural populations’ access to psychiatric services in Washington.
Implementation of this model throughout Wisconsin could have a similar impact.
Equity of Access: The AIMS Center in Washington stated that the Collaborative Care model was
designed for underserved, Medicaid populations. According to the APA, The Centers for Medicare and
Medicaid have announced billing codes for use by primary care physicians to fund the Collaborative Care
model beginning in January 2017. It is expected that commercial payers will follow. 60 Thus, integrated
care improves equity of access for Medicare and Medicaid recipients.
Underserved Access: Currently, the APA is training 3,500 psychiatrists in Collaborative Care by
2020, priming the workforce for an evolution in access to psychiatric services and expertise. This
revolution would expand access to psychiatric services through telepsychiatry and the co-location of
psychiatrists in primary care settings. Furthermore, according to the National Center for Biotechnology
Information, integrated care models have increased patient access to needed mental health services, while
simultaneously enabling primary care clinicians to receive the support and collaboration needed to meet
the psychiatric needs of the population. 61 In the case of the AIMS Center, once their original project
showed good returns, some counties added more underserved populations, such as women seeking
perinatal services, veterans, and people over the age of 50. 62 Thus, the integrated care model can improve
overall access to those seeking psychiatric services.

Efficiency
Cost of Operation: Considering that integrated care places a psychiatrist into an existing general
practice or primary care office, the costs of the clinic would be minimal. Potential costs include a
relocation package for the psychiatrist along with their salary. Furthermore, these short-term costs would
be far outweighed by the long-term benefits of integrated care. According to the National Institute of
Mental Health, addressing the whole person is essential for positive health outcomes and cost-effective
care. Combining mental health services/expertise with primary care can reduce costs and save lives.
According to HRSA, community-based addiction treatment can lead to a 35 percent decrease in inpatient
costs, a 39 percent decrease in ER costs, and a 26 percent decrease in total medical costs. 63
Examining the Collaborative Care model, the AIMS Center has found that this model is a cost-
effective and efficient way to utilize psychiatric services. Through this model, a psychiatric consultant
who devotes two to three hours a week to work with behavioral health council members can provide
critical input to meet the needs of ten to fifteen patients each week. This is impossible for a psychiatrist to
do if they are personally meeting with the patients.
Ease of Implementation: Having a psychiatrist come to an existing general practice or primary
care office would entail recruiting costs to attract a potential psychiatrist, training so that the psychiatrist
could become accustomed to the Integrated Care model, potential relocation expenses, costs and energies
associated with streamlining information and patient transfers, among other implementation costs.64 Thus,

60
“Making the Case: Medicaid Payment for the Collaborative Care Model.” 2018. Collaborative Care Model.
American Psychiatric Association.
61
Guerrero et al. “Primary care integration of psychiatric and behavioral health services: A primer for providers and
case report of local implementation.” Hawai'i Journal of Medicine & Public Health 76, no. 6 (2017): 147.
62
Personal interview, Debra Morrison
63
“Can We Live Longer? Integrated Healthcare’s Promise.” 2018. Integrated Care Models / SAMHSA-HRSA.
SAMHSA. Accessed March 20. https://www.integration.samhsa.gov/Integration_Infographic_8_5x30_final.pdf
64
Shih, Terry, Lena M. Chen, and Brahmajee K. Nallamothu. “Will bundled payments change health care?
Examining the evidence thus far in cardiovascular care.” Circulation 131, no. 24 (2015): 2151-2158.

18
since there could be multiple unforeseen costs associated with the implementation of an Integrated Care
clinic, ease of implementation is one area that receives a negative benchmark score.
Political Feasibility: Integrated care is a politically feasible recommendation, as it has a great
deal of support from the psychiatric community, general practitioners, and primary care physicians. The
success of the AIMS Center required the willingness of the state to take a chance on the Collaborative
Care model. The AIMS Center worked with the state of Washington to serve people on short-term state
disability who had a high burden of mental health problems, but whose problems were not being
addressed because health coverage did not cover mental health services. Following the success of the
AIMS Center, the state of Washington implemented Collaborative Care statewide with community health
center patients. The University of Washington Department of Psychiatry provided consulting psychiatrists
for the statewide project. The state of Washington worked with the Center for Medicaid Services to
implement payment for Collaborative Care through a new set of codes that pay clinics and primary care
providers who are working with a Collaborative Care team. Additionally, there is a nationwide plan
through which states would receive money from the federal government to reform their delivery system
for care. States that are following Washington’s example include New York and South Carolina. 65
Considering that there is widespread state and federal support for the Collaborative Care model,
integrated care is a politically feasible recommendation to implement in Wisconsin.

Quality
Integrated Care has significant positive effects on quality of health care. A 2012 Cochrane
Review concluded that the Collaborative Care model of integrated care significantly improved depression
and anxiety outcomes in primary care based on 79 randomized-controlled trials. 66 Integrating mental
health, substance abuse, and primary care services produces the best outcomes and proves the most
effective approach to caring for people with multiple healthcare needs.67 According to the Substance
Abuse and Mental Health Services Administration (SAMHSA), a one-year integration program enrolled
170 people with mental illnesses. After one year in the program, 86 participants spent fewer nights
homeless per month. Additionally, monthly mental health hospitalizations declined by 50, and
participants spent 17 fewer nights in both detox and ER visits. 68 According to a report by Dr. Wenke
Hwang and Dr. Jongwha Chang from Pennsylvania State University, 21 studies showed a positive
association between increased integration in health care delivery and an increase in the quality of care.69

Stigma
Professional Stigma: Integrated Care provides medical professionals with the opportunity to
provide their patients with comprehensive treatment and rely on their unique sets of expertise across the
health field. Through collaboration, integrated care can encourage appreciation for different
specializations among physicians and reduce professional stigma.
Societal Stigma: Perception of integrated care clinics is generally positive. By highlighting
psychiatrists as integral parts of such a model and placing mental health on the patient’s treatment agenda,
integrated care can reduce societal stigma associated with psychiatric care. Because of convenience, many
patients are more willing to access mental health treatment when provided at their routine doctor’s office

65
Personal Interview, Debra Morrison.
66
Archer, et al. “Collaborative care for depression and anxiety problems.” Cochrane Database of Systematic
Reviews 10 (2012).
67
“Integrated Care Models,” SAMHSA
68
“Can We Live Longer? Integrated Healthcare’s Promise,” SAMHSA
69
Hwang et al. “Effects of integrated delivery system on cost and quality.” American Journal of Managed Care 19,
no. 5 (2013): e175-84.

19
than at a specialty mental health clinical setting. 70 Furthermore, older primary care patients—often the
ones most in need of care—are more likely to accept collaborative mental health treatment within primary
care than in mental health/substance abuse clinics.71 Because of these factors, we conclude that integrated
care significantly improves societal stigma.

Nonprofit Contracting
Another policy that addresses the psychiatrist shortage in Wisconsin is nonprofit contracting.
Nonprofit contracting is similar to integrated care in that it better utilizes the limited supply of
psychiatrists. However, rather than placing a psychiatrist in a general practice or primary care setting,
nonprofit contracting relocates psychiatrists to a behavioral or mental health facility/organization for a
few hours each week in order for psychiatrists to manage patient’s medications. Under a nonprofit
contracting model, the psychiatrist does not primarily provide care to the patient. Rather, qualified staff
such as psychologists, social workers, nurse practitioners (NPs), and physician assistants (PAs) treat the
patients and pass their recommendations to the psychiatrist. The psychiatrist would come into the
behavioral/mental health center a few hours each week to perform the highly administrative role of
signing off on the recommendations and writing corresponding prescriptions. Since nonprofit contracting
is an under-researched topic, the majority of information/data on this model has been drawn from
interviews with individuals including heads of community action agencies, psychologists, therapists, and
directors for behavioral and mental health centers in Wisconsin. An interview with Dr. Kathleen O’Brien,
a psychologist who runs a community behavioral health organization in Maryland and has served on
various state and national commissions on topics ranging from addictions treatment to health care reform,
provided first-hand knowledge about nonprofit contracting.

Workforce
Within State: Similar to integrated care, nonprofit contracting has little impact on the workforce.
There is no direct correlation between nonprofit contracting and the number of psychiatrists training in
the state.
Recruiting: Furthermore, we cannot assume that nonprofit contracting will recruit psychiatrists
from other states. The nonprofit contracting model can impact workforce by relying on nurse practitioners
and clinical social workers to increase the workforce of psychiatric services. 72 However, this does not
directly impact the size of the workforce.

Access
Nonprofit contracting has a positive impact on access, though it is not as strong as that of
integrated care because contracting psychiatrists visit mental and behavioral health centers for a small
number of hours each week. Additionally, psychiatrists have limited incentive to contract with
nonprofits. 73 Dr. O’Brien compared finding a psychiatrist to contract with a nonprofit to “finding a
unicorn.” Interviews with CEOs of community action agencies and behavioral health care centers shed
light on this policy’s impact on access.

70
“Frequently Asked Questions.” 2018. FAQ. American Psychiatric Association. Accessed March 20.
https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/learn/faq.
71
Bartels, Stephen J et al. "Improving access to geriatric mental health services: a randomized trial comparing
treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use."
American Journal of Psychiatry 161, no. 8 (2004): 1455-1462.
72
Dr. Kathleen O’Brien, CEO of Walden/Sierra Inc., personal interview, March 2018.
73
ibid

20
 Rural Access: According to Pam Guthman, who holds a Master’s of Science in Nursing and runs
a community action agency, the nonprofit contracting model would increase access for rural clients who
may not otherwise receive medication management from a psychiatrist.74
Equity of Access: Many rural clients receive Medicaid, so having psychiatrists go to behavioral
and mental health centers to prescribe medications to patients would address equity of access as well.75
Mental and behavioral health centers serve some of the neediest populations in a variety of settings apart
from rural areas. 76 Thus, by having a psychiatrist visit these centers and treat these individuals, the
nonprofit contracting model addresses equity of access.
Underserved Area Access: The nonprofit contracting model would expand the reach of
psychiatrists into underserved areas of Wisconsin.

Efficiency
Cost of Operation: The operating costs of this policy option are small. Nonprofits would pay for
the psychiatrist to come in for a few hours a week, but this cost would be relatively minimal.
Ease of Implementation: Rural areas typically do not have a high income or high benefit
population. 77 Reimbursement for services would likely originate from Medicaid funding, which doesn't
adequately compensate psychiatrists. Thus, a sustainable nonprofit contracting model would require
additional funding. One option would be for Health and Human Services or Wisconsin DHS to implement
a pilot project in a rural area that is funded by local taxes or a grant. 78 Implementing such a project would
pose some costs.
Political Feasibility: The nonprofit contracting model is not likely to be politically feasible
because psychiatrists may oppose the utilization of their services under a model that eliminates direct
patient care. Such a model would also require significant input from the Wisconsin Medical Society and
the Wisconsin Hospital Association. In Maryland, state regulations mandate that in order to have a mental
health clinic, a psychiatrist must be on-site for at least 20 hours. Furthermore, some states allow only
psychiatrists practicing in that state to treat their populations. This forces mental and behavioral health
centers to rely on the psychiatric workforce within their home states, which can be difficult given
widespread shortages. 79 According to DHS administrative code 61.71, psychiatrists must provide .8 hours
of service per patient each week. 80 If this regulation were broadened to allow for telepsychiatry (which
could be a component of an Integrated Care model), then psychiatrists could more efficiently serve
patients seeking mental health services at behavioral and mental health clinics, especially patients in
underserved areas.

Quality
Nonprofit contracting could negatively impact quality of care. In the nonprofit contracting model,
the psychiatrist prescribes treatment for a patient based on paperwork completed by other individuals
serving at the mental/behavioral center. Pam Guthman explained that because people like face-to-face
contact, such a set-up could compromise care. According to Guthman, it is important for a rapport to
develop between the practitioner and client. 81 Without such a relationship, there is less likelihood of

74
Pam Guthman, community action agency, personal interview, March 2018.
75
ibid
76
Dr. Kathleen O’Brien, personal interview.
77
Pam Guthman, personal interview.
78
ibid
79
Dr. Kathleen O’Brien, personal interview.
80
Psychiatry, Wisconsin Administrative Code, Register May 2009 No. 641, DHS 61.71.
81
Pam Guthman, personal interview.

21
engagement and dedication by the client, which is critical to initiation, continuation, and commitment to
treatment for mental health issues. Thus, under nonprofit contracting, quality of care is likely to suffer.

Stigma
Professional Stigma: If psychiatrists become seen as only necessary for prescribing medication
rather than comprehensive patient treatment, they could be poorly perceived by other medical
professionals who directly treat their patients in their provision of care.
Societal Stigma: Pam Guthman concluded the interview by stating her concern that if
psychiatrists are not visible and available in rural communities, they will appear to be “unavailable and
out of touch with the real mental health issues.” 82 As a result, society may begin to view psychiatrists as
mere “prescription pads,” rather than a valuable medical resource for direct patient treatment.

Loan Assistance
According to a survey from the Association of American Medical Colleges (AAMC), 73 percent
of medical students graduated with some debt in 2017. 83 Of those with debt, medical graduates reported
median medical school debt of $180,000, and total educational debt of $195,000. As such, conditional
loan assistance has become a popular tool for encouraging physicians and other medical professionals to
work in underserved areas. Many states, including Wisconsin, operate programs that cover a portion of a
physician's debt obligations in exchange for a commitment to work in a rural or underserved area.
In Wisconsin, there are three loan assistance programs available to psychiatrists working in rural
and underserved areas of Wisconsin: The Health Professions Loan Assistance Program (HPLAP), the
Rural Physician Loan Assistance Program (RPLAP), and the National Health Services Corps (NHSC). 84
Through HPLAP, health care professionals (general physicians, psychiatrists, dentists, dental hygienists,
physician assistants, nurse practitioners and certified nurse midwives) who agree to work full-time in a
federally designated urban or rural HPSA in Wisconsin can receive up to $50,000 in education loan
assistance, which is paid over the course of the requisite three-year commitment. HPLAP is funded by
both federal and state government.
The Rural Physician Loan Assistance Program (RPLAP) functions similarly but is funded entirely
by the state and granted only to physicians practicing in a rural community (a city, town, or village that
has a population of less than 20,000 and that is at least 15 miles from any municipality that has a
population of at least 20,000, as defined by the Federal Census Bureau). Physicians practicing in a rural
HPSA are eligible for both programs, and can potentially receive a total award of $100,000 over 3 years,
though eligibility does not guarantee acceptance.
Physicians (and other health professionals) are also eligible for the Health Resources and Services
Administration’s NHSC loan assistance program. Administered by each state, the NHSC is a federal
program that awards up to $50,000 in education loan repayment funds for health care providers who agree
to work for two years in a HPSA. 85

82
Pam Guthman, personal interview.
83
“Medical School Graduation Questionnaire: 2017 All Schools Summary Report.” Association of American
Medical Colleges (July 2017).
84
“Health Professions Loan Assistance Program Information.” 2018. Education Loan Repayment | Wisconsin Office
of Rural Health. Wisconsin Office of Rural Health. http://worh.org/loan-repayment.
85
“NHSC Loan Repayment Program.” 2018. NHSC Loan Repayment Program. HRSA. Accessed March 20.
https://www.nhsc.hrsa.gov/loanrepayment/loanrepaymentprogram.html.

22
 According to data from the Wisconsin Office of Rural Health, psychiatrist participation in
Wisconsin’s loan assistance programs is low; since 2012, less than 5 percent (7 of 157) HPLAP/RPLAP
awards have been granted to psychiatrists. 86 Improving psychiatrist participation in these programs may
help to draw more psychiatrists into rural areas. Below, we consider two different ways of making loan
assistance programs more attractive to psychiatrists. First, we evaluate the impact of reserving a portion
of program slots to psychiatrists. Next, we evaluate the impact of increasing the size of the loan assistance
award.

Designate Loan Assistance Awards for Psychiatrists

Wisconsin’s HPLAP and RPLAP are competitive programs with limited capacity. As such,
application does not guarantee acceptance. Since 2012, 57 percent of applicants to RPLAP/HPLAP have
received an award. Among physicians, who generally receive a higher award, it is even more competitive;
46 percent of physician applicants since 2012 were granted an award. Total annual funding for the
programs is $1,000,000 ($750,000 for HPLAP, and $250,000 for RPLAP). 87 Thus, HPLAP, which is
available to many different specialties and disciplines, can grant up to 15 $50,000 awards or 30 $25,000
awards. RPLAP, which is only available to physicians, grants five $50,000 awards each year and is
significantly more competitive. Under this policy option, a proportion of currently available spots in
existing loan assistance programs would be reserved for psychiatrists each year.
Data from the Wisconsin Office of Rural Health reveal that low psychiatrist participation is
driven by a lack of applicants. Indeed, psychiatrists have only applied for 10 loan assistance awards since
2012, of which seven have been awarded. In other words, 70 percent of psychiatrist applications for
Wisconsin’s loan assistance programs are awarded, a higher rate than any other physician specialty (see
Figure 3). Additionally, while psychiatrists represent only 7 percent of physician applicants to either
program, they represent 10 percent of physician award recipients.

Figure 3: Acceptance Rates by Specialty

RPLAP/HPLAP Awardees as a Percentage of Applicants by Specialty, 2012-2017

86
Applicant Data from the Wisconsin Office of Rural Health (2011-2017).
87
Kevin Jacobson (Rural Communities Initiatives Program Manager) and John Eich (Director) of the Wisconsin
Office of Rural Health, personal interview, (February 23, 2018).

23
 Other programs devoted to encouraging psychiatrists to work in underserved areas have faced
similar problems. For example, the Higher Education Aids Board runs the Primary Care and Psychiatry
Shortage Grant, which provides a minimum $20,800 annual award for physicians and psychiatrists who
write a letter of intent to serve in an underserved area after residency. 88 To date, no one has ever applied
for the program. 89
Using past applicant data, reserving one or two awards for psychiatrists would only have
increased the number of awards granted to psychiatrists by one. In other words, without a corresponding
increase in psychiatrists applying to Wisconsin’s Loan Assistance Program, reserving a spot would only
marginally change the number of psychiatrists receiving an award. It’s possible that officially reserving
spots for psychiatrists may encourage more psychiatrists to apply.

Workforce
Within State: According to an AAMC survey of medical school graduates, 22 percent of
respondents said that debt had a “strong” or “moderate” influence on their choice of specialty. 90 Given
that psychiatrists are among the lowest paid physicians, guaranteeing that psychiatrists will be given
priority in loan assistance programs may encourage more medical students training in Wisconsin to
consider specializing in psychiatry. 91 However, this policy option would likely have a minimal impact, as
loan assistance is still available for all other specialties.
Recruiting: Regarding recruitment from other states, there are many factors to consider. Many
other states have loan assistance programs. The NHSC, which requires a shorter commitment, has
approved sites and vacancies in every state. 92 Additionally, 36 states and D.C. have state-run loan
assistance programs for medical professionals. 93 Of surrounding states, Illinois offers up to $50,000 for a
two-year commitment, or $100,000 for a four-year commitment (see Table 2, below). 94 Michigan offers
up to $200,000 over 8 years. 95 Minnesota offers $20,000 per year for a minimum of 2 years. 96 Given that
other states/areas have loan assistance programs, location choice will come down to other factors, such as
the availability of job opportunities for physician spouses, colleagues, recreational activities, and other
amenities. Interviews with current participants in Wisconsin’s loan assistance programs confirms this. Of
the two psychiatrists currently participating in Wisconsin’s loan assistance programs interviewed, neither
reported that loan assistance was influential in their decision to practice in Wisconsin.97 Instead,
proximity to extended family and cultural factors drew them to the state. 98

88
“Primary Care and Psychiatry Shortage Grant.” State of Wisconsin Higher Educational Aids Board (February
2018).
89
Kevin Jacobson and John Eich, Wisconsin Office of Rural Health staff, personal interview.
90
“Medical School Graduation Questionnaire,” Association of American Medical Colleges
91
Peckham, Carol. 2016. “Medscape Physician Compensation Report 2016.” Medscape. Medscape. April 1.
https://www.medscape.com/features/slideshow/compensation/2016/public/overview#page=2.
92
“Quick Map.” 2018. HRSA Data Warehouse. US Dept. of Health and Human Services. Accessed March 22.
https://datawarehouse.hrsa.gov/Tools/MapToolQuick.aspx?mapName=NHSCApprovedSites.
93
“State Loan Repayment Contacts.” 2018. HRSA/NHSC. HRSA. Accessed March 22.
https://nhsc.hrsa.gov/loanrepayment/stateloanrepaymentprogram/contacts.html.
94
“Illinois National Health Service Corps State Loan Repayment Program (SLRP).” 2018. Illinois National Health
Service Corps State Loan Repayment Program (SLRP) | IDPH. Illinois Department of Public Health. Accessed
March 22.
95
“Michigan State Loan Repayment Program Overview.” 2018. MDHHS - Michigan State Loan Repayment
Program Overview. Michigan Department of Health and Human Services. Accessed March 22.
96
“Loan Repayment for Primary Care Physicians Practicing in Rural and Urban Health Professional Shortage Areas
in Minnesota.” 2018. Minnesota State Loan Repayment Program. Minnesota Department of Health. Accessed
March 22. http://www.health.state.mn.us/divs/orhpc/funding/loans/state.html.
97
Dr. Jennifer Beyer, personal interview
98
Anonymous Psychiatrist, personal interview

24
 Table 2: Loan Assistance Programs in the Midwest

Access
Rural Access: There is some evidence to suggest that loan assistance programs can draw
physicians to rural and underserved areas and needier populations. An analysis of 43 studies exploring the
effectiveness of financial incentive programs in recruiting and retaining healthcare workers in
underserved areas found that financial incentives (including service scholarships and loan repayment
programs) contributed to large numbers of healthcare workers working in underserved areas.99
Equity of Access: In addition, participants in these programs were more likely than non-
participants to work in underserved areas in the long run. One study found that 68.4 percent of physicians
participating in financial incentive programs, and 73.3 percent of those in loan assistance programs, work
in a rural area. 100 Additionally, loan repayment recipients, 66 percent of whom remained in their service
sites 8 years after starting work there, had the longest retention of any program. Physicians participating
in loan assistance programs also practiced in demonstrably needier areas and had a higher share of
patients insured under Medicaid or uninsured (48 percent vs. 28.5 percent).
Interviews with current loan assistance program participants provides further evidence that loan
assistance can influence a physicians’ decision to work in a rural or underserved area. Of the two
psychiatrists currently participating in Wisconsin’s loan assistance programs interviewed, one was already
working in a rural area prior to applying for the program. The other, however, stated that she chose to
work in an underserved part of Wisconsin in order to qualify for the NHSC loan assistance program. In
other words, while family drew her to Wisconsin, the opportunity for loan assistance drew her to work in
an underserved and rural area.
Underserved Area Access: Prioritizing psychiatrists among Wisconsin’s applicants to loan
assistance programs may encourage a greater number of psychiatrists to apply and thus increase the
number of psychiatrists working in rural and underserved areas, and serving needy populations. That said,
without additional efforts to increase the number of psychiatrists applying to existing loan assistance
programs, the impact is likely to be minimal.

99
Bärnighausen, Till, and David E. Bloom. “Financial incentives for return of service in underserved areas: a
systematic review.” BMC health services research 9, no. 1 (2009): 86.
100
Donald E. Pathman et al., “Outcomes of States’ Scholarship, Loan Repayment, and Related Programs for
Physicians,” Medical Care 42, no. 6 (2004): 560–68.

25
Efficiency
Cost of Operation: Earmarking existing funds for psychiatrists means that this option will pose
no additional operating costs.
Ease of Implementation: Part of the appeal of this policy option is that it would cost very little to
implement.
Political Feasibility: This policy option may take spots from physicians and medical providers in
other specialties, making it politically unpopular, particularly if earmarked funds go unused due to too
few psychiatrists applying.

Quality of Care
There is no reason to think that reserving loan assistance awards for psychiatrists would
positively or negatively impact quality of care.

Stigma
Professional Stigma, Societal Stigma: Designating loan assistance awards to psychiatrists is
unlikely to have a significant impact on stigma, though it may help to legitimize the specialty by openly
prioritizing it.

Increase the Loan Assistance Award for Psychiatrists

According to the Wisconsin Office of Rural Health, psychiatrists who work in rural, underserved
areas are eligible for HPLAP, RPLAP as well as the federal NHSC. While HPLAP and NHSC can be
awarded consecutively, they cannot be combined. Therefore, physicians cannot simultaneously participate
in all three assistance programs. That said, all three programs allow for reapplication. Thus, there is no
limit to the amount of loan assistance that a physician can obtain through Wisconsin’s programs over
time. For a three-year commitment, however, the maximum award in Wisconsin is $100,000. Increasing
the maximum three-year award available to psychiatrists could make Wisconsin’s loan assistance
programs more attractive to psychiatrists. For example, the state could offer an additional $25,000 to
psychiatrists working in a rural or underserved area, increasing the maximum possible award from
$100,000 to $125,000 over three years for those participating in both RPLAP and HPLAP, and from
$50,000 to $75,000 for those participating in one or the other.

Workforce
Within State: As stated, an AAMC survey of medical school graduates found that 22 percent of
respondents said that debt had a “strong” or “moderate” influence on their choice of specialty. Another
study found that medical students with higher debt were more likely than their peers to choose a specialty
with a higher average annual income. 101 Given that psychiatrists are among the lowest paid physicians,
high debt levels may be influencing medical students’ decision to avoid the specialty. Increasing the loan
assistance award for psychiatrists may alleviate concerns about debt and thus encourage more medical
students training in Wisconsin to choose psychiatry as a specialty.
Recruiting: Additionally, the increase could make Wisconsin a more competitive option for out of
state psychiatrists choosing among loan assistance programs. That said, Wisconsin’s $33,333 annual
award is already high compared to surrounding states. Most surrounding states and the NHSC offer
maximum annual awards of $25,000, though they typically require a shorter commitment. It could be that
the existing difference between Wisconsin’s annual award and other awards is not enough to induce
psychiatrists to move to Wisconsin. In which case, increasing the amount of the loan may help to recruit
psychiatrists from out of state. However, given that awards can be used only to pay off loans, which are

101
Rohlfing, James, Ryan Navarro, Omar Z. Maniya, Byron D. Hughes, and Derek K. Rogalsky. “Medical student
debt and major life choices other than specialty.” Medical education online 19, no. 1 (2014): 25603.

26
finite, there is an upper limit to how much value available loan assistance has for prospective applicants.
For someone with $100,000 worth of debt, increasing the maximum 3-year award to $125,000 poses no
additional value. Given that the annual awards in Wisconsin are already high compared to other states, it
is not clear that a $25,000 increase will significantly impact the number of psychiatrists coming to work
here from out of state.

Access
Rural Access, Equity of Access, Underserved Area Access: As previously mentioned, there is
evidence to suggest that loan assistance awardees are more likely to serve in rural, underserved areas and
serve needier patients than physicians not receiving financial incentives. Interviews with current loan
assistance program participants confirm that loan assistance can influence a physicians’ decision to work
in a rural or underserved area. Increasing the loan assistance award for psychiatrists may help to
incentivize Wisconsin psychiatrists who are currently not participating in a loan assistance program to
apply for these awards and accept positions to work in underserved areas.

Efficiency
Ease of Implementation: This program would cost little to implement and have no added
administrative burden.
Cost of Operation, Political Feasibility: This option’s impact on operating costs and political
feasibility depend on how the change is funded. If no additional revenue is added to the programs, the
increased available loan to psychiatrists will end up taking award funds from other physicians and/or
medical professionals, which would likely be politically unpopular. If, on the other hand, the increased
loan assistance awards are funded by additional state funds, annual operating costs of the programs would
increase by $8,333 (one-third of $25,000) for every award granted to a psychiatrist.

Quality of Care
If the increased loan assistance award for psychiatrists results in fewer awards available for
support staff such as nurse practitioners, this option may leave some psychiatrists in rural and underserved
areas even more overburdened than they are currently, thereby posing new challenges in maintaining
quality of mental health care.

Stigma
Professional Stigma, Societal Stigma: There is little reason to believe that increasing the amount
of loan assistance available to physicians would impact cultural or professional stigma, though it may
help to legitimize the specialty by openly prioritizing it.

Residency and Recruitment Programs

As mentioned, more than a quarter of the state’s psychiatrists are over the age of 65; close to half
are over the age of 55. 102 Over the next decade, nearly half of the state’s current psychiatrist workforce
will retire. Given that psychiatry, nationally, has the 3rd highest proportion of physicians practicing at 55
or older, Wisconsin’s aging workforce is not unique. 103 To expand the psychiatric workforce, Wisconsin
needs to train more psychiatrists and retain them to practice within the state.
Based on the AAMC 2017 State Physician Workforce Data Report, physicians tend to practice
where they do their residencies. 104 Currently, there are two organizations that train psychiatrists in
Wisconsin: the University of Wisconsin–Madison School of Medicine and Public Health (UW–Madison)
and the Medical College of Wisconsin (MCW). MCW’s chair and professor of psychiatry and behavioral

102
Wisconsin Medical Society, “Mental and Behavioral Health Fact Sheet”
103
Data, American Medical Association, “Physicians”
104
“2017 State Physician Workforce Data Report.” Association of American Medical Colleges (November 2017).

27
medicine, Dr. Jon Lehrmann, commented that expanding psychiatry programs has historically had many
challenges. 105 This is primarily due to the fact that in 1997, the federal government capped the number of
residency positions it would fund in existing programs. Thus, the expansion of residency class sizes or
program locations requires hospitals to seek external funding.
Despite this, UW–Madison and MCW have had some recent success in expanding their
programs. MCW was able to expand residency opportunities by partnering with health systems in
northeastern and north-central Wisconsin, creating 2 new programs. 106 UW–Madison has been able to
increase their residency class sizes by seeking out special grants that were awarded through the DHS and
the Department of Veterans.
Compounding limited class sizes are the relative deficiency of medical students choosing to
specialize in psychiatry and the fact that many who do leave Wisconsin after their training. 107 Relative to
other specialties, psychiatry does not offer competitive financial compensation. This can affect a
psychiatrist’s ability to practice in rural areas, particularly given the large amount of debt that typical
medical students incur during their training. Barring an explicit connection to the state, many psychiatry
trainees will seek out more competitive compensation elsewhere.
Below, we evaluate two policy options that address these issues: expanding psychiatry residency
graduate medical education (GME) slots by increasing class sizes or creating new residency programs,
and adjusting or expanding recruitment programs to attract medical students to train and practice as
psychiatrists in Wisconsin.

Expand Residency Programs

Currently, Wisconsin has four psychiatry residency training programs: UW-Madison, MCW-
Milwaukee, MCW-Northeastern, and MCW-Central. Both the MCW-Northeastern and MCW-Central
programs were created within the last five years through Graduate Medical Education (GME) expansion
grants allocated by DHS through funds derived from special session bills. 108 Despite the recent addition
of two new programs, class size capacity remains relatively small. Both MCW-Milwaukee and UW-
Madison psychiatry residency programs have yearly class sizes of eight and nine students respectively.
MCW-Central and MCW-Northeastern programs, which enrolled their first cohorts of residents in 2016,
admit three and four residents each year. Without accounting for program attrition or those who seek
additional years of subspecialty training, the state can train 24 new psychiatrists each year. Raising caps
on current Wisconsin residency programs will help increase the rate at which the state trains psychiatrists.
However, each additional residency slot costs nearly $320,000 to fund. 109 And given the lack of federal
support for increasing residency class sizes, the feasibility of this alternative is rooted in the state’s
willingness to fund additional slots.
Nationally, approximately 50 percent of residents across all specialties practice within the state in
which they trained. Wisconsin ranks 23rd in the nation in retaining state-trained physicians. Approximately
45 percent of residents who train in Wisconsin end up practicing here. 110 Though some will leave Wisconsin

105
Linnane, Rory. 2018. “Shortage of mental health care providers hits crisis point just as more teens seek help.”
Milwaukee Journal Sentinel. Milwaukee Journal Sentinel. January 4.
https://www.jsonline.com/story/news/local/milwaukee/2017/11/16/more-youths-need-mental-health-tshortage-
mental-health-professionals-crisis-point-particularly-youth/842964001/.
106
ibid
107
“2017 State Physician Workforce Data Report.” AAMC.
108
“New Psychiatry Residency Programs Accredited.” 2018. MCW: MCW Magazine Summer 2016 |. Medical
College of Wisconsin. Accessed March 22. https://www.mcw.edu/MCW-Magazine/Summer-2016/New-Psychiatry-
Residency-Programs-Accredited.htm.
109
Magen, Jed, and Deborah Banazak. “The cost of residency training in psychiatry.” Academic Psychiatry 24, no. 4
(2000): 195-201.
110
Data, American Medical Association.

28
after training here, expanding residency opportunities can increase the net number of psychiatrists who
practice in the state.

Workforce
Within State: Expanding residency programs through either increasing class sizes or creating
additional rural residency programs will directly increase the number of psychiatrists trained in Wisconsin.
Recruiting: Given the limited number of slots per program, program recruitment agendas may
conflict. In an interview with UW-Madison’s residency training director, Dr. Art Walaszek, he mentioned
there is a conflict between recruiting talented trainees who will progress the field of psychiatry and
recruiting trainees who are likely to practice within Wisconsin. 111 Adding spots to residency programs
alongside the creation of rural residency programs will create opportunities for Wisconsin to attract talented
out of state applicants, while granting the flexibility to recruit applicants with ties to the state. Both
outcomes will increase the number of residents practicing within the state. 112

Access
Rural Access: Creating additional psychiatry residency slots will increase yearly net graduate
totals as well as the number of residents will practice in the state. Given the focus of new programs on
rural psychiatry development (i.e. the Central and Northeastern MCW program), we expect that the
increase in rural psychiatrist placements will improve access in rural parts of the state.
Equity of Access: Despite increased geographic access, equity of access is expected to only
marginally improve, regardless of placement, as a large portion of psychiatrists end up in private practice
and charge out-of-pocket for services.
Underserved Area Access: Overall, there will be a net benefit to access due to the growing
workforce.

Efficiency
Cost of Operation: This alternative poses significant operating costs. It costs about $320,000
($80,000 per year for 4 years) to add an additional residency slot.113 Medicare funding of residency
programs has been capped since the Balanced Budget Act of 1997. 114 Although the cap was increased for
rural training programs in 1999, expansion has not reflected the rapidly changing trends in medicine. To
increase class sizes and create additional residency programs, Wisconsin needs to continue supporting
policy efforts that increase funds for GME opportunities. These mechanisms include GME grants allotted
by the DHS 115 and grants awarded by the Veterans' Access to Care through Choice, Accountability, and
Transparency Act of 2014 (VACAA) 116 through the Department of Veterans Affairs.
Ease of Implementation: Provided that external funding is available, the implementation of new
residency slots to existing programs is straightforward. The creation of additional residency programs
would be more challenging, given the difficulty of establishing an administrative training structure and
obtaining accreditation. However, administrative and program modeling can be provided by existing
institutions (MCW or UW-Madison), as was done for the set-up of the MCW-Central and MCW-
Northeastern programs.

111
Dr. Art Walaszek, personal interview
112
Robbins, Rebecca and Bronshtein. November 9, 2017. “Explore: How many young doctors does your state retain
after residency?” STAT, https://www.statnews.com/2017/11/09/doctors-medical-residents-retention-rural/
113
Magen et al. “The cost of residency training in psychiatry.”
114
“Medicare Resident Limits ("Caps").” 2018. Association of American Medical Colleges. Accessed March 22.
https://www.aamc.org/advocacy/gme/71178/gme_gme0012.html.
115
“DHS Announces New Grants to Support Graduate Medical Education.” Wisconsin DHS.
116
“Impact of the VACAA (Choice Act) on Training at VA.” 2015. Office of Academic Affiliations. U.S Department
of Veteran Affairs. September 8. https://www.va.gov/OAA/VACAA_Impact.asp.

29
 Political Feasibility: Regarding political feasibility, support for expanding residency training
programs has been quite favorable. As mentioned above, the state legislature and DHS supported the
creation of two new rural residency programs. In addition, momentum for supporting mental health
programs has opened up a policy window within the state; several special session bills that support mental
health program funding have been passed. 117 As of January 2018, grants totaling more than $2.9 million
to support development of three new residency programs and eight new resident position slots in current
programs were announced by DHS. As a result of DHS’s GME Initiative, launched in July 2014, those
efforts were able to build numerous partnerships among hospitals and clinics, health systems and
academic institutions to expand GME and improve access to quality health care in rural and underserved
areas of the state. 118

Quality of Care
Expanding residency programs will not necessarily change the overall quality of mental health
care. However, psychiatrists trained in rural and underserved population curriculum will possess a care
approach sensitive to the needs of rural communities. Expanding residency programs with a focus on rural
practice will improve quality through community-specific care.

Stigma
Professional Stigma: Expanding residency programs will help to alleviate professional stigma by
validating the need for more residency positions in the field of psychiatry to address the lack of access to
mental healthcare. 119
Societal Stigma: Historically, most rural medicine training initiatives have targeted primary care.
Expanding rural psychiatry residency programs would help to de-stigmatize mental illness and support
the idea that mental health treatment is as important as the treatment of physical illness. This, in turn, will
help societal stigma by changing the way the public approaches healthcare. Creating a partnership
between physical and mental health maintenance will help to demonstrate that many physical medical
problems such as obesity, heart disease, and diabetes are comorbid with mental health disorders such as
anxiety, depression, bipolar disorder, and obsessive compulsive disorder. 120

Recruit Medical Students into Psychiatry

Psychiatry residencies have a lower application rate compared to other specialties, which may be
partly explained by the specialty’s perceived prestige, stigmatized legitimacy, and low relative financial
compensation. 121 Wisconsin has made several efforts to attract medical students to train within the state.
To attract students with ties to the state and have specific interests in working in local communities,
Wisconsin created rural and urban outreach curriculum programs like Training in Urban Medicine and
Public Health (TRIUMPH) 122 and the Wisconsin Academy for Rural Medicine (WARM). 123 Another

117
“DHS Announces New Grants to Support Graduate Medical Education.” Wisconsin DHS.
118
“DHS Announces New Grants to Support Graduate Medical Education.” 2018. Wisconsin Department of Health
Services. January 3. https://www.dhs.wisconsin.gov/news/releases/010318.htm
119
Eden, J., D. Berwick, and G. Wilensky. “Graduate medical education that meets the nation‫ ׳‬s health needs.
Committee on Governance and Financing of Graduate Medical Education. Board on Health Care Services.” (2014).
120
Prince et al. “No health without mental health.” The lancet 370, no. 9590 (2007): 859-877.
121
“2017 Review of Physician and Advanced Practitioner Recruiting Incentives: An Overview of the Salaries,
Bonus, and Other Incentives Customarily Used to Recruit Physicians, Physician Assistants, and Nurse Practitioners”
Merritt Hawkins (2017).
122
“Training in Urban Medicine and Public Health (TRIUMPH).” 2018. UW School of Medicine and Public Health.
University of Wisconsin Madison. Accessed March 22. https://www.med.wisc.edu/education/md-program/triumph/.
123
“Wisconsin Academy for Rural Medicine (WARM).” 2018. UW School of Medicine and Public Health.
University of Wisconsin Madison. Accessed March 22. https://www.med.wisc.edu/education/md-program/warm/.

30
method of recruiting individuals to train and practice within the state is to incentivize foreign-trained
doctors looking to migrate to the United States. One such program is the Wisconsin Conrad 30 Waiver
program, which recruits foreign-trained physicians to train and practice in rural areas in exchange for
expedited immigration. 124 This program bypasses the J1 visa requirement that calls for a two-year return
to their home country before reentry.
These recruitment programs could be expanded or adjusted to attract medical students into
psychiatry. For example, programs such as WARM and TRIUMPH could be tailored to emphasize the
need for psychiatrists through additional mental health curricula. Additionally, a portion of J-1 waiver
visas available through the Wisconsin Conrad 30 program could be reserved specifically for psychiatry
residents.

Workforce
Within State: Expanding recruitment efforts through programs like TRIUMPH and WARM to
attract Wisconsin residents will help retain psychiatrists who want to stay within the state and work in
traditional underserved rural and urban communities.
Recruiting: Increasing efforts in recruiting foreign-trained psychiatrists through the Conrad 30
program will help to increase out of state recruitment and the likelihood that they will practice within the
state given rural residency requirements of the program.

Access
Rural Access: Recruiting medical students who come from rural areas in Wisconsin to enter
psychiatry will help promote placement of students into rural communities. We expect that those with ties
to the state will have a greater desire to work in those communities. 125 Those that participate through the
expanded Conrad 30 program would also help to increase rural access.
Equity of Access: Equity of access is predicted to improve. Graduates from these rural and urban
outreach programs will work to incorporate community-based need approaches to better utilize public
reimbursements in their practices’ compensation structure, making mental health treatment more
accessible to all.
Underserved Area Access: Access will increase in health professional shortage areas as outreach
and immigration facilitation programs incentivize placement into rural and urban underserved areas.

Efficiency
Cost of Operation: Costs will be relatively low compared to other policy alternatives.
Ease of Implementation: Expansion of outreach curriculum programs will pose administrative
costs to support program coordinators, curriculum development, and advertising materials to attract
medical students. Efforts to attract foreign-trained psychiatrists through expedited immigration would be
relatively easy to implement as the program structure already exists and would only need to be altered to
attract more mental health specialists.
Political Feasibility: Regarding political feasibility, political backing for this option already
exists, as evidenced by recent efforts to support mental and behavioral health initiatives such as the
expansion of residency programs.

Quality of Care
Quality of care is not expected to increase significantly as a direct result of this policy alternative.
However, increasing the number of psychiatrists with interests in community engagement and training for

124
“Wisconsin Conrad 30 Waiver Program - General Information.” 2017. Wisconsin Department of Health Services.
November 29. https://www.dhs.wisconsin.gov/primarycare/j-1visa/index.htm.
125
Curran, Vernon, and James Rourke. “The role of medical education in the recruitment and retention of rural
physicians.” Medical teacher 26, no. 3 (2004): 265-272.

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rural health, especially those who have ties to areas in which they will practice, will aid in the provision
of culturally sensitive care.

Stigma
Professional Stigma: Efforts to attract medical students into psychiatry through outreach program
expansion at the medical school level will help curb professional stigma by offering insight into the need
for psychiatrists in the state.
Societal Stigma: We expect that the community partnership projects associated with some of
these medical outreach programs will reduce societal stigma. 126

Reimbursement and Parity Enforcement

Reimbursement
Psychiatrists have the lowest acceptance rates for all types of insurance including private,
Medicaid, and Medicare. Just 55.3 percent of psychiatrists accept private insurance, compared to 88.7
percent of other physicians. Similarly, 54.8 percent of psychiatrists and 86.1 percent of other physicians
accept Medicare; 43.1 percent of psychiatrists, compared to 73 percent of other physicians, accept
Medicaid. 127 One possible reason for this disparity is that reimbursement rates for psychiatrists are low
relative to other medical specialties. Because of antitrust laws, exact data on insurance reimbursement
rates are not possible to get; however, on average, behavioral health providers are paid 20.7-22.0 percent
less for office visits than primary care physicians, and 17.1 percent to 19.1 percent less than surgical or
medical specialty doctors. 128 Because low reimbursement rates lead to low insurance acceptance rates
among psychiatrists, they threaten access to mental healthcare.
Under this policy proposal, the state would increase Medicaid reimbursement rates for psychiatric
services. We propose rate increases for Medicaid exclusively because, unlike private insurance and
Medicare, it falls under the purview of the state.

Workforce
Within State: Increasing reimbursement rates for psychiatric services could serve as an incentive
for Wisconsin medical students considering psychiatry, to choose this field over higher paid medical
professions.
Recruiting: Additionally, increasing reimbursement rates could draw psychiatrists in other states
to Wisconsin. Currently, Wisconsin’s reimbursement rates for physicians are, on average, seven-tenths of
the national average (1.00) and rank 47th of 50 states, as shown in Figure 4 below. 129

126
“Curriculum, Wisconsin Academy for Rural Medicine (WARM).” 2018. UW School of Medicine and Public
Health. Accessed May 8. https://www.med.wisc.edu/education/md-program/warm/curriculum/.
127
Cummings, Janet R. 2015. “Rates of Psychiatrists’ Participation in Health Insurance Networks.” JAMA: The
Journal of the American Medical Association 313 (2): 190–91.
128
“Addiction and Mental Health vs. physical health: disparities in network use and provider reimbursement rates”
Milliman Research Report (December 2017).
129
“Medicaid Physician Fee Index.” The Henry J. Kaiser Family Foundation, (July 12, 2017). accessed March 21,
2018, https://www.kff.org

32
 Figure 4: 2016 Medicaid Physician Fee Index, Primary Care

Given that psychiatrists are paid, on average, 20 percent to 22 percent less than primary care
physicians, it follows that Wisconsin’s reimbursement rates for psychiatrists are even further from the
national average. 130 Increasing these rates to better compete with rates elsewhere could entice more
psychiatrists to practice in Wisconsin and convince those who are already here to stay.

Access
This policy positively impacts rural access, equity of access, and underserved area access. Serious
mental health and substance abuse disorders (MH/SUD) disproportionately affect low income and
uninsured adults, and 35 percent of Medicaid recipients require MH/SUD services. 131 Because of this
disparity, public assistance programs such as Medicaid are important to the mental healthcare system, and
increasing reimbursement rates would have a significant impact on access mental health services.
Rural Access: Rural areas tend to have high numbers of Medicaid beneficiaries; increasing
reimbursement rates would serve to increase access within these areas.
Equity of Access: Psychiatrists in private practice don’t have any negotiating powers with
insurance companies, therefore they often have even lower rates than their counterparts that are employed
by clinics or other larger entities. 132 This makes it difficult for psychiatrists in private practice to accept
insurance, as they are reimbursed less, and don’t have the ability to negotiate higher rates with insurance
companies. Because its rates are so low, when Medicaid serves as a secondary insurer, it often fails to
cover copays because the amount that primary insurers cover exceeds what Medicaid would have

130
Cummings, Janet R. 2015. “Rates of Psychiatrists’ Participation in Health Insurance Networks.”
131
“The Role of Medicaid for People with Behavioral Health Conditions - Fact Sheet.”
https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8383_bhc.pdf.
132
Anonymous Psychiatrist, personal interview.

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reimbursed for that service. Additionally, private insurance rates tend to track Medicaid rates, so it is
possible that this policy option would induce private insurance companies to raise their rates. 133
Underserved Area Access: This policy would improve access in underserved areas by increasing
the number of psychiatrists accepting insurance, thereby helping to reduce cost barriers to mental health
treatment.

Efficiency
Cost of Operation: This policy alternative is very costly. Implementation would require a
significant expansion to the Wisconsin Medicaid program (called BadgerCare), and more money
allocated for the program in the state budget.
Ease of Implementation: This policy is not easy to implement. Changing Medicaid
reimbursement rates is a complicated process, requiring sophisticated analysis and negotiation to
determine proper rates that are acceptable to all players in the healthcare system.
Political Feasibility: Because of the high costs associated with this policy and the charged
political history of Medicaid in Wisconsin, this alternative is not politically feasible. In addition to push
back from the state government, there may be pushback from other physicians and medical professionals
who would like to see their own reimbursement rates increase.

Quality
Increasing reimbursement rates for Medicaid could have a positive impact on quality. Higher
reimbursement rates could allow private practice psychiatrists to hire staff to handle billing and other
administrative tasks, leaving psychiatrists with more time and energy to spend on direct patient care, thus
increasing quality of care. 134

Stigma
Professional Stigma, Societal Stigma: This policy alternative will have no impact on stigma,
either professional or societal.

Parity Enforcement
In the past few years, and particularly under President Obama, mental healthcare has been made a
federal priority. In an effort to address this issue, the Mental Health Parity and Addiction Equity Act
(MHPAEA) was passed in 2008. Parity means that health insurance coverage for mental health services
must be equivalent to health insurance coverage for traditional medical services. The MHPAEA extended
parity to mental health and substance abuse disorders services (MH/SUD).
This was a significant step for mental healthcare, but the MHPAEA failed to adequately address
disparities in coverage, as the law was only applied to Group Health Insurance Plans and neglected to
include individual health insurance plans, and public assistance plans such as Medicare and Medicaid.
Over time, more healthcare plans and programs were included; effective October of 2017, the Final Rule
of the MHPAEA officially extended parity to Medicaid managed care organizations, Medicaid
Alternative Benefit Plans, and the Children’s Health Insurance Program. 135
However, the law is difficult to enforce on a state level, as providers are still not required to
accept insurance of any kind, and insurance companies find ways to game the system. According to an

133
Anonymous Psychiatrist, personal interview.
134
ibid
135
“The Mental Health and Substance Use Disorder Parity Task Force.” US Department of Health and Human
Services (2016).

34
interview with a rural psychiatrist in Wisconsin, parity is difficult to enforce partly because insurance
companies exploit loopholes:

“Insurance companies get around parity by reimbursing specific orders the same for all
physicians within a particular system. So, all psychiatrists, obstetricians, etc.… get the same
amount for the same procedure/service. So, the insurance company is upholding parity within
that system… but that does not help private practices, which will get a lower reimbursement
rate from the insurance company without having anyone else in the system to claim parity
against (it’s just them, so there are no primary care physicians to claim parity against). Private
practices have less clout”136

In addition to this, insurance companies reserve the right to decide if something is “medically necessary”
or not, therefore circumnavigating parity rules.

This is a particularly salient issue within psychiatry because insurance acceptance rates in the
specialty are low. Given the complexities of parity, we recommend that Wisconsin adopt best practices
for enforcement of parity. In report titled “Approaches in Implementing the Mental Health Parity and
Addiction Equity Act: Best Practices from the States,” SAMHSA identified seven states as employing
“best practices” for parity enforcement: California, Connecticut, Maryland, Massachusetts, New York,
Oregon, and Rhode Island. 137 These “best practices” for parity enforcement are as follows:

● Open channels of communication

● Standardize all materials relating to parity
● Create templates, workbooks and other tools
● Implement market conduct exams and network adequacy assessments
● Collaborate with multiple agencies and stakeholder groups so that insurance companies, stage
agencies, and watchdog agencies know what parity is and how best to enforce it.138

Workforce
Within State, Recruiting: Implementing “best practices” would have no impact on the psychiatrist
workforce within Wisconsin or on recruitment of psychiatrists to Wisconsin.

Access
Rural Access: Parity enforcement would increase access to private practice psychiatrists, who are
often the only mental health providers available in rural areas.
Equity of Access: Better enforcement of parity will lead to more affordable care because
insurance companies will be required to cover mental health services at the same rate as other medical
services. Better affordability will increase access for all people, therefore making mental healthcare more
equitable.

136
Anonymous Psychiatrist, personal interview.
137
Substance Abuse and Mental Health Services Administration. “Approaches in Implementing the Mental Health
Parity and Addiction Equity Act: Best Practices from the States.” HHS Publication No. SMA-16-4983, Substance
Abuse and Mental Health Services
Administration (2016).
138
ibid

35
 Underserved Area Access: This policy will improve access in underserved areas. Greater
insurance compliance with parity would help break down the cost barrier to getting mental health
treatment, leading to more equal access for HPSAs, both urban and rural.

Efficiency
Cost of Operation: While this option is certainly less expensive than some of our other
alternatives, there are costs associated with creating a mechanism for enforcement of parity in Wisconsin.
If Wisconsin adopts the “best practices” identified by SAMHSA, creating training tools, designing and
conducting market studies and assessments, as well as standardizing materials all pose costs to the state.
Ease of Implementation: Generally speaking, adopting the “best practices” serves to clarify
expectations of the parity law already in place. Thus, this policy is fairly easy to implement because it
suggests strategies for improving enforcement through existing enforcement mechanisms. The execution
of these strategies would present some additional administrative burden, but costs would be minimal as
there are already executive and adjudicatory systems in place for parity enforcement.
Political Feasibility: Because the adoption of these “best practices” serves only to strengthen a
system of enforcement already in place, this policy option is politically feasible.

Quality
This policy option would not impact quality of care.

Stigma
Professional Stigma: The policy options would not impact professional stigma.
Societal Stigma: Better enforcement of parity would reduce societal stigma. Providing insurance
coverage equal to that of other medical treatments would help to destigmatize mental illness by
financially equating it to physical illnesses, thereby affirming mental illness as a disease rather than a
personal shortcoming.

Conclusion and Recommendation

Wisconsin faces a serious and growing shortage of psychiatrists. This analysis serves as an
evaluation of policy options for alleviating this shortage. Using a combination of literature reviews, data
analysis, and personal interviews, we evaluated each policy option according to five broad goals:
Workforce, Access, Efficiency, Quality, and Stigma. Based on our findings, we recommend a series of
policy options, as no one solution will suffice to address the challenges facing the state. We are confident
that each of these proposals, if well implemented, can positively impact the psychiatrist workforce and
access to mental healthcare in the state of Wisconsin.
Appendix A shows our completed goals matrix with scores for each impact category and goal.
Each policy option’s overall score equals the weighted sum of scores within each goal and impact
category. Our weighting system prioritized the goals of workforce and access, while minimizing stigma
and quality. Scores ranged from 5.5 for “Nonprofit contracting” and 16 for “expand residency programs.”
This section summarizes the five policy proposals with the highest scores, as well as the goals they most
effectively achieve.

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1. Expand Residency Programs
Our top recommendation is for Wisconsin to continue expanding psychiatry residency training
programs. Doing so directly increases Wisconsin’s psychiatrist workforce and improves access in rural
and underserved areas. Thus, the expansion of residency programs by either increasing psychiatry
residency program spots or creating new programs can meaningfully combat the shortage of psychiatrists
in the state. While such an expansion poses significant costs, they are greatly offset by resulting benefits.

2. Integrated Care
Our second recommendation is to implement and expand an integrated care model throughout the
state. Integrated care models can significantly improve access to psychiatrists in rural and underserved
parts of the state, and make access more equitable. Additionally, integrated care can reduce stigma
surrounding psychiatry and improve quality of care. These impacts are likely to increase as models of
integrated care become more widely used and refined.

3. Telepsychiatry
A third recommendation is to utilize telepsychiatry to improve access to psychiatric services in
areas without practicing psychiatrists. The chief advantage of telepsychiatry programs are that they can
reach broad audiences, while being relatively inexpensive and easy to implement, depending on their
scale. Additionally, telepsychiatry models can be easily adjusted to the needs of specific clinics or clients.

4. Parity Enforcement
Next, we recommend that the state adopt the “best practices” for enforcement of the Mental
Health Parity and Addiction Equity Act. Improving enforcement of parity could induce more private
practice psychiatrists to accept insurance and break down cost barriers to mental health treatment, thereby
improving access. With little cost, this is a relatively simple and effective policy option.

5. Recruitment into Psychiatry

Finally, we recommend expanding efforts to recruit medical students to train and practice as
psychiatrists in Wisconsin. This policy alternative would increase the number of psychiatrists training,
and eventually practicing, in rural and underserved parts of the state.

Table 3: Policy Recommendation Matrix

Ranking Score Goal Maximized Policy Recommendation

1 16 Workforce, Access Expand Residency Programs

2 14.5 Access, Quality Integrated Care

3 14 Access Telepsychiatry

4 13.5 Access Parity Enforcement

5 13.5 Workforce Recruitment into Psychiatry

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Appendices

Appendix A: Goals Matrix

38
Appendix B: Economic Impact Analysis of a Psychiatrist

The AMA’s economic impact analyses track the revenues, jobs, spending and taxes generated by physicians
through the economy in the U.S. and in each state. 139 In order to track both indirect and direct impacts, the
analysis developed state specific “multipliers” to estimate “the number of times that each dollar generated in
patient care activities circulates through the local economy” for three vital economic barometers: output, jobs,
and wages and benefits. Wisconsin’s multipliers in 2015 were as follows:
● Output: 1.937, indicating an additional $0.94 of indirect output is generated for every $1 in direct
output.
● Jobs: 6.795, indicating an additional 6.79 indirect full-time jobs are supported for every $1M in direct
output.
● Wages and benefits: 0.298, indicating an additional $0.30 of indirect wages and benefits is generated
for every $1 in direct output.

Using these multipliers, combined with a masterfile of physicians by state and state-adjusted per-physician
revenue and cost data, the AMA estimated the economic impact of the physician industry (Table 2) as well as
for 10 specialties (Table 3). The figure provides a visual overview of the methodology used in these
calculations.

Table 4: Total Output, Jobs, Wages & Benefits, and State and Local Taxes Supported by Physicians in
Wisconsin, 2015

139
IQVIA, “The Economic Impact of Physicians in Wisconsin: State Report” The American Medical Association
(January 2018)

39
Table 5: Total Economic Impact of Physicians in Wisconsin, for 10 Select Specialties

Figure 5: Output, Jobs, and Wages & Benefits Calculations Methodology

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Appendix C: North Carolina Telepsychiatry Program Model

Figure 6: North Carolina Statewide Telepsychiatry Program (NC-STeP)

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