Bloomberg Businessweek August 19, 2019
Even so, tele-consultations are beginning to transform
mental health care throughout rural America. Dickson spends
20 hours a week providing psychiatric services at the local VA
office, where about 85% of her sessions are done remotely.
Inside her windowless office at the VA, a large monitor that’s
propped up on packages of printer paper sits behind her reg-
ular computer screen. “Let’s see who’s on my list,” she says
on a recent Monday, scanning her schedule of appointments.
She’s to see one patient from Bozeman, another from Great
Falls, and another from Helena.
The case file of the woman in Helena indicates that she’s
bipolar and developed PTSD after being sexually abused
while in the military. The woman hasn’t been on her meds
since she moved to Montana from another state about a year
ago, and in her session she asks Dickson to restore her pre-
vious prescription. Dickson would love to, but the medica-
tion isn’t listed by the Montana VA as a first-line drug. She’d
have to prescribe a different, less costly, generic. Dickson says
she and the patient most likely will wait for the drug to fail
to work, and then they’ll try to get approval for the drug of
choice, which they know effectively treats her.
The woman on the other end of the video call, like every-
one else who undergoes a remote consultation, isn’t see-
ing Dickson from her home. She’s had to travel to a clinic to
access a nurse-supervised computer—the only kind approved
for tele-health consultations. A patient Dickson treats through
the VA travels 110 miles to reach the nearest supervised com-
puter screen.
5 DICKSON COULD SPEND ALL OF
her time seeing psychiatric patients if she wanted
to. But that’s what she was doing in 2006, when
she burned out and had to spend a year on the road to clear
her head. So she’s more selective in her private practice.
It’s important, she says, to guard some of her time for her-
self—for hiking in the badlands, for dinners with friends, for
treasure-hunting at auctions.
For general, family-practice consultations, she charges a flat
rate of $40 for a half-hour session; for psychiatric work, the
rate is $200 for a first-time customer and $100 for a follow-up.
She doesn’t accept insurance plans for either type of service,
because she says she’d spend all of her time fighting for reim-
bursement if she did. She’d have to hire an employee just to
deal with the paperwork.
Meiram Bendat, a California attorney who specializes in
helping mental health patients litigate claim disputes with
insurers, empathizes with her. “No sane provider who has bet-
ter options would want to participate in an insurance company
network under the way these services are being rationed in
2019,” he says. The situation is so dire for mental health provid-
ers, he says, that even in areas where there are plenty of practi-
tioners, patients needing services often end up on long waiting
lists. “We hear all the time from patients in Northern California
that even in San Francisco they can’t see psychotherapists or
psychiatrists, and I can assure
that there is no shortage of
practitioners in those areas,”
Bendat says. “What there is,
though, is a shortage of peo-
ple willing to participate in
insurance company networks
and panels, and that’s largely
driven by the paltry reimburse-
ment rates that insurers are
willing to pay for mental health
services.”
Dickson likes to cast her decision to keep insurance com-
panies at arm’s length as a part of a self-care routine, one she
emphasizes is a key reason she’s still in the business while so
many colleagues have left the field. She’s seen how occupa-
tional pressure can undermine the mental health of rural pro-
viders, and monitoring her own well-being has been a priority
from the very beginning of her career, thanks to an extremely
painful lesson in her third year of medical school.
Her older brother—the Jeff to her Mutt—was a physician,
too, and the job was everything to him. “That was his identity,
completely,” she says. After practicing in Oregon, he returned
to Montana to open a rural practice in Glasgow, the commu-
nity Truesdell now visits once a month by plane. There, his
life unraveled.
After a rough divorce, he began to self-medicate and became
addicted to prescription drugs. The state board of medicine
busted him for writing prescriptions to himself. “He’d already
lost his marriage, his relationship with two kids, was on the
verge of bankruptcy, and when his identity as a doctor was
threatened, well... .” The state board, she says, confronted him
on a Friday, giving him the option of losing his license or under-
going treatment. Then they left him alone for the weekend. On
Monday morning, he didn’t show up for treatment. “He sui-
cided,” Dickson says.
Last year her sister, the only other surviving member of
her family, was diagnosed with leukemia. Dickson considered
temporarily moving to Colorado to take care of her. She didn’t
want to abandon her patients in eastern Montana, but she felt
strongly that neither she nor her patients should be under the
illusion that she’s personally responsible for the mental health
of a 48,000-square-mile swath of the rural West.
Dickson had vowed to avoid falling into the trap of getting
wrapped up in her own professional identity, even if she was
the only person in eastern Montana left in that profession. So
early last year, the last psychiatrist moved away. In an email
explaining her departure to her patients, she wrote, “Being a
doctor is what I do, but it’s not who I am.”
She’d always known it would be a temporary relocation,
and she returned six months later, after her sister’s health
improved. When she reopened her office, demand for her
services was as high as it had ever been, as was her conviction
that she was exactly where she needed to be. She guesses she’ll
probably live and work in Glendive until the day she dies. <BW>TRUESDELL47