Richard Immler, MD, is a child psychiatrist who works with clinics in northern Wisconsin. As a doctor providing subspecialist care, Immler is the only board-certified child psychiatrist in residence north of Merrill.

“There is an enormous need for child psychiatric services here,” Immler says. “I feel it’s a crisis. My waiting list at the Human Service Center in Rhinelander is up to two years. To have a two-year waiting list is extremely discouraging. Innocent children and their families are suffering, as they are waiting for months to get optimized care.” While waiting, many families drive to Green Bay, Wausau or Marshfield to receive services.

Immler also provides services for North Central Health Care in Wausau and Ministry Health Care in Rhinelander. At the former, he has a waiting list of three months, and at Ministry, “the caseload is saturated,” he says.

A shortage based on burn-out

The causes for the waiting period are nation-wide, Immler says. “There is a shortage of child psychiatrists everywhere.” One of the main reasons, he believes, is that the cost of medical school – involving four years of post-college training – is very expensive, and the compensation for child psychiatry is lower on the scale of subspecialties.

Psychiatric services are also emotionally and time-intensive, requiring long hours to achieve the best outcomes, Immler explains. “It’s not procedure-oriented,” he notes, “in a reimbursement system that compensates physicians by billable hours. There are medical students who are drawn to child psychiatry, but feel they can’t afford it and end up in another field.”

Immler is quick to clarify that he feels psychiatrists are not in the poorhouse, but when other factors are added in, the profession looks disadvantaged. “There is also a high burn-out rate,” he says. “Nine child psychiatrists in northern and central Wisconsin have come and gone in last 12 to 15 years. It’s a field that demands quite a bit of time and coordination with others involved in the child's life."

Immler has chosen to practice in rural northern Wisconsin “because I grew up in here and I love living here,” he says. “Otherwise, I wouldn’t be here. There’s a saying that we need to grow our own healthcare providers. It’s especially true now, with the looming shortage in all healthcare professionals as the baby boomers retire.”

Another factor contributing to doctor burn-out, Immler believes, is the isolation that psychiatrists may experience in a rural area. “If I’m working with a team, if we’re in this together, I can handle the stress, versus going it alone. We need a collaborative approach here, a wrap-around services model like Wausau has. Other cities, like Milwaukee and Madison, have adopted this too. We don’t have it up here, and we’re not nearly as effective as we could be.”

The wrap-around approach

The current system of human services is fragmented and patched together, notes Immler. “To serve the children and families with highest needs we need to work with a model of coordinated services," he explains. "The challenge in Wisconsin is that funding of human service needs is on county by county basis, so county supervisors and administrators struggle with patching together funding for all the different services, and often the services compete with each other for funding.”

Immler says the wrap-around coordinated approach was here for a time. “In the late 1990s, U.S. Rep. Dave Obey sponsored a wrap-around approach. It was called the Northwood’s Alliance for Children and Families (NACF) and Obey brought about the funding of six counties – Lincoln, Langlade, Marathon, Forest, Vilas and Oneida – to serve as a model. It lasted from 1998 to 2004. It now survives only in Marathon County.”

“Our tri-county area didn’t continue it after the six-year federal funding period ran out,” Immler says. “That’s the sad part. It was a wonderful program. We had two in-home treatment teams, a crisis response worker and five care coordinators/service facilitators, each of whom worked with average of eight to 10 families out of the Human Service Center.” Around 40 to 50 families were served at a given time.

Those six years saw a dramatic reduction in out-of-home placements, according to Immler. After a steep learning curve, the program achieved peak functioning from 2001 to 2004. “It allowed for the fact that in more challenged situations it often takes longer to treat, sometimes as much as nine to 15 months to form a trusting relationship with a family, to find the necessary supports to create a team, and to reach the point where the parents and child don’t feel like they are just being talked to but are being listened to. It was a plan that was consumer-driven.”

What’s in place now is a much reduced program. “From a staff of seven to eight for NACF, we now are down to a staff of two,” Immler says. “It falls under a medical assistance payment mechanism called Children’s Waiver, and is much more restrictive.”

Immler’s job of serving children in need would be unbearable if it weren’t for other healthcare providers. “There are a variety of dedicated providers here – a great deal of the need is met by individual therapists,” he says. “We’re fortunate to have a child and adolescent day-treatment program. We have two small in-home treatment programs, and very committed pediatricians and high-quality special education teachers for children with emotional and behavioral needs.”

What keeps him working in a profession under siege, Immler says, is the satisfaction of helping children. “I’m always impressed with kids’ natural capacity to recover once we get the barriers out of the way.”

In addition, he says, it’s an exciting time to be in psychiatry. “Some of the assumptions of the past weren’t based on evidence,” Immler says, “they were more ‘philosophies’. With new methods, we’re learning that causes of mental illness can be environmental, genetic, medical or involving dietary issues – all of which can affect the brain.

"Our brain is our most significant organ – there’s no transplant procedure for it," Immler continues. "We’re not just a product of our genetics either. We’re learning that some genes turn on or turn off to protect us or harm us, in a cascading fashion. We’re learning that it’s all far more complex than a 1+1 = 2.”

Fixing the mess

There are ways to fix the mess, Immler recommends. One is to adopt a collaborative service model that brings families and professionals together. Another is to restructure the reimbursement system for psychiatry payments to be based on “outcomes” rather than “procedures” which work better for other specialties, such as surgery or radiology.

Immler is actively involved at the state level on projects that will eventually, he hopes, draw more psychiatrists into rural areas and provide better outcomes for patients. A bright spot is a project sponsored by a UW-Madison grant, from a Blue Shield endowment, to develop a Wisconsin children's mental health scorecard. The scorecard will provide a way of evaluating the needs, effectiveness and efficiency of services and work force distribution. The grant will be coordinated by the Wisconsin Family Ties, a parent advocacy group. Jackie Baldwin is the local representative and Hugh Davis is the executive director in Madison.

Immler laments, “We haven’t done a good job in linking outcomes in healthcare to the work that we do. If we don’t find a way to meet the needs of our children, higher-cost outcomes occur – hospitalization, emergency treatment, incarceration and even suicide. These reflect failures to work together with clear goals in mind and come at an enormous cost.”