During Dr. Larry Severidt’s 24 years of practicing family medicine in Manchester and Pella, neither Delaware nor Marion counties had even a single psychiatrist practicing there. Sadly, rural physicians in about two-thirds of Iowa counties can still say the same thing, says Severidt, who is now director of medical education at Broadlawns Medical Center in Des Moines. 

Broadlawns is among the three hospital systems in Greater Des Moines that are working to increase the number of Iowa-trained doctors in a critical physician shortage area — psychiatry. 

In July, two new psychiatry residency programs to train newly graduated physicians will begin at Mercy Medical Center-Des Moines and at Broadlawns, which is partnering in an initiative with UnityPoint Health-Des Moines. Both programs received three-year accreditations last year from the Accreditation Council for Graduate Medical Education. 

While both programs are starting out small — just four new doctors have been selected for each of the two residency programs — each program will add four more residents in each of the next three academic years. So when both four-year programs reach maturity four years from now and graduate their initial cohorts of residents, the pipeline will be primed with 32 doctors in training to potentially fill psychiatry openings throughout the state. 

The need is very real. With about 200 active practicing psychiatrists for a population of more than 3.1 million, Iowa ranks 49th out of 50 states in the number of practicing psychiatrists per capita. And a new report this year from the National Council for Behavioral Health estimates that at the current pace of retiring professionals and recruitment, the demand for psychiatrists in the United States will exceed supply by 25 percent in 2025. 

Expanding the number of medical residents in psychiatry should greatly increase the number of trained psychiatrists who choose to stay and practice in Iowa, say leaders of both programs.  

“From our [residency] experience in family medicine,” Severidt said, “if a student goes to medical school in Iowa and then does the residency training in Iowa, about 80 percent of [those students] end up spending their career in Iowa,” he said. “So we’re hoping the same thing will happen here. Obviously, these graduates can go anywhere they want and they’re in high demand, but we have a track record of keeping people in the state, which is something that we hope to accomplish with this.” 

‘Extensive interest’ in psychiatry
Many people have assumed that lack of interest in psychiatry is one of the reasons why young doctors aren’t getting into the specialty. However, Mercy’s experience has proved there is tremendous interest, and not just among international medical graduates. 

Mercy officials said they received nearly 1,000 applications from doctors graduating from medical school for its four slots. From those applicants, Mercy interviewed 52 candidates and ranked 40 of them for selection through the match program. 

“When we started this process, I was under the assumption that there was a shortage because there wasn’t enough interest [by doctors] in going into psychiatry,” said Deb Bagnall, manager of medical education and research for Mercy-Des Moines. “That’s not the case at all — there is extensive interest out there in specializing in psychiatry. The issue is there aren’t enough residency programs out there to take those interested. We can’t meet the demand.” 

Health system leaders say the cost of establishing and maintaining residency programs, coupled with outdated reimbursement guidelines for federal funding to support the programs, is a key reason for the shortage. In Iowa, a matching grant program approved by the Legislature three years ago is credited for making the two new programs feasible.  

Psychiatry is actually an “extremely competitive” specialty across the country, said Dr. Sasha Khosravi, a Mercy psychiatrist who leads the new residency program. Nationally, nearly every residency slot this year was filled with a student, with the exception of one new program that failed to properly apply for the match program, he said. 

“The applications from American graduates have increased as well,” Khosravi said. “In years past it’s been international graduates dominating psychiatry applications, but we’re definitely seeing a greater interest from American graduates as well, which is a good sign.” 

A match made in the Legislature 
When Mercy’s program is fully populated with residents in the next four years, it will increase its operating expenditures by about $3 million annually. The combined expenditure by Broadlawns and UnityPoint Health will be about the same amount. 

For Broadlawns and UnityPoint Health, “it’s another $1.5 million on our balance sheets each year, which reflects the commitment of both institutions,” said Dr. William Yost, vice president of medical education and research for UnityPoint Health-Des Moines. 

Another indication of the level of commitment: Both parties have signed a “no-way-out” 10-year contract to partner in the program, which Yost called “truly a long-term commitment in what has been really challenging fiscal times for hospitals.” 

Mercy’s Bagnall credited a $1.5 million matching grant that Mercy received from the state of Iowa as a key factor that helped make the program a reality. Mercy has used the grant to recruit and hire faculty and to complete an outpatient clinic in which residents will participate in providing continuity care for discharged patients, she said.  

The money was awarded by the state through a competitive request-for-proposal process. Broadlawns and Mercy each received $1.5 million and UnityPoint Health received $1 million through a state appropriation made in March 2016. The enabling legislation, signed in 2015 by Gov. Terry Branstad, was meant to reduce barriers for medical residency programs to receive funding and increase the likelihood that hospitals would invest in more costly residency programs such as psychiatry. 

“I truly believe that neither of these [Mercy’s and Broadlawns’] programs would have been started without that grant from the state, so that’s a very critical piece,” Bagnall said. 

Following the initial $4 million appropriation, the Legislature suspended funding for the program for the current fiscal year that ends June 30 due to a tight budget, but this session restored $2 million in funding for the program for the coming fiscal year. 

Meanwhile, the hospitals are receiving less federal money for additional residents, Broadlawns’ Severidt noted. Because both UnityPoint Health and Broadlawns are at their federal funding cap for residency programs, neither hospital will receive any Medicare or Medicaid reimbursements usually received for each psychiatry resident it adds — which for four residents totals about $280,000 per year. 

Mercy was in the same position with the federal cap on resident reimbursements, which hasn’t been adjusted since it was set in 1997, Khosravi said. 

“This is one of the biggest reasons that this state grant is so needed,” he said. “It’s a real burden to health systems to come up with 100 percent funding for any new programs in today’s current health care environment. The state’s willingness to fund 50 percent is the reason we have two new psychiatry programs, which likely would not have happened without the funding.”

More inpatient beds ahead
In early May, Mercy filed a letter of intent signaling that it plans to seek state approval to build a 100-bed psychiatric hospital in Polk County. If that hospital is approved and built, the additional facility would “absolutely” drive a larger residency program for Mercy, Khosravi said. 

“With the capacity that we would have, potentially, we could accommodate more residents, eventually up to 24,” he said. Mercy officials had initially considered launching the residency program with six residents per year rather than four, but decided to begin with four to ensure the program’s quality, Khosravi said. 

UnityPoint Health’s Yost said he thinks Mercy’s proposed additional inpatient beds would serve the state well. “That [hospital] will require a lot of psychiatrists, so I’m sure there will be lots of interest in our graduates, I have no question about that,” he said. 

Broadlawns, which added 14 additional inpatient beds six months ago, would also welcome an influx of more inpatient capacity, Severidt said. “We see Mercy as a partner in the community, because the goal is to develop a full continuum of care from outpatient all the way to inpatient,” he said. 

Considering partnerships, Broadlawns and UnityPoint Health have collaborated in medical education for the past 50 years, Severidt said. 

“It started with a surgical residency, but for years Broadlawns residents have gone over to Methodist for rotations in internal medicine, cardiology and critical care,” he said. “And during that same time, internal medicine residents from [UnityPoint’s] program have come over here for rotations. We also share pediatric residents — our residents go over to Blank, and they come over here. It’s not a new concept at all, so it just made sense that we would do this collaboratively.”

UnityPoint Health’s affiliation with the VA Medical Center in Des Moines means that the VA hospital will be incorporated into Broadlawns’ psychiatry residency program as well, Yost said. “So we have psychiatrists and leadership at the VA who are enormously enthusiastic about this because they’ll be a part of the program,” he said. “Our residents will go there typically for a couple of months each year. It’s a great educational opportunity for our residents; they learn a ton of medicine at the VA.” 

In a similar fashion, Mercy collaborates with Des Moines University for its medical students to get experience at Mercy’s inpatient psychiatric units, Khosravi said. About 40 students rotate through each year, and typically about 10 percent express an interest in specializing in psychiatry. “We actually built a psychiatry track within their rotation, so people who are genuinely interested can get a little bit more [experience]” he said. “That’s a new thing we’ll be starting in August.” 

More outpatient clinics to open 
Because many psychiatry patients have to wait several months before they can get an outpatient appointment, having a psychiatry outpatient clinic open this summer at Mercy will make a significant difference, Khosravi said. 

“If you look at the Des Moines metro area and even the state, there is very little for this population, especially if they’re [enrolled in Medicaid] and don’t have any resources,” he said. “So establishing this clinic is going to be a huge investment into our community and our mental health services in Iowa.” 

In a similar vein, Broadlawns will be opening a psychiatric urgent care center on its campus June 4. Located adjacent to its Crisis Observation Center that’s open on a 24-hour basis, Broadlawns Psych Urgent Care will be available weekdays for walk-in appointments from 9 a.m. to 7 p.m., with a psychiatric medical provider on-site for 50 hours per week. 

Mercy’s commitment to launch a psychiatry residency program is already paying dividends in recruiting additional staff psychiatrists, Bagnall said. The program recently hired two new faculty members — one for the outpatient clinic and one for inpatient clinic, both of whom came to Mercy specifically because they wanted to teach in the residency program, she said. 

UnityPoint Health’s Yost said he believes one of the biggest intangible benefits of a residency program is that it tends to strengthen the care and professional level of the hospital. 

“I’m convinced it makes us better doctors,” he said. “If I have these sharp young 28-year-olds looking me in the eye on rounds and saying, ‘Well, why do we do this?’ then it forces me to stay abreast of the literature and be more knowledgeable about it. A lot of studies have shown that patients actually get better care in teaching hospitals.”