Washington Emilio Moscoso got an answer earlier this month from the Kansas medical board about his application for a physician’s license.
Moscoso, an 80-year-old who graduated from an Ecuadorian medical school in 1966, had never passed the required state or national medical exams. But he wrote the Kansas State Board of Healing Arts, anyway, saying he was seeking a license under a “grant father claus (sic)."
The board denied Moscoso’s request, saying that such a clause didn't actually exist.
So he went back to his job as a staff psychiatrist at Larned State Hospital.
Moscoso is among the 19 doctors at Larned and the state’s other mental institution, Osawatomie State Hospital, who have special “institutional licenses” that allow them to work in those facilities or any of the state’s prisons.
The license allows Moscoso to work at Larned even though he hasn't passed the three-step United States Medical Licensing Examination, or USMLE, and has no plans to try at this point. Moscoso said the exam is meant for people who are fresh out of medical school.
“I am no spring chicken anymore," Moscoso said. "For me, it would be a very difficult test.”
Nine of the 13 physicians at Larned are currently on institutional licenses, according to Kansas Department for Aging and Disability Services. At Osawatomie State Hospital, which is about 30 miles from the Kansas City metro area, only 10 of 22 physicians are.
That's still a higher ratio than in Kansas prisons, though, where one of nine medical doctors and four of nine doctors who specialize in psychiatric medicine have institutional licenses, according to Corizon Health, the state's corrections health care contractor.
KDADS Sec. Tim Keck said the doctors at Osawatomie and Larned are providing a valuable service in a state that's short on psychiatrists.
“The agency appreciates our institutionally licensed doctors," Keck said in an emailed statement. "They are dedicated and they work hard every day to provide good care to our patients.”
But Rick Cagan, the executive director of the National Alliance on Mental Illness’ Kansas branch, said creating a lower bar for the state facilities means that Kansans who need the most help often get it from doctors who, at least on paper, are less qualified.
“I am concerned that the most acutely ill individuals are receiving treatment from physicians who do not meet the highest standards for practice,” Cagan said. “It’s counter-intuitive that those most seriously ill have access to physicians who are denied the ability to establish a community-based practice.”
It’s been like that in Kansas and elsewhere for decades, largely because it's hard to find good psychiatric help.
Kansas Sen. Barbara Bollier, a Republican from Mission Hills and a retired physician, said it's worth talking about whether that should change.
“Why are we still doing this?" Bollier said of the institutional licenses. "That’s the biggest question. I don’t have an answer. ... If that is good enough for (state hospitals), why aren’t these same things in place for the entire population of the state? Why do we have different standards?”
Moscoso's plans and past
Moscoso, who has had an institutional license in Kansas since 2006, said in a phone interview that he applied for a full medical license because he might want to practice elsewhere after he retires from Larned.
“They denied my request because I don’t pass any tests, but anyway, I've worked here for more than 10 years now," Moscoso said. "I thought maybe I qualified to get the license.”
Moscoso was one of several doctors who were part of a series of stories on military health care that earned the Dayton Daily News a Pulitzer Prize in 1998.
Then a medical officer at a U.S. Army hospital in California, he and other doctors had gotten special licenses in Oklahoma that allowed them to work on military bases all over the country even though they Dayton paper reported they had flunked their medical exams many times — in Moscoso's case, 14.
Moscoso said he remembered having the Oklahoma license, but didn't remember failing his exams that many times. He said he's since had years of training in psychiatry and he's good at it.
"I treat my patients very careful," Moscoso said. “... I don’t like to use poly-pharmacy. So many doctors in U.S., they use poly-pharmacy, two or more medications for the same condition. That’s no good.”
Moscoso said he's an American citizen and Vietnam veteran. To get his institutional license, he had to graduate from a medical school that has been around for at least 15 years — though the Kansas Board of Healing Arts has waived even that requirement for some other doctors.
To maintain the institutional license he has had to do continuing medical education every year and abide by the same standards of care the Kansas medical board requires of other physicians.
Without passing the USMLE exam, his options are limited.
With the institutional license, doctors can practice at Larned, Osawatomie or the state prisons. After three years in those settings they're eligible to practice in Kansas at other public facilities like community mental health centers.
None of the doctors practicing on institutional licenses has ever been sanctioned for violating standards of care, according to information provided by Kathleen Lippert, the executive director of the Kansas Board of Healing Arts.
Reji Varghese, the deputy director of Oklahoma's medical board, said its records show that Moscoso had its special license for one year. The state no longer offers it.
But Kansas and about 20 other states still offer limited licenses to allow doctors who aren't able to start a private practice to work in state mental institutions.
The law that established the institutional medical license in Kansas dates back to 1969, at the beginning of a nationwide shift in psychiatric care.
After decades of long-term institutionalization, states began shifting to community-based care, which mental health advocates argued would be less expensive and more humane.
The demand for psychiatric care grew even as bed space plummeted because the purpose of state hospitals shifted from "warehousing" people to keep them away from the general public to stabilizing and treating them so they could return to their communities.
Larned and Osawatomie are the last state hospitals left in Kansas and have about 300 beds between them.
Osawatomie generally serves the eastern part of the state, while Larned serves the rest. But Larned is also home to a sex predator treatment program and a forensic psychiatry program that evaluates whether people accused of crimes are mentally competent to stand trial.
Since de-institutionalization, the use of institutional licenses has been steady, in Kansas and other states.
A 1990 report from the National Association of State Mental Health Program Directors found that 21 states had some sort of limited license that allowed physicians to practice in state mental hospitals.
They ranged from licensing exemptions for psychiatry medical residents to parallel licensing tracks like the one in Kansas. The report determined that Kansas' state hospitals had 18 physicians with limited licenses at that time.
By calling state licensing boards and checking their websites, the Star determined that most of the 21 states still offer the limited licenses. But a few have phased them out. Oregon wasn't offering any new institutional licenses even in 1990 and the mental health program directors association's report said "the law is on the books to allow the two remaining individuals to complete their careers."
Missouri, which employed a national-high 47 limited license physicians in its mental health program in 1990, has also since phased it out.
Debra Walker, a spokeswoman for the Missouri Department of Mental Health, said its seven state mental institutions have been able to recruit psychiatrists by working closely with medical school residency and fellowship programs.
"Most psychiatric residents and fellows receive clinical rotations through DMH operated hospitals and staff from DMH hospitals also serve as teaching and clinical faculty in these programs," Walker said via email. "DMH also provides limited financial support for these programs."
Walker said the department also allows flexible work schedules so its psychiatrists can grab shifts outside of the state system for additional income.
Still, staying fully staffed has not been easy in Missouri.
Walker said the department currently employs 34 psychiatrists and has 6.5 openings, a vacancy rate of about 16 percent.
Walker said the average salary of psychiatrists in the Missouri Department of Health is $211,155.00.
Pay in Kansas was comparable for licensed psychiatrists last year. Those with institutional licenses made, on average, about $20,000 less. Moscoso made $183,500.
According to a 2016 report on state hospitals, Kansas has faced similar staffing struggles for a variety of positions, especially at Larned, a "rural area with low unemployment."
A 2013 report from an independent consulting group looked specifically at psychiatrists and found that Larned had only about half as many as it should have.
“It is no news that there is a shortage of psychiatrists in Kansas, and nationwide," Keck said. "This was first brought to the attention of the Kansas Legislature in 2013, with a recommendation for more psychiatric residencies to be funded at KU Med. Kansas is addressing this need."
Keck pointed to a bill the legislature passed last year to expand the number of psychiatric residency slots in Kansas.
But Cagan said there's more to Kansas' use of institutional licenses than just sheer shortage of psychiatrists. The state has an incentive to hire doctors with limited licenses because they can't leave for private practice — something he says has been brought up when his group has raised concerns about the licenses.
"I am advised that what happens is that individuals who are able to upgrade their license to practice beyond the institutional setting would then be most likely to leave the state hospital practice for a more lucrative practice," Cagan said, "creating turnover in the workforce for the state hospitals."