Psychosomatics 50:93-107, March-April 2009
doi: 10.1176/appi.psy.50.2.93
© 2009 Academy of Psychosomatic Medicine
Psychiatrists for Medically Complex Patients: Bringing Value at the Physical Health and Mental Health/Substance-Use Disorder Interface
Roger G. Kathol, M.D.,
Elisabeth J.S. Kunkel, M.D.,
Joseph S. Weiner, M.D.,
Robert M. McCarron, M.D.,
Linda L.M. Worley, M.D.,
William R. Yates, M.D.,
Paul Summergrad, M.D., and
Frits J. Huyse, M.D.
Received May 26, 2008; revised September 10, 2008; accepted October 6, 2008. From the Dept. of Internal Medicine and Psychiatry, Univ. of Minnesota (RGK); the Dept. of Psychiatry, Thomas Jefferson Univ. (EJSK); the Dept. of Internal Medicine and Psychiatry, Albert Einstein College of Medicine (JSW); the Dept. of Internal Medicine and Psychiatry, Univ. of California, Davis (RMM); the Dept. of Psychiatry and Obstetrics/Gynecology, Univ. of Arkansas (LLMW); the Dept. of Psychiatry and Family Practice, Laureate Institute for Brain Research ((WRY); the Dept. of Psychiatry and Internal Medicine,, Tufts Univ. (PS); and the Dept. of General-Internal Medicine, Univ. Medical Center, Groningen, The Netherlands (FJH). Send correspondence and reprint requests to Roger Kathol, M.D., 3004 Foxpoint Rd., Burnsville, MN 55337. e-mail: roger-kathol{at}attglobal.net
© 2009 The Academy of Psychosomatic Medicine
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ABSTRACT
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BACKGROUND: In their current configuration, traditional reactive consultation–liaison services see a small percentage of the general-hospital patients who could benefit from their care. These services are poorly reimbursed and bring limited value in terms of clinical improvement and reduction in health-service use. METHOD: The authors examine models of cross-disciplinary, integrated health services that have been shown to promote health and lower cost in medically-complex patients, those with complicated admixtures of physical, mental, social, and health-system difficulties. CONCLUSION: Psychiatrists who specialize in the treatment of medically-complex patients must now consider a transition from traditional consultation to proactive, value-added programs and bill for services from medical, rather than behavioral, insurance dollars, since the majority of health-enhancement and cost-savings from these programs occur in the medical sector. The authors provide the clinical and financial arguments for such program-creation and the steps that can be taken as psychiatrists for medically-complex patients move to the next generation of interdisciplinary service.
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INTRODUCTION
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The ability of psychiatrists for medically-complex patients (PMCs) to improve the health of medical and surgical patients has grown tremendously over the past two decades. We need to understand the prevalence, presentation, and impact on health of psychiatric conditions seen in those with general-medical illnesses. Furthermore, studies now demonstrate improvement in clinical and economic outcomes when high service-use, "complex" patients with concurrent physical health (PH) and mental health/substance-use disorders (MH/SUDs) receive evidence-based psychiatric interventions, especially when coordinated with treatment of physical disorders in the medical setting.1
An important question to ask, however, is: "Are general-medical patients with comorbid psychiatric conditions currently receiving better care than they have in the past?" In 2008, the short answer to this question appears to be "No." This is despite improved skills in uncovering and treating patients with concurrent illness, the presence of 36 psychosomatic-medicine fellowships, 46 combined-residency training programs (17 in internal medicine/psychiatry, 10 in pediatrics/psychiatry/child psychiatry, 10 in psychiatry/neurology, and 9 in psychiatry/family medicine), and a steadily increasing number of general-medical practitioners with an interest in better addressing MH/SUDs in their patients. With few exceptions, medical patients have little access to psychiatric services that consistently lead to better physical and MH/SUD outcomes. In fact, many hospitals and clinics have experienced shrinking resources supporting such services.
PMCs are composed of psychosomatic-medicine subspecialists with and without board certification and physicians trained in combined residencies. This article is intended to challenge some of the basic assumptions that PMCs have about the clinical services that they provide and about the way that they provide them. It also is intended to stimulate thought about alternatives that should be considered, based on an evolving literature, and guide the development of value-added hospital- and clinic-based programs for the future. The ultimate objective is for the PMC to help improve the care of patients with complex conditions; that is, those with psychiatric and physical, as well as social and health-system barriers to improvement, in a fiscally responsible way. We describe this objective as "bringing value."
The development of value-added programs is the only way for PMCs to alter their current funding challenges. The objective is to market the benefits they bring to stakeholders who are likely to be those who pay for the services that they provide. In today’s world, PMCs working as primary-care physicians (graduates of combined programs) rely on support for the MH/SUD care they provide from medical benefits, most often achieved by miscoding psychiatric symptoms as general-medical conditions.2 PMCs with MH/SUD backgrounds, on the other hand, are funded by psychiatry department chairpersons agreeing to insufficient payments through managed behavioral-health organizations (MBHOs) or by the MBHOs themselves, which have a vested interest in shifting costs for MH/SUD services delivered in the medical setting to medical benefits.3 An analysis of traditional, reactive consultation programs sets the stage for understanding the importance of moving toward value-added programs.
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Do Traditional Reactive Consultation Programs Consistently Bring Value to Patients?
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Hospital parameters often establish personnel needs: private, public, or academic; large or small; metropolitan or rural. The relationship of psychiatrists and/or their departments to other MH/SUD personnel determines whether collaborative, as opposed to competitive, support is provided for MH/SUD needs in general-hospital patients. The payer mix of patients—that is, commercial insurance, public program, indigent—predicts the financial solvency of the clinical service. Financial resources, in turn, establish the number and types of consultants available and the quality of care they are able to provide. These, among other factors, play a role in staffing traditional consultation services.4–6 Despite high organizational variability, however, traditional reactive consultation programs are more alike than different in the type of services that they deliver.5,7,8
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Value and Limitations
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In 1996, Hall and Frankel published an article in Psychiatric Services extolling the clinical and financial value that PMCs bring to patients with comorbid conditions through traditional consultation–liaison services.9 Unfortunately, few traditional consultation services have the characteristics that lead to the value they described, such as early and appropriate referral, timely response, and consistent implementation and follow-through on consultant recommendations. Inherent limitations of traditional consultation programs (Table 1) mitigate against outcome-change for most patients.8,10–13 Traditional reactive consultations can be typified in the following way: In most general-hospital settings, one or two psychiatrists are willing to see medical-surgical inpatients. Not infrequently, however, consultations are performed without the assistance of a psychiatrist. Unsupervised nurse-clinicians, psychologists, or social workers with lower salaries, but also limited understanding of the complex interactions of general-medical and psychiatric illnesses in many of the patients they see, become the primary and, often, the only consultants.
Consultation requests often do not represent referral of the patients most likely to benefit from PMC expertise. Approximately 40% of referrals are for situations requiring psychological support, but not psychiatric intervention.11 Importantly, psychiatric consultation requests are never submitted on a substantial number of patients who could benefit from PMC intervention or they arrive too close to the day of discharge, when little can be done.8
PMC response to the consultation may be delayed in favor of better-paying clinical/professional commitments or because of the need for insurance approval before seeing the patient. Assessments are generally problem-focused and crisis-oriented, with little time available to obtain collateral history. Implementation of PMC recommendations occurs in only half the instances.10,12,13 Furthermore, nursing staff in general-medical settings have limited ability to institute nonmedication-related MH/SUD interventions for patients, such as behavioral limit-setting and/or providing emotional support to psychotic or depressed patients. Finally, PMC follow-up visits are the exception, rather than the rule, because of limited staff time and reimbursement issues. For instance, medical-assistance insurance only reimburses the first two consultations of the hospitalization, regardless of specialty. For all these reasons, traditional consultation programs in most locations bring limited value to the hospitals in which they operate. PMCs see few of the complex patients for whom they could truly make a difference. MH/SUD personnel without the background and skills to change outcomes often staff hospital consultation–liaison programs with limited or nominal psychiatrist back-up. Nonetheless, traditional consultation services are essential and beneficial in the medical/surgical patients who need emergent psychiatric intervention. They also serve a required psychiatric residency-training function in hospitals with academic affiliations.
Because of this rather dismal assessment of the value that traditional "reactive" consultation programs bring, PMCs should consider designing programs that could produce better performance metrics (Table 2). In order to understand what services should be provided, let us first discuss characteristics of patients with complex illnesses and link them to value-added PMC activities.
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Impact of the Interaction of Concurrent PH and MH/SUDs
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The journal Medical Clinics of North America published an issue on integrated care for complex medically ill patients,1 which reinforced the importance of psychiatric factors as they relate to 1) clinical outcomes; 2) cost of care; and 3) personal functioning in patients with chronic physical illnesses, multi-morbid disorders, elderly patients, and those with high scores on their levels of case- and care-complexity, such as assessed with the INTERMED measure.14 It is this 5%–10% of patients who use 50%–70% of healthcare dollars.15 Surprisingly, a Veterans Administration conference on identifying and addressing the needs of complex patients16 failed even to mention the role of MH/SUD issues as a component of complexity in many of the papers presented.
Complexity, defined as the interaction of suboptimally-controlled psychological, social, physical, and health-system problems, should be the core focus of the PMC.1 Complex patients are of major concern to most health systems, nationally and internationally, largely because of their contribution to health-service utilization and total healthcare costs. Importantly, in 50%–80% of complex patients, psychiatric morbidity exacerbates many factors, such as poor clinical outcomes; the persistent, excessive healthcare cost burden; healthcare resource utilization; disability; and public program costs.17 Catastrophically, over two-thirds of patients with psychiatric needs remain undiagnosed and untreated.18 Redefining service-delivery models will increase the frequency with which complex patients are seen and evidence-based treatments are given. The next section will discuss potential starting-points.
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Models of PMC Use With Promise of Value
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Jim Collins transformed Voltaire’s quote " the ‘best’ is the enemy of the ‘good ’" into "the ‘good’ is the enemy of the ‘great’" in his book Good-to-Great.19 Jim Collins is challenging us not to be satisfied with the status quo. PMCs currently find themselves in a broken treatment and reimbursement environment, yet they have initiated few activities that would effectively change the status quo. In this article, we suggest that PMCs have an opportunity to make a major difference at all levels of the health system by promoting use of the skills they provide by focusing on the initiation of programs that bring value.
The core conceptual shift for PMCs, as they suggest clinical models, is to intervene with the greatest number of complex patients possible. The July 2006 issue of Medical Clinics of North America illustrates the types of patients who would be considered complex.1 In it, the concept of complexity is divided into two major components: 1) the complexity of the case; and 2) the complexity of the care required.20 Lyons proposes a mechanism to transform complexity into actionable items.21 Huyse and colleagues describe the use of clinic and clinician-level "red flags" to uncover at-risk patients, saving time and money by obviating the need for population-based screening.22 For instance, readily-identifiable general-medical patients with multiple hospitalizations, numerous emergency room visits, psychiatric histories and/or symptoms, those on many medications, or having several and/or varied doctors providing their care, would be at increased risk for poor outcomes and high future healthcare service use. Finally, Stiefel and colleagues describe the development, testing, and use of an instrument, the INTERMED, which transforms components of complexity in these "red-flagged" patients into preventive clinical action based on biopsychosocial principles.14,23,24
The complexity assessment drives preventive clinical care designed to maximize recovery and reduce unnecessary healthcare service use. It helps formulate a comprehensive treatment plan that includes the psychological, social, biological, and/or health-system factors needed for success. Using this framework, we propose the concept of value-added PMC programs, summarized in Table 3. Although Table 3 is not comprehensive, the programs listed serve as examples of those with evidence of value to patients and the health system.
In order to implement valued-added PMC programs, one first must grasp the magnitude of the challenge for PMCs. Currently, national agendas encouraging assessment and intervention in patients with MH/SUDs focus on disparities of care seen in the MH/SUD sector of the health system (Figure 1). The majority of MH/SUD resources go to only 10% of all patients with MH/SUDs;25–27 90% of patients with MH/SUDs are seen in the general-medical health sector, and approximately two-thirds of these patients receive no treatment for their MH/SUDs.18,27–29 In short, a small number of PMCs are expected to pick up the MH/SUD burden for the majority of those with MH/SUDs in an environment in which pennies are paid on the billed dollar. For this reason, collaboration with other MH/SUD professionals in the development of PMC programs and in supporting primary and specialty medical clinicians is crucial. Primary and specialty medical clinicians will continue to deliver care to the majority of less severely ill MH/SUD patients seen by PMC teams. Such medical clinicians, however, usually receive only marginal training in the diagnosis and treatment of MH/SUDs.30,31 For this reason, it is necessary to augment the limited number of psychiatrists available to support primary and specialty medical physicians with other MH/SUD clinicians, preferably working in concert with PMCs.
Nonpsychiatric MH/SUD professionals who are logical candidates for participation on PMC program teams include social workers, SUD counselors, nurses, physician-assistants, pharmacists, psychologists, and marital and family therapists, among others. These MH/SUD practitioners bring selected skills and should be hired in proportion to the estimated or documented number of patients with which they will become involved and bring value. PMC involvement also needs to be evaluated in terms of the clinical care and supervision they provide as they support evidence-based treatment for non-complex and complex patients seen in the medical setting.
For instance, a proactive inpatient consultation service may primarily include services from psychiatrists, advanced practice nurses, and social workers. An integrated outpatient clinic may incorporate the services of psychiatrists, psychologists, social workers, nurses, marital and family therapists, and/or SUD counselors. Delirium-prevention programs may be staffed primarily by physician-assistants or advanced practice nurses supervised by PMCs. There are far too many patients for value-added PMC programs to limit their staffing to PMCs.
Although PMCs should be program leaders for all MH/SUD services available in the PH setting, the number and type of collaborative and multidisciplinary MH/SUD professionals with varying skills involved in each program should be matched to patients’ needs, so that outcomes for the patients seen are improved. When this is possible, existing research already demonstrates the value that can be brought to patients with a variety of conditions in terms of clinical improvement and healthcare cost-reduction (Table 2).32–43 An important function of the MH/SUD professionals in the general-medical setting should also be education of primary and specialty medical physicians and their staff so that they can follow and treat patients when specialized MH/SUD services are no longer required.
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Inpatient Value-Added Programs
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Proactive Case-Finding Consultation Services
The discussion of traditional reactive consultation programs above was not intended to suggest that PMCs cannot add value through consultation activities; rather, it was intended to point out that the way that most services are organized in today’s health system does not typically lead to good use of PMCs and their team’s skills, nor does it improve outcomes in the majority of patients who need MH/SUD attention in the medical setting. We propose substantive changes for PMC care-delivery (Table 4) through the development of proactive consultation services. Proactive PMC consultation can lead to better use of PMC time and skills, clinical improvement for patients, lower costs for hospitals, and reduced healthcare service-use for the medical health plans insuring the patients assisted through PMC consultations.44,45 In most hospitals, psychiatric consultations are requested in fewer than 1% of admissions.5,6 Even then, a large percentage of referrals are for emotional concerns that do not require emergent PMC attention (life-circumstance problems). In the proactive consultation model, there is an active process used to uncover complex patients at admission to the medical setting and to automatically involve the PMC team when a predetermined level of complexity is found. Complexity-assessment tools, such as the INTERMED, can be performed as a part of the admitting-nurse assessment in selected high-risk patients.46–48 Through rapid quantification of patient-complexity, several of the impediments to adding value through consultation–liaison activity are overcome: 1) contact with patients most likely to benefit from psychiatric involvement is maximized; 2) patients are seen early in their hospital stay; 3) intervention can be matched to patient need; and 4) active collaboration between the PMC team with staff and physicians on the admitting units is initiated. Behavioral changes throughout hospitalization in patients not identified through proactive case-finding will continue to necessitate additional referrals, but those uncovered early after admission will constitute the majority of patients seen by the PMC team.
The proactive consultation model includes the coordinated involvement of MH/SUD professionals from various backgrounds. Special areas of expertise and skill-sets specific to each specialty can be accessed on behalf of the patients. For instance, medically ill patients with disruptive or maladaptive personality disorders may create dissension among nursing staff on a surgical floor. A proactive consultation team nurse could educate the unit staff about "splitting" behavior and how to set limits. In another clinical situation, a consultant team social worker may assist a unit social worker in identifying community MH/SUD resources, which would increase the chance of medical and MH/SUD adherence post-discharge.
Finally, a proactive consultation service should be sufficiently staffed to service all initial and follow-up care. The services should provide the educational and support needs of the staff on the medical/surgical services (liaison-like activities, but related to acute patient-care circumstances) to facilitate ongoing management during hospitalization. If patients are referred for life-circumstance problems, proactive consultation team therapists can provide the crisis-intervention and support needed. This would free up psychiatrist and nurse-clinician time for more complicated "med-psych" issues and for managing acute psychiatric illness. Consultation team members also can assist with transfers to inpatient complexity intervention units (CIUs; see below) or integrated outpatient services.
All proactive consultation services should strive to work with general-medical unit staff to redress as many barriers to improved long-term outcome as possible. Control of emotions and behavior is a primary goal, but social, physical, and health-system factors that impede progress toward recovery also should be part of the proactive consultation-service accountability. One key to improved outcomes is coordination of services.
Delirium-Prevention Programs
Delirium has high morbidity, mortality, and associated costs, both during and after acute hospitalization.49–52 A natural target of a proactive consultation service would be delirium-prevention. Inouye and others have confirmed that the development of delirium can be prevented in about one-third of those at risk.32,53–57 Surprisingly, few hospitals support delirium-prevention programs, despite the tremendous value that they could bring in terms of lowered morbidity, mortality, cost, and staff "burnout."
Implementing delirium-prevention programs requires an understanding of the interaction of medical and psychiatric illness in seriously ill patients. In those cases where delirium occurs despite prevention efforts, PMCs already will be involved and can reduce the morbidity and mortality associated with delirium by providing suggestions for acute treatment to the patients’ clinical unit staff.58,59
PMCs can also help facilitate transfer of patients with delirium to CIUs when the delirium is life-threatening or persistent. Although delirium commonly occurs in general-medical settings, general-medical staff usually are not trained to manage agitation and sometime are reluctant to administer treatments that would terminate delirium symptoms, such as intravenous haloperidol and/or ECT.60–62 General-medical and surgical physicians typically order physical restraints, and/or constant observation, without considering further diagnostic evaluation and/or other environmental and somatic treatments for delirium. In the CIU, staff are trained to deal with agitation and the use of both physical and chemical restraints.
Delirium-prevention programs also add value for hospitals. Through delirium-prevention (and intervention), it is possible to substantially shorten lengths of stay (LOS) and reduce the need for constant-observation nurses. This opens bed-days for additional hospital admissions, improves diagnostic-related group profit margins, and lowers hospital resources spent for one-on-one nursing staff.
Complexity Intervention Units
"Complexity Intervention Units," or CIUs, is the suggested new name for what used to be called "Medical Psychiatry Units" (MPUs) or "Psychiatric Medicine Units" (PMUs).46–48,63,64 Although the clinical activities and personnel working on CIUs will continue to include professionals with PH and MH/SUD expertise, changing the name is an attempt to help the health system recognize that the value related to such units occurs most consistently when they are located in general-medical, and not psychiatric, settings and when they target assistance to complex patients, often with severe and acute general-medical disorders. Currently, over 80% of generic medical-psychiatry units are organized under psychiatric licensure. This creates major barriers to the clinical value that they can bring to patients with complex illness because of limits in the ability to address acute PH illness. Furthermore, the financial viability of CIUs organized under psychiatry is limited, since per-diems for psychiatric units, paid through MBHOs, are substantially less than on medical units. Also, ancillary services are not reimbursed. This makes it difficult to target highly complex patients, that is, those most likely to benefit, because of financial issues relevant to payment within the psychiatric setting.
Why should CIUs be set up in general-medical hospitals when psychiatric consultation services are available? Although the majority of patients with concurrent general-medical and psychiatric illness can be treated in standard PH settings with proactive PMC consultation team support, a considerable number of complex patients with comorbid medical and psychiatric illness create special problems when cared for in the medical/surgical setting. Constant observation is needed to protect delirium patients from pulling tubes or wandering; to prevent admitted SUD patients from getting drug supplies from friends; to protect medically unstable, suicidal patients from themselves; or to stop anorexic/bulimic, insulin-dependent diabetic patients from surreptitiously supplementing their diet when on a medical/surgical unit. Unfortunately, many hospitals assign untrained personnel to the task of "observing." This puts patients with psychiatric (and physical) illness at increased risk and creates increased liability for hospitals.
CIUs add value through their ability to institute aggressive, combined treatment for patients with complicated PH and MH/SUDs from the first day of admission (concurrent rather than sequential care). For instance, a psychotically-depressed patient with renal failure can be peritoneally dialyzed at the same time electroconvulsive therapy is being given. A delusional patient with schizophrenia and seizures related to hyponatremic primary polydipsia can be treated for psychosis while access to water is restricted and hyponatremia is corrected. An AIDS patient with delirium can be treated for pneumocystis pneumonia and immunosuppression while delirium is reversed with intravenous haloperidol. Technically, these capabilities should be available through well-formulated PMC consultations; however, medical/surgical staff training and nurse-to-patient ratios do not allow consistent and concurrent intervention, which necessarily retards improvement, increases PH and MH/SUD complications, and lengthens hospital stays. In fact, it is in highly complex patients that CIUs bring their greatest value, both in terms of quality and rapidity of clinical improvement and of healthcare cost-reduction to the system.
Core characteristics of CIUs are summarized in Table 5. These units would care for patients requiring medium-to-high psychiatric and general-medical treatment capabilities or both high psychiatric and general-medical treatment capabilities (Type III and IV units). Type I and Type II units, that is, lower-acuity units, as previously described by Kathol et al., would not be considered CIUs.64
CIUs focus on providing care for the 1%–2% of patients who use one-quarter to one-third of healthcare resources. Since CIUs provide efficient and effective PH and MH/SUD intervention during hospitalization and improve comprehensive post-discharge planning, the admission–readmission cycle can be broken. Symptom-control in polysubstance abuse patients with medical complications, malingering, and factitious-disorder patients, and in nonadherent patients with chronic medical illness and personality disorders is easier to achieve.
Other, indirect benefits brought by CIUs include 1) reduction in burnout of nurses on other units that would otherwise have to deal with these complex patients in settings ill-equipped to do so; 2) better relationships between MH/SUD and PH physicians and staff through a focus on mutual assistance; 3) improved ability of staff in other areas of the general hospital to handle psychiatric comorbidity because of nurse-to-nurse in-services and communication; and 4) excellent training for many health professionals (staff physicians, medical students, residents, nurses, pharmacy students, social workers, etc.) in integrated-care techniques.
Outpatient Value-Added Programs
Although inpatient value-added programs in complex patients have the potential to reap the greatest dividends in terms of reversal of complex illness cycles, reduction in healthcare service use, and return to improved functioning, outpatient programs are necessary to sustain and augment gains achieved during inpatient admission. They also address the needs of those patients seen only in the general-medical outpatient setting who have complexity associated with PH, MH/SUD, social, and health-system factors that create barriers to improvement and lead to high healthcare utilization, with associated functional impairment.
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Primary and Specialty Medical Clinician Training in Physical Symptom-Reframing
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Patients with serious and/or chronic general-medical conditions undoubtedly have emotional reactions to the way their lives are affected by their illnesses. These patients use more general-medical services because they have medical illnesses that warrant it. There may also be a component of increased PH service use related to augmented, emotion-laden health concerns. Increased general-medical service use has also been noted in patients with psychiatric symptoms.65–68 Depression, anxiety, substance-dependence, and other MH/SUDs lower the threshold for symptom-concern, leading patients with what would otherwise be overlooked symptoms, such as constipation, dizziness, visual blurring, and so forth, to seek explanations from their medical practitioners.
Furthermore, it is more socially acceptable (less stigmatizing) for patients with MH/SUDs to embrace the "sick role" when they have physical problems than when they have MH/SUD problems. A high incidence of disability is associated with headaches, back pain, fibromyalgia, and other conditions, often with limited objective medical findings. These patients are primarily seen in the PH setting, allowing patients with depression or other MH/SUDs to use a nonpsychiatric reason for their lower functioning and limited activity without admitting to psychiatric illness. Regardless of the cause for increased PH service use in MH/SUD patients, attention must be paid to the PH-and-MH/SUD interaction.
Primary and specialty medical practitioners order unnecessary tests, obtain unnecessary consultations, and give unnecessary medications to patients with augmented PH concerns. It is important for them to learn how to recognize and conservatively manage these patients to limit the development of iatrogenic illness and curb the overuse of healthcare resources.
The health systems that have done the most to assist primary and specialty medical physicians in this regard are Denmark (TERM technique training69) and the United Kingdom (reattribution training38,70). Both have active training campaigns for general and other practitioners in how to address the needs of patients with unexplained physical complaints. Both use a technique in which patients are helped to reframe somatic symptoms. Although much remains to be done in helping physicians link this activity to conservative test-ordering, lower referral rates, limited prescribing of medications, and addressing emotional problems, it is an important start in dealing with problems associated with excessive health-service use in patients with unexplained physical symptoms. Researchers who have investigated procedures fostering conservative approaches to medical care consistently show healthcare cost-reduction without increasing the risk of missing physical illnesses.
It is worth noting that primary-care physician training training in the art of reframing the interpretation of physical symptoms does not require the involvement of PMCs. Patients see primary and specialty medical physicians for somatic complaints, rather than psychiatrists. PMCs, on the other hand, play an important role in training-programs for nonpsychiatrist physicians in both Denmark and the U.K., since reframing often moves in the direction of emotional factors, which then have to be addressed. Training in how to deal with unexplained physical complaints is therefore a natural segue into the integration of MH/SUD with PH care.
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Integrated MH/SUD Primary and Specialty Medical Clinics
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There are now several research groups that have shown value in co-locating PH and MH/SUD professionals in medical settings to enhance the treatment of depression,45,71–75 anxiety,76–78 and chemical abuse/dependence.35,79 Using co-location and active psychiatric intervention in the medical setting makes it possible to improve target psychiatric symptoms and lower total healthcare costs (Table 2), especially when a >12-month follow-up period is used to document outcomes. Few studies, however, have demonstrated that comorbid medical conditions are also improved in the patients who are treated for their psychiatric symptoms. Co-located PH and MH/SUD practitioners collaborate but continue to focus on their separate disciplines as their area of accountability. As a result, research reports have not included coordination of general-medical and psychiatric treatment as a major component in their design.
Patients’ minds should no longer be considered separate from their bodies. Patients should be treated so that they experience total health improvement. The inclusion of MH/SUD interventions clearly brings value to patients in the primary-care setting.32,35,38,56,76,80–82 It is now possible to increase this value with proactive case-finding and coordination of PH and MH/SUD services by using case-management1,45–48 in patients with the greatest need, that is, those with higher complexity.
Integrated outpatient core organizational attributes are summarized in Table 6. The first two bullets draw heavily from the stepped-care model,83 the three-component model,84 and shared-care models,85 among others. Bullet 3 draws on work by those using the INTERMED to identify and preferentially intervene in patients at high risk for poor outcomes.14,48,86 In order for proactive case-finding of complex outpatients to be successful, it is necessary to have dedicated personnel; that is, nurse case-managers (Bullet 4), with the time to assist the treatment team to coordinate services in a complicated health system. In complex patients, case-management assistance is often the ticket needed to achieve success. Bullets 5 and 6 endorse a seemingly peripheral component of some of the programs listed above, but are of major importance in moving value-added services forward. Outcome measurement is necessary to justify growth and ongoing programmatic support, thus reversing insolvent outpatient PMC programs found in the current reimbursement environment.
Integrated PH and MH/SUD services should be a part of every outpatient general and specialty medical/surgical clinic. All physicians have cared for patients who do not do well because of comorbid MH/SUDs. Some do very poorly because of the complexity of their situation. By introducing integrated practices, it is at least possible to identify at-risk patients early; to support, reassure, crisis-manage, and/or give medication for emotional and behavioral issues in the medical setting; to refer for more sophisticated MH/SUD interventions, such as formal psychotherapy; and to limit aggressive medical testing and intervention in those with unexplained physical complaints because reframing techniques are used and assistance with MH/SUDs is available. PH-and-MH/SUD integrated capabilities also facilitate the introduction of primary care-based clinical programs, such as depression screening and treatment,87,88 screening and brief interventions for alcohol abuse,89 buprenorphine clinics,90 and SUD rehabilitation for medically-compromised patients,35,79 all of which have been shown to improve clinical outcomes and lower total healthcare costs.
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Selling PMC Value-Based Programs
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Many will question whether the suggestions for value-added PMC programs found in this article are feasible in the current fiscal environment. There certainly are challenges involved in bringing the programs described to fruition. We strongly encourage marketing, debate with decision-makers in care-delivery systems, and lobbying for support of such programs. Initial discussions will likely meet with resistance for a variety of reasons, such as manpower shortages, reimbursement issues, interdisciplinary leveraging, and so on. With time, receptivity will improve and action will be taken, small step-by-small step.
There is now indisputable evidence that patients with concurrent PH and MH/SUDs 1) are common, yet, in most, MH/SUDs, remain untreated; 2) are associated with worse PH outcomes; 3) manifest high healthcare service-utilization; 4) are identifiable by use of standardized patient-complexity identification tools; 5) commonly become disabled; 6) will predictably improve (many, if not most), if given evidence-based treatment; and 7) show reversal, or at least improvement, of these adverse outcomes when effectively treated for both their general-medical and psychiatric problems in the medical setting.91
Furthermore, general-medical and surgical physicians are clamoring to have PMC help in addressing the needs of these "difficult" patients for whom they do not want to accept MH/SUD accountability. Traditional reactive consultation programs bring little improvement to most of the patients who are seen. It is hard to justify arguing for something of such limited value. Alternatively, PMCs could encourage support of programs in which existing evidence shows good health outcomes in patients with complex problems. Because these programs bring clinical value to patients and economic value to healthcare delivery systems and medical health plans, they offer creative alternatives as PMCs seek financial support for the services they provide.
These proposals need to come from PMCs. To do this effectively, PMCs must become conversant in the value that they can bring when they suggest programs that best use their expertise to effect change. They need to sell the program(s) using both data and patient examples to present their points. Finally, they must have thought through the clinical and financial components needed to make the transition to a new approach to care in their setting; these may be personnel needs, space requirements, physical-plant changes, administrative involvement, billing and collections, start-up costs, anticipated break-even points, and so on, and PMCs must present their plans to stakeholders with the potential to benefit; these include medical colleagues, general-hospital administrators, and medical health plan executives.
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Reimbursement Issues
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We would like to think that decisions about support for clinical programs are based primarily on their potential to improve care and supported by evidence of efficacy, or, at least, effectiveness. Unfortunately, this does not hold true in the real world. Clinical value is helpful in driving change and is a good place to start negotiations with stakeholders. Realistically, financial viability is the most important issue to the principle stakeholders when it comes to decisions about new program development or replacing ineffective or unprofitable programs with alternatives. For this reason, it is important to be able to frame program proposals in the context of value that would be brought to each of the stakeholders as well as to the system as a whole. It is hard to justify asking psychiatry department chairs to underwrite clinical consultation services that are financial drains and have limited value to patients and hospitals in their present configuration.
The first challenge is for PMCs to find a way to underwrite their work. MBHOs have a disincentive to pay for MH/SUD services outside the behavioral-health setting; it just costs them extra money. As a result, it is necessary to identify alternative sources of funding. Logically, PMCs should approach funding partners who would benefit from the services that PMCs provide. The most obvious potential partners are 1) general-medical care delivery systems (hospitals/clinics); 2) non-psychiatrist provider groups; and 3) medical health plans.
• With care-delivery systems, it is possible to generate arguments for financial support because delirium-prevention programs, proactive consultation services, and CIUs will decrease costs for one-on-one nursing care, shorten lengths of stay (thereby improving diagnosis-related-group [DRG] profits and per-diem financial losses in non-paying patients), and reduce liability for adverse MH/SUD-related events in the medical setting. Importantly, if organized correctly, the cost of the programs is far less than the savings.
• With non-psychiatrist physician groups, PMCs would allow ready access to support for outcome-changing MH/SUD care for both inpatients and outpatients in the context of cost-conscious interventions with an evidence base. Furthermore, if primary and specialty medical physicians partner with PMCs for payment through medical benefits (see below), the incentive for internal-medicine and family-medicine departments to hire their own psychiatrists increases.
• With medical health plans, a better and longer-term strategy is for PMCs to identify ways to be paid through medical, rather than behavioral, health benefits. Value-based PMC activities save medical health plans money through reductions in nonbehavioral claims costs. Savings can be substantial. By paying PMCs to see patients in the medical setting in value-based programs, it makes medical health plans look good to their purchasers (potentially increasing their market share) in addition to being able to offer more competitively-priced products. Interestingly, they can do this by supporting services that provide better care to their members, not through medical-necessity denials.
PMCs could approach medical health plans in several ways. Here are two: 1) They could negotiate directly with medical managed-care companies, but not MBHOs, at the time of annual contract renewal in their region for the clinical services that they provide; 2) They could partner with their non-psychiatrist physician colleagues during group provider contract renewal to be included as a part of the "medical" network and paid only through medical benefits (preferred). In this scenario, non-psychiatrist physicians would not sign contracts for medical care with the carrier unless psychiatrists (and their team members) were a part of the contract.
PMCs are not business people; they are doctors. Financial negotiations usually are not within the scope of their training, nor part of their areas of comfort. Psychiatrists rely on psychiatric administrators to take care of finances and to find ways to support their work. Unfortunately, psychiatric administrators have little incentive to advocate for PMCs since MBHOs pay so little for the services that PMCs provide. Furthermore, medical health plans are outside most psychiatric administrators’ sphere of activity; thus, they are uncomfortable even approaching them.
One solution would be for PMCs to become members of non-psychiatric departments where there is more comfort in dealing with the medical payment system, which could support PMC care. PMCs need to start acting as their own financial agents. This may also require realignment of their professional accountability; for example, moving appointments from the department of psychiatry to the department of internal medicine.
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DISCUSSION
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PMCs, although highly trained and with great potential in a healthcare environment filled with complex, multi-morbid, and high-cost patients, find themselves fighting for their very existence. The clinical care they provide is financially unsustainable because they treat patients in the PH sector, yet bill for services through the MH/SUD sector. The MH/SUD sector, unfortunately, has an economic interest in limiting PMC service availability. In an attempt to survive within restricted budgets, PMCs have pieced together traditional reactive consultation programs, which are low-budget, yet bring limited value to the patients exposed to PMC assessments and treatments.
It is time to rethink the way that PMCs approach organizing and marketing their services. Patients with concurrent MH/SUDs and PH illnesses abound. Non-psychiatrist physician colleagues are desperate for PMC help, and the health system is squandering massive amounts of health resources by supporting a delivery approach that increases the total cost of care in complex patients. Instead of repeated, often unsuccessful, requests for additional PMC staff directed at psychiatry department chairpersons, and struggles with managed behavioral-health plans for better reimbursement, it is time to market enhanced PMC programs, some of which are described above, from the perspective of bringing the most clinical and financial value. Requests for support should target those most likely to benefit from the services rendered.
Data regarding each of the sample programs listed in Table 3 show promise in their ability to decrease patients’ suffering, improve adverse PH and MH/SUD clinical outcomes, lower functional impairment, and reduce the total cost of care. The only way they will become widespread, however, is when PMCs take the steps necessary to persuade clinical and financial stakeholders to provide a basis for their existence. To accomplish this task, PMCs may have to partner with non-psychiatrist colleagues in becoming a part of general-medical provider networks and service-delivery systems. As a part of these networks, payment for services should be realigned so that PMCs and their team members are paid only through general-medical, not behavioral health, benefits and at profession sustainable reimbursement levels. PMCs may need to switch their appointments from departments of psychiatry to departments of family medicine, internal medicine, or pediatrics or request joint appointments in order to create programs that will bring value and expand service capabilities in PH settings.
Recognizing that behavioral-health, managed-care companies have a vested interest in curbing care outside the MH/SUD sector, it is time for PMCs to take the formative step of working only through medical health-plan benefits. This is feasible if they propose value-added programs, support their proposals with the accumulating evidence, give cogent examples of specific high-cost patients with complexity that would benefit, and marshal the forces of non-psychiatric colleagues and their patients to support value-added program development in their discussions with medical managed-care company representatives. Such discussions can be bolstered by the political backing of the general-medical community with whom PMCs find themselves increasingly aligned.
The recommendations in this article are radical. They will not lead to funds that support the addition of PMCs, nurse-clinicians, or social workers to existing traditional reactive consultation services. They will not lead to increased reimbursement for existing consultation programs by managed behavioral-health companies. In fact, this article argues that we should not even be trying to achieve support for traditional consultation.
It is time to accept the fact that fighting for funds to buttress traditional consultation merely retards the initiation of the steps that are needed to create the next generation of service-support provided by PMCs. There are now robust data documenting the value that PMCs could bring and where and how they could bring it. It is time for PMCs to start fighting a new battle, which will lead to a world of medicine that allows growth in the number of PMCs, since they will be adequately reimbursed for the value they bring, through their clinical expertise, to some of the most difficult-to-treat and costly patients in our healthcare system.
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ACKNOWLEDGMENTS
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The first author is President of Cartesian Solutions, Inc., a health-management consulting company that specializes in assisting with the development of programs for medically-complex patients and the integration of general-medical and mental-health care. Because this article discusses what the authors consider value-added models for the clinical integration of health services, Dr. Kathol has a potential conflict of interest.
Dr. Frits Huyse has developed a proactive approach to complexity assessment and intervention through the INTERMED. In addition to being part time faculty at the University of Groningen in the Netherlands, he actively endorses and assists with implementation in the use of the INTERMED through consultations to various institutions.
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ABSTRACT
INTRODUCTION
