The future of consultation-liaison psychiatry and medical-psychiatric units in the era of managed care

EL.SF.VIEK

The Future of Consultation-Liaison Psychiatry Medical-Psychiatric Units in the Era of Managed Care

and

Richard J. Goldberg, M.D., and Alan Stoudemire, M.D. Abstract: There has been increasing recognition and documentation of the impacf of psychiufric problems on the outcome and cosf of medical care. Because consu~fafion-l~ison psy~hiafrisfs have fhe experfise to address the psychiatric aspecfs of medical illness, this group should be in a strong position to facilitate integration of medical and psychiatric services in managed care delivery systems. Alfhough consultation-liaison psychiatry (CLPI has documented ifs ability to shorteninpatient medical~~gfhsof stay for somedi~rders, a greaterchallengeexists in developingcomprehensive systemsto identify and carefor patientswith mentalhealthproblemsin primary caresettings.This paperreviewsthe fiscaland programmatic implicationsfor managed medicalcaresystemsof findingsfrom outcome-based C-L research.The future roleof CLP and combinedmedical-psychiatric units in an era of ma~ged care is &sodiscussed.

Introduction During the past few years, consultation-liaison (CL) psychiatrists have awakened to find themselves in the era of managed medical care. Some managed care systems have developed negative reputations because of limitations of treatment benefits, intrusive micromanagement of clinician practice patterns, and discounted fee schedules. However, managed care has also generated emphasis on outcome measures, patient satisfaction, integrated medical care delivery systems, primary care, prevention strategies, and cost-consciousness. Departments of Psychiatry & Medicine, Brown University, Rhode Island HosDitaf. and Women & Infants’ Hospital, Providence, Rhode Is&d (RJG); and Department of Psyihiatry and Behavioral Sciences, Emory University School of Medicine, and Clinical Services in Psychiatry, Emory University Hospital and Clinic, Atlanta, Georgia (AS) Address reprint requests to: Richard J. Goldberg, M.D., Psychiatrist-in-chief, Rhode Island Hospital, Providence, RlO2903.

268 ISSN 01634X343/95/$9.50 SSDI 0163-8343(95)00053-T

In the midst of the changes in psychiatric practice caused by managed care, consultation~liaison psychiatry (CLP) has been affected in a number of ways. On the negative side, C-L psychiatrists often must seek prior authorization for their services. Such authorization policies are experienced as a time-consuming administrative burden by clinicians. Like other clinicians, C-L psychiatrists have found themselves in disagreement with managed care reviewers about the need for additional psychiatric follow-up care. Furthermore, because of the practice of administratively “carving-out” mental health benefits from general medical care benefits, C-L psychiatrists often find themselves caught between the general medical budget and the separate (carved-out) mental health budget [l]. Controllers of the mental health budget may see CLP as a “medical” service, whereas the medical budget may see CLP as a “psychiatric“ service. This cost-shifting debate has occupied the time of many C-L psychiatrists trying to provide care to patients with combined medical and psychiatric disorders. As managed care systems grapple with the challenge of integrating medical and psychiatric care, the skills and practice model of CLP should be of significant value. By tradition, temperament, and training, C-L psychiatrics strive to integrate medical, psychiatric, and behavioral aspects of patient care to improve medical outcomes. In fact, the problems which CLP addresses have a potential impact on a wide variety of medical disorders. CLP also represents the component of psychiatry with the best established history of collaborating with other physicians. How can CLP of the future escape from the lim-

General Hospital Psychiatry 17, 268-277, 1995 0 1995 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010

Consultation-Liaison itations inherent in preauthorized, micromanaged, carved-out funding? External authorizations and micromanagement will tend to diminish for psychiatry as mental health services become financially integrated into mature medical care systems which function within capitated funding arrangements. In order to become more accepted and integrated into general medical care, however, CLP needs to demonstrate that it can add value by improving the overall quality and outcome of health care. The remainder of this paper is intended to provide current information on progress made and challenges that face CLP in establishing that both the quality of care can be improved and costs reduced by effective and timely psychiatric interventions in patients with comorbid medical-psychiatric illness.

The Scope of Opportunity

for CLP

Because of a resurgence of interest in primary care and in the recognition of the impact of psychiatric and behavioral components on medical care, CLP may be entering an era of enhanced opportunity. The mental health and substance abuse (MHSA) carve-out, which addresses problems seen in the specialty mental health sector, represents about 4%-12% of the health care dollar, with direct costs for treatment of all medical disorders being $67 billion in 1990 out of a total health care cost of $670 billion [2]. The carve-out approach to financing MHSA care was designed to identify and control costs. To a great extent, this strategy has succeeded (largely through decreased inpatient days) even though many consider the resulting product to be suboptimal. The specialty mental health sector, with its carve-out budget, is not the primary concern for CLP. Rather, CLP’s two areas of interest involve psychiatric problems within medical populations, which include both psychiatricbehavioral comorbidity as well as unrecognized or inadequately treated psychiatric disorders. The so-called hidden mental health network (psychiatric patients treated in the medical sector) is probably equal in scope to the number of patients seen in the MHSA carve-out and is, therefore, likely to account for an equal budget, or an additional 10% of the health care dollar. Because MI-ISA treatments provided by general medicine providers have generally proven to be less accurate and efficient, it can be assumed that there are additional savings to be found by improving care for

Psychiatry and Managed Care

those patients. CLP can potentially contribute significantly to this area, as will be discussed later. In addition to the costs associated with the MHSA carve-out and the “hidden” mental health network, there are additional costs associated with medical-psychiatric comorbidity and MI-ISA problems that masquerade as medical problems. For example, unrecognized panic disorder often presents as atypical chest pain leading to repeated expensive cardiology procedures. It has been estimated that up to $81 billion/year, or 12% of total health care spending, is spent (unnecessarily) on physical symptoms due to mental health problems [2]. Another example involves utilization of intensive care unit (ICU) beds. Total annual costs for ICU beds in the United States have been estimated to be as much as $63 billion/year [3]. Generalizing from one study [4], almost one-third of adult ICU admissions are related to substance abuse, and are more costly and longer than other admissions. There is obviously significant potential for cost savings associated with recognition and prevention of these problems. CLP has the opportunity to actively pursue the development of substance abuse services for high-risk medical areas such as trauma, gastroenterology, and cardiology. Iiealth care systems would be making a wise potential investment in addressing substance abusers, as the cost of a full-time clinician to identify at-risk patients and coordinate treatment would be significantly less than the cost of a single ICU admission for repeated trauma or a gastrointestinal bleed. Overall, through the area of medical-psychiatric comorbidity, CLP can become involved in an additional significant percentage of the health care dollar.

The Role of CLP in Inpatient Medical Care The traditional realm of CLP has been medical/ surgical inpatients with combined medical-psychiatric problems. Therefore, it is no surprise that this was the first area to become a focus for cost containment research.

Psychiatric Comorbidity and Medical Length of Stay (LOS) The potential to shorten medical LOS through CLP interventions exists because of the well-documented positive correlation between psychiatric

269

R. J. Goldberg and A. Stoudemire comorbidity and length of medical inpatient stay. Studies of this relationship have been summarized in a review by Saravay and Lavin [5]. The 26 studies reviewed included a variety of patient ages, types of settings, and medical disorders. The overall conclusion of this review was that “psychiatric comorbidity significantly contributes to increased costs by extending hospital LOS and by contributing to greater hospital use after discharge from index admission.” Disorders most often con~buting to increased LOS include depression, delirium, dementia, and personality disorders. However, substance abuse is another strong predictor of medical inpatient utilization. In a study of 435 consecutive intensive care unit admissions to a large community tertiary hospital [4], 28% were substance use related, and these 28% accounted for 39% of overall costs. Substance abuse trauma patients are at high risk for re-injury and re-admission [6]. Having established that certain psychiatric problems contribute to medical admissions and increased medical LOS, attempts have been made to demonstrate if formal psychiatric interventions can reduce LOS for those patients. Unfortunately, because of complex methodologic problems, there have not been many convincing demonstrations of cost savings in this regard. Cohen-Cole et al. [7] suggested that in order to demonstrate the costeffectiveness of an intervention program aimed at psychiatric comorbidity in medical inpatients, there must be “a demonstration that the psychiatric condition is associated with an increased medical LOS, that the inte~ention can effectively treat that psychiatric problem, and that medical costs and/or utilization be reduced from baseline concurrent with or following the clinical interventions.” Strain et al. [S] reviewed cost-offset studies of the impact of psychosocial interventions in the general hospital inpatient setting. One project demonstrated an overall reduction in LOS of 6%. For each dollar spent on the program, the hospital involved saved $48, a return on investment of almost 500%. Another notable study [9] involved 142 patients admitted for hip fracture. CLP interventions led to a reduction in LOS of about 2 days, as well as decreased rehospitalization and postdischarge rehabilitation days, without cost-shifting to the ambulatory setting. CLP effects, however, are likely limited primarily to certain high-risk populations. It is, therefore, important to develop screening methods to preemptively identify such high-risk patients. JS Hammer, H-T Lam, and JJ Strain (personal communication) are examining

270

the cost-benefit and clinical effectiveness of using a screening program to detect patients with medicalpsychiatric issues who could potentially benefit from CLP interventions. Patients’ problems that might potentially benefit from identification include psychosocially determined placement difficulties, somatoform symptoms leading to unnecessary tests, noncompliance, and substance abuse. The potential for documenting reduced LOS by formal psychiatric interventions has been mitigated by a consolidated effort of general hospitals to reduce LOS through the use of clinical protocols, high-risk placement teams, the development of ambulatory alternatives, and by setting targeted admission-discharge parameters for given procedures, Another potential contribution of CLP to inpatient medical revenues has been the “up-coding” of DRGs (thereby increasing the hospital’s net reimbursement) by appropriately recognizing and documenting psychiatric comorbidities [lo]. Unfortunately, liaison con~butions in this area may be limited by improved medical documentation and the fact that inpatients are generally so medically ill that there is little or no possibility of upcoding even in the addition of some psychiatric comorbidity. Though opportunity remains for CLP to assist in decreasing LOS for certain high-risk groups, overall CLP should broaden its efforts beyond inpatient units, in concert with the shift towards capitated models of care which consider the cost of an entire duration of an episode of illness rather than just the isolated inpatient component. An example of a systematic, well-conducted study examining the impact of psychiatric illness on the costs of medical care has recently been completed. Simon et al. [ll] recently examined the overall health costs associated with depression and anxiety in a population of primary care patients treated in a capitated staff model HMO. In this study, 1942 patients were screened with the 12item General Health Questionnaire. A stratified random sample of patients (based on frequency of positive s~ptoms) was selected for further diagnostic assessment, including a structured psychodiagnostic interview conducted at baseline and at 12 months follow-up. Computerized cost analyses were used to calculate total health care costs for the &month period surrounding the baseline assessment and a similar period surrounding the follow-up assessment. (Disorders examined were major depression, dysthymia, panic disorder, agoraphobia, and generalized anxiety disorder.)

Consultaiion-Liaison

Analysis of the fiscal data revealed that primary care patients with EM-III-R anxiety or depressive disorders at baseline had markedly higher costs ($2,390) than patients with “subt~shol~’ disorders ($1,098) (that is, patients whose frequency of symptoms fell slightly below those required for a formal DSM-III-R diagnosis) and those with no anxiety or depressive disorder ($1,397). Even after adjustment for severity & medical morbidity, the higher cost calculations for patients with DSMIII-R diagnoses persisted. Cost differences were due to higher utilization of general medical services rather than higher mental health treatment costs. In patients whose levels of depression improved over time, however, no corresponding decrease in use of medical costs was observed. The study did not provide for structured treatment interventions in the patients identified with formal or subthreshold psychiatric disorders. In this sample, patients who showed complete resolution of their psychiatric disorder still had follow-up costs more than twice as high as those with no disorder at either evaluation (mean of $1,991 vs $972). The increased cost of medical care due to comorbid medical-psychiatric illness is now reasonably well established. But can CLP decrease these costs and improve outcome?

The increasing focus of managed care on primary care has begun to shift the attention of CLP to the outpatient setting. There are two categories of psychiatric issues that need to be addressed in primary care medicine. The first involves patients with mental health or substance abuse (MHSA) problems who seek care within genera1 medical settings rather than the specialty mental health sector. This phenomenon, as noted earlier, has been called “the hidden mental health network”

WI. The Hidden Mental Health Network in Primary Care Data from the Epidemiologic Catchment Area Study (ECA) [13] indicate that a majority (60%70%) of patients with affective, anxiety, somatoform, and substance abuse disorders are seen within the primary care sector and only one-fifth of these patients are seen by specialists. About onethird of consecutive primary care attendees show significant psychological distress and 15%-25%

and Managed Care

can be assigned a specific diagnosis of depression or anxiety [14]. MHSA patients seen in general medicine present a significant challenge because very little is known about associated costs or efficacy of treatment. In regard to depression in the general medical sector, data from the Rand Medical Outcomes Study [15] indicate that about 50% of depressed patients are not recognized and that psychiatric treatment is generally inadequate. A 50% recognition rate seems to hold for anxiety disorders as well [14]. Overall, improving the recognition. and treatment of psychiatric problems in the primary care sector is a major challenge. A number of models for screening and treatment now under development have been reviewed by Katon and Gonzales [ 161; however, no one has established what models are most effective. CLP should see the “‘hidden mentaf health

network”

nity for becoming new strategies and prevention.

involved

as a significant

opportu-

in the development

of case identification,

of

treatment,

The Prevalence of Psychiatric Co~oyb~d~ty in Medical Outpatients Psychiatric

problems

have an increased prevalence and adversely affect their course and outcome 1171. Goldberg [18] has recently summarized some of the data documenting the high rates of association of psychiatric symptoms with common primary care problems (Table 1). A seminal review of the role of psychiwith a number

The Role of CLP in Primary Care

Psychiatry

of medical disorders,

Table 1. The association of psychiatric symptoms with selected primary care problems Primary care problem Fatigue [19,20] Insomnia (21,221 Chronic medical disorders (arthritis, diabetes, HTN, COPD) [23] Myocardial infarction [24] Parkinson’s disease [25f Stroke [26,27] Alzheimefs disease [28[ Cancer [ 291 Cardiology patients [30]

Psychiatric association 20%--40% depressed 33%-66% psychiatric disorder Increased prevalence of psychiatric disorders 20%-50% QOSt-MI depression 33% depression 25%-50% depression 30%40% psychotic 20% depressed 9% panic disorder ---.l^_-----

271

R. J. Goldberg and A. Stoudemire atric and behavioral factors in the practice of medicine [31] clearly described how behavioral factors (such as smoking, obesity, and alcohol consumption) place individuals at risk for illness. A number of disorders, such as chronic low back pain or postare associated with increased MI depression, health care costs resulting from a combination of medical and psychiatric factors. Though CLP has not traditionally addressed the area of behavioral risk factors for disease prevention, there is a clear need for C-L psychiatrists to extend their attention to these areas [32]. Data from the Medical Outcomes Study 133, 341 indicate that patients with depression are more socially and vocationally disabled than patients with most chronic medical illnesses. Panic disorder and substance abuse are also associated with high levels of social and vocational impairment [35, 361. Moreover, patients with depression, panic disorder, or substance abuse utilize a disproportionate share of health care resources [37-391.

One of the most recent frontiers of CLP research has been exploring the possible effects of psychiatric factors on medical outcomes. For example, Frasure-Smith 1241 reported that major depression in patients hospitalized following magnetic imaging (MI) was an independent risk factor for mortality at 6 months, with a negative impact on prognosis at least equivalent to medical risk factors such as left ventricular dysfunction and history of previous MI. Studies in progress are addressing the medical impact of treating comorbid depression. Psychiatric and behavioral comorbidity in general medicine are exactly the types of problems that CLP should be prepared to clinically address. Katon and Gonzales [16] recently reviewed the literature and summarized controlled trials of CLP ~te~entions in the primary care arena. Overall, the evidence for CLP effectiveness in altering medical outcome is relatively weak. For example, Katon et al. [40] examined a group of distressed, high utilizers of two HMO primary care clinics. The intervention consisted of a treatment protocol jointly developed by the primary care physician and a consulting psychiatrist. The major effect was an increased use of antidepressants, although there was no demonstration of an effect on decreasing patient distress or medical care utilization. The failure of this study to demonstrate influence on uti-

272

lization points to the complexity of the problem and how simple interventions may not be able to alter patterns of care that may be strongly influenced by the structure and style of ambulatory primary care practice (such as length of visits, clinician training, and range of services offered). Furthermore, the heterogeneity of the population and lack of inte~ention intensity are factors that may limit the effectiveness of psychiatric interventions. There have been some positive demonstrations of CLP effectiveness. In a classic CLP study, Smith et al. [41] reported that a brief written protocol provided to primary care physicians managing somatization disorder patients resulted in decreased patient utilization of medical services. This study was important because it demonstrated the effectiveness of a brief CLP intervention, and has been replicated in a follow-up study [42]. Recently, this same research group, in a randomized controlled clinical trial, demonstrated that by identify~g patients with somatization disorder and providing physicians with a management protocol, the patients whose physicians had been so advised had increased physical functio~ng and a 32.9% reduction in annual median cost of their care 1431. A recent review of recognition and intervention studies examining the impact of efforts to improve the recognition of anxiety and depression in primary care settings, as well as the ability of primary doctors to treat anxiety and depression, concluded that although recognition rates of psychiatric illness could be improved, there was little reliable data to support the fact that increased recognition of psychiatric illness by primary care physicians reduced symptom severity, reduced duration of psychiatric illness, or decreased health care utilization and costs [44] for the most common psychiatric disorders (such as anxiety and depression) in primary care. With the exception of somatization disorder (as noted above), even when primary care doctors are provided with direct psychiatric recommendations as to the management of identified psychiatric illness in their patients, no difference in the clinical course of the patient’s disorder or health care utilization has consistently been observed as compared with primary care providers not receiving such psychiatric consultation f4f. Why has it been so difficult to prove that increased detection of mental disorders in primary care improves outcome and reduces costs, at least for anxiety and depression? Part of the answer may relate to the simplistic notion that by simply providing diagnostic information regarding psy-

Consultation-Liaison chiatric illness to primary care physicians they will then be able to utilize the diagnostic information in a manner to implement an effective treatment plan. Using depression as an example, not only are depressed patients in primary care settings diagnosed appropriately only 50% of the time [45] but minor tranquilizers are likely to be ~app~p~ately prescribed and antidepressants are likely to be used at subtherapeutic doses [44]. The clinical competency of primary care providers to render effective treatment of psychiatric illness is usually presumed rather than proven. Short-term psychiatric educational interventions, often at best in the form of oversimplified “protocols“ or “practice guidelines,” do not take the place of systematic formal didactic training and clinical supervision in the treatment of psychiatric disorders. Hence, though efforts to provide basic education to primary care doctors in psychiatric case identi~cation and psychiatric treatment is an admirable endeavor, such efforts have had a low impact on the outcome of the most prevalent psychiatric illnesses in the primary care setting. Attention has therefore been directed towards examining the value of access to trained mental health specialty care in managed care systems. A recent study demonstrated that integration of psychiatrists into the management of major depression in a primary care setting (as compared with a group who received standard management by a primary care physician), along with intensive patient education and enhanced surveillance of antidepressant regimens, resulted in improved compliance, improved patient satisfaction, as well as improved depression outcomes 1471. Documentation that active involvement of psychiatric consul~tion in managing psychia~c illness in the primary care setting is a crucial consideration in assessing the value of care being provided. One study by Sturm and Wells [15] examined the issue of value in regard to mental health care in the primary care setting utilizing a decision analytic model. They attempted to determine the cost and health effects of changes in the quality of care for depressed patients treated in prepaid general medical practices, family practice and internal medicine, and mental health specialty practices. Outcome measures included changes in serious function limitations, annual treatment costs per patient, and costs per reduction in units of functional limitations. The results revealed that more appropriate care for depression (increased counseling, use of appropriate doses of antide-

Psychiatry and -managed Care

pressants, and avoidance of minor ~anq~~zers) improved functional outcomes. Although utilizing specialty mental health care increased total costs, it also improved the value of care because each dollar spent on care provided more benefits in terms of overall health improvement. The trend away from mental health specialty care in some I-B&% with general medical care providers rendering mental health care may reduce costs while worsening outcomes and failing to increase the value of health care expenditures in terms of health improvement per dollars spent 1151. The relative low quality of psychiatric care in primary care settings has been documented, as well as the added value of having patients with psychiatric disorders treated by mental health specialists, but it has not been documented that overall reduction in costs in the prepaid plans can be achieved. On the contrary, the costs of providing ~~a~~~~ mental health care may increase overall costs. It is evident, however, that by restricting patient access to quality psychiatric specialty care, patients are most likely receiving suboptimal treatment and achieving poorer ~nc~o~a~ outcomes,

Managed Care and Medica&Psychiatric Units Medical-psychia~c units have been considered an extension of CLP services in that they provide the capability of providing intensive psychiatric care for patients with more severe mental disorders complicated by medical illness that requires inpatient care ]48-501. Medical-psychiatric units, however, are typically viewed by managed care systems as high-cost centers, p~c~arly under capitated arrangements which place the provider of services at financial risk for the costs of medical utilization. It might be predicted that med-psych units would not fare well in capitated systems because they treat patients with potentially longer LOSS, who also are IikeLy to utilize more laboratory and radiographic studies and medications. Medpsych units also require more intensive staffing patterns. In many respects, however, DRG-exempt medpsych units have already been operating under a form of capitated arrangement in respect to hospital costs. Under the Medicare Tax Equity and Fiscal Responsibility Act (TEFRA) system, hospitals with DRG-exempt psychiatric units receive a set reimbursement payment per Medicare discharge re-

273

R. J. Goldberg and A. Stoudemire gardless of LOS or utilization of procedures, medications, and tests. The method of calculating this target amount per discharge (the “TEFRA cap”) has been described elsewhere 1511. LOS is the critical variable in controlling costs. Hence, to keep costs close to or under the TEFRA cap, the primary focus of cost control is on the most efficient use of inpatient days. Such efforts include preadmission treatment planning, rigorous attention to utilization of bed days, strategic planning prior to admission (to anticipate any disposition problems that would prolong length of stay), an appropriate “case-mix” of public vs private pay patients, and rigorous documentation of inpatient admissions to avoid postdischarge reimbursement denials. Hospitals may generate a profit on short-stay patients, such as those briefly admitted for acute delirium or medication stabilization, that can partially offset losses from patients whose cost of care exceeds the TEFRA reimbursement. The costs of caring for patients on a med-psych unit are predictably higher than what would be predicted for a general psychiatric unit due to less medical comorbidity, but in integrated delivery systems where medical and psychiatric health care costs are managed from a consolidated budget, the costs of not providing integrated medical psychiatric inpatient care for patients must be assessed. As it has been well demonstrated that patients with comorbid psychiatric illness on medical-surgical units have longer LOSS, the cost of undetected or undertreated psychiatric illness almost inevitably adds to the overall costs of medical care utilization. A system involving integrated psychiatric consultation services with inpatient med-psych facilities to readily identify and effectively intervene in situations requiring conjoint care would potentially contain overall costs. Unfortunately, there has not been any definitive demonstration of the financial benefit of a med-psych unit as compared with a more traditional consultation model, the so-called scatter-bed approarh. Though most community-based hospitals will be unlikely to have the resources for a full service med-psych unit similar to those often described in the literature in academic centers, it is more feasible to enhance the capability of general hospital psychiatry units to care for such patients via selection and training of nursing staffs with conjoint medical-psychiatric skills and by modest remodeling of existing psychiatric units to provide medical care (e.g., nasal oxygen, intravenous hydration,

274

medical bed care) for selected patients. Many general hospital psychiatric units are already serving as “de facto” med-psych units given the diverse nature of their patient population and the medical services provided. With restrictions placed on the utilization of general psychiatric inpatient beds with criteria requiring that the patients be suicidal, homicidal, acutely psychotic, violent, or unable to care for themselves (because of psychiatric reasons), the presence of incapacitating conjoint medical-psychiatric or neuropsychiatric conditions may be one of the few remaining types of clinical situations in which inpatient psychiatric care can be fully justified. The survival of hospital-based conjoint medicalpsychiatric inpatient care will depend on expansion of the model of clinical care from that of a specialty inpatient unit to a model of a comprehensive ~~~gr~~ offering a range of services. Hence, “Medical-Psychiatric Programs” should ideally include not only a short-stay med-psych inpatient unit but partial hospitalization, intensive outpatient care, outpatient clinics, and home outreach programs. Models of outpatient-based C-L clinics have been developed and described in the literature [52-541. These programs would also be the focus of health enhancement programs with a focus on preventative strategies such as weight reduction, smoking cessation, exercise, as well as chemical dependency treatment. Such programs would provide for the screening of psychiatric and psychosocial disorders in both inpatient and outpatient medical setting such as the detection and prevention psychiatric complications of medical illness (depression following stroke and myocardial infarction). Hence, medical-psychia~y programs would integrate many of the services traditionally offered by behavioral medicine and health psychology in addition to inpatien~outpatient psychiatric consultations and inpatient med-psych care. The emphasis on prevention as a strategy for cost containment would be attractive for managed care systems.

Conclusions The potential role of CLP in managed care represents a window of opportunity unparalleled in the history of the subspecialty. Between the hidden mental health network and med-psych comorbidity, CLP is in a position to influence a significant portion of total health care expenditures. First,

Consultation-Liaison managed medical care systems prefer practical, strategic, and goal-oriented psychiatric interventions. C-L psychiatrists have traditionally served as expert consultants, diagnosticians, psychopharmacologists, short-term therapists, and have facilitated med-psych system integration. This is exactly the type of psychiatric practitioner that integrated managed medical care delivery systems require. The role of the C-L psychiatrist as educator of general medical physicians-at times, derided as a superfluous function of the C-L psychiatristhas now been rejuvenated, particularly in light of studies that demonstrate the sub-par diagnostic and treatment skills of general medical physicians to treat psychiatric illnesses. Moreover, C-L psychiatrists have traditionally shown great interest in the detection of psychiatric illness in medical populations as well as made efforts to effectively intervene to reduce costs and improve outcomes. Although the existing data are as yet not sufficient to fully convince the managed care sector to alter their funding of C-L services, the basic methodologic models to provide the data have been established. Adequate funding of studies to demonstrate the cost-benefit of specialty psychiatric care to medical populations should enhance the position of CLP in the evolving health care systems. CLP must also consider its relationship to behavioral medicine practitioners, who are also positioned to make strong contributions to managed care through expertise in prevention and therapies that alter medical behaviors. It is beyond the scope of this paper to debate the potential boundary and control issues that could develop between behavioral medicine (a discipline primarily involving psychologists) and CLP. Overall, CLP should consider collaborative integration with other behavioral medicine specialists. CLP should continue to prioritize screening and treatment outcomes research. C-L has always been limited by sample size problems and generalizability issues. Managed care programs often create greatly expanded data bases that can be used to assess new program interventions. Studies should not only address outcomes, but also clinical processes. For example, interviewing, length of visits, and follow-up activities may all contribute to outcomes but are not easy to change. Early phases of outcome studies should include small homogeneous samples to be sure potential effects are not being mitigated by groups that do not benefit. CLP must continue to assure its own financial viability. Articles written on how to make a CLP

Psychiatry and Managed Care

service fiscally viable [55] describe basic sound business practices required of program directors. As CLP is able to demonstrate its added value to ambulatory medical care, it should begin to access dollars that are currently part of the medical (not mental health) budget. The future of CLP and medical-psyc~~at~ units appears to be shared and potentially favorable, provided the care of patients with med-psych disorders be viewed along a continuum of needed services and not be strictly based on inpatient consultation and inpatient care. C-L and med-psych services will need to develop an integrated comprehensive ~r~gr~~~fic p~~osophy, offering the spectrum of services outlined above, The data provided by the Medical Outcomes Study [15] strongly suggest that expert mental health care adds value to provision of care to medical care systems. The research agenda for CLP dictates that “value added” will result in improved med-psych outcomes.

References 1. Lazarus A: Disputes over payment for hospitaliza-

tion under mental health “carve-out” programs. Hasp Communes Psychiatry 45:115-116, 1994 2. Winters CM, Oss ME: Mental he&h costs and outcomes data exists. In Open Minds. 8(10):9, Jan 1995 3. Raffin T, Shurkin J, Sinkler W: Intensive riare: facing the critical choices. New York, WC Freeman h Co, 1989 4. Baldwin WA, Rosenfeld BA, Breslow MJ, et al: Substance abuse-related ad~s~~o~s to adult intensive

care. Chest 103:21-25, 1993 5. Saravay SM, Lavin M: Psychiatric ca-morbidity

and length of stay in general hospital. Psgrho~~matics 35:(3)233-252, May-June 1994 6. Cottrol C, Frances R: Substance abuse, co-morbid psychiatric disorder, and repeated traumatic injuries. Hosp Community Psychiatry 44:715-716, 1993 7. Cohen-Cole SA, Howell EF, Barrett JE, et al: Consultation-liaison research: four seieleckd tqics. In Judd FK, Burrows GD, Lipsitt DO (eds), Handbook of Studies on General Hospital Psychiatry. New York, Elsevier B. V. X991, pp 79-98 8. Strain JJ, Hammer JS, Fulap G: APM Task Force OR psychosocial interventions in the general hospital setting. A review of cost-offset studies. bychosomatics 35(3):253-262, 1994 9. Strain JJ, Lyons JS, Hammer

JS, et al: Cost offsets from a psychiatric consultation-Wilson intervention with elderly hip fracture patients. Am I Psychiatry 148(8):~~~1~9, 1991 10. Koran LM: Funding consultation-liaison psychiatry via Medicare screening. Gen Hosp Psychiatry 14:714, 1992

R. J. Goldberg and A. Stoudemire 11. Simon G, Ormel J, VonKorff M, Barlow W: Health care costs associated with depressive and anxiety disorders in primary care. Am J Psychiatry 152:352357, 1995 12. Schurman RA, Kramer PD, Mitchell JB: The hidden mental health network. Arch Gen Psychiatry 42:8994, 1985 13. Shapiro S, Skinner EA, Kessler LG, et al: Utilization of health and mental health services; three epidemiologic Catchment area sites. Arch Gen Psychiatry 41:975-978, 1984 14. Ormel J, Koeter MW, van den Brink W, van de Willige G: Recognition, management and course of anxiety and depression in general practice. Arch Gen Psychiatry 483700-706, 1991 15. Sturm R, Wells KB: How can care for depression become more cost-effective? JAMA 273:51-S%, 1995 16. Katon W, Gonzales J: A review of randomized trials of psychiatric consultation-liaison studies in primary care. Psychosomatics 35:268-278, 1994 17. Stoudemire A (ed): Psychological factors affecting medical conditions. In American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington DC, APA, 1994 18. Goldberg RJ: Psychiatry and the practice of medicine: the need to integrate psychiatry into comprehensive medical care. So Med J 88~260-267, 1995 19. Kroenke K, Wood DR, Magelsdorff D, et al: Chronic fatique in primary care, prevalence, patient characteristics, and outcome. JAMA 260~929-934, 1988 20. Walker EA, Katon WJ, Jemelka RP: Psychiatric disorders and medical care utilization among people in the general population who report fatigue. J Gen Int Med R436-440, 1993 21. Gillin JC, Byerley WF: The diagnosis and management of insomnia. N Engl J Med 322:239-248, 1990 22. Mellinger GD, Balter MB, Uhlenhuth EH: Insomnia and its treatment: prevalence and correlates. Arch Gen Psychiatry 42225-232, 1985 23. Wells KB, Golding JM, Burnam MA: Affective substance use, and anxiety disorders in persons with arthritis, diabetes, heart disease, high blood pressure, or chronic lung conditions. Gen Hosp Psychiatry 11:320-327, 1989 24. Frasure-Smith N, Lesperance F, Talajic M: Depression following myocardial infarction. JAMA 270: 1819-1825, 1993 25. Cummings JL: Depression and Parkinson’s disease: a review. Am J Psychiatry 149:443-454, 1992 26. Koenig HG, Studenski S: Post-stroke depression in the elderly. J Gen Intern Med 3:.%X$-517, 1988 27. Robinson RG, Starkstein SE: Current research in affective disorders following stroke. J Neuropsychiatry Clin Neurosci 2:1-14, 1990 28. Mendez MF, Martin RJ, Smyth KA, et al: Psychiatric symptoms associated with Alzheimer’s disease. J Neuropsychiatry 2:28-33, 1990 29. Bukberg J, Penman D, Holland JC: Depression in hospitalized cancer patients. Psychosomatics 46: 19%212, 1984 30. Goldberg R, Morris P, Christian F, et al: Panic disorder in cardiac outpatients. Psychosomatics 31:168173, 1990

276

31. Houpt JL, Orleans CS, George LK, Brodie HK: The role of psychiatric and behavioral factors in the practice of medicine. Am J Psychiatry 137:3747, 1980 32. Stoudemire A, Hales RE: Psychological and behavioral factors affecting medical conditions and DSMIV: an overview. Psychosomatics 325-13, 1991 33. Wells KB, Stewart A, Hays RD, et al: The functioning and well-being of depressed patients. JAMA 262: 914-919, 1989 34. Hays RD, Wells KB, Sherbourne CD, Rogers W, Spritzer K: Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses. Arch Gen Psychiatry 52: 11-19, 1995 35. Markowitz JS, Weissman MM, Ouelette R, et al: Quality of life in panic disorder. Arch Gen Psychiatry 46:984-992, 1989 36. Jones KR, Vischi RT: Impact of alcohol drug abuse and mental health treatment on medical care utilization: a review of the research literature. Med Care 17(suppl):l-82, 1979 37. Katon W, Von Korff M, Lin E, et al: Distressed highutilizers of medical care: DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry 12~355-362, 1990 38. McFarland BH, Freeborn DH, Mullooley JP, et al: Utilizations patterns among long-term enrollees in prepaid group practice health maintenance organization. Med Care 231221-1233, 1985 39. Simon GE: Psychiatric disorder and functional somatic symptoms as predicators of health care use. Psychiatr Med l&49-59, 1992 40. Katon W, Von Korff M, Lin EH, et al: A randomized trial of psychiatric consultation with distressed highutilizers. Gen Hosp Psychiatry 14:8&98, 1992 41. Smith GR, Monson RA, Ray DC: Psychiatric consultation in somatization disorder. N Engl J Med 344: 1407-1413, 1986 42. Rost K, Kashner TM, Smith GR: Effectiveness of psychiatric intervention with somatization disorder patients: improved outcomes at reduced costs. Gen Hosp Psychiatry l&381-387, 1994 43. Smith GR, Rost K, Kashner M: A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry 52:238-243, 1995 44. Higgins ES: A review of unrecognized mental illness in primary care: prevalence, natural history and efforts to change the course. Arch Fam Med 3908-917, 1994 45. Wells KB, Hays RD, Burnam MA, Rogers WH, Greenfield S, Ware JE Jr: Detection of depressive disorder in prepaid and fee-for-service practices: results from the Medical Outcomes Study. JAMA 262: 925-930, 1989 46. Wells KB, Katon W, Rogers WH, Camp P: Use of minor tranquilizers and antidepressant medications by depressed outpatients: results from the Medical Outcomes Study. Am J Psychiatry 151:69&7(X$ 1994 47. Katon W, Von Korff M, Lin E, et al: Collaborative management to achieve treatment guidelines. JAMA 273:1026-1031, 1995 48. Fogel BS, Stoudemire A: Organization and develop-

Consultation-Liaison ment of combined medical-psychiatric units: part 2. Psychosomatics 27~417-428, 1986 49. Kathol RG, Harsch HH, Hail RCW, Shakespeare A, Cowart T: Categorization of types of medicalrpsychiatric units based on Level of acuity. Psychosomatits 33:37&386, 1992 50. Stoudemire A, Fogel BS: Organization and development of combined medical-psychiatric units: part 1. Psychosomatics 27341-345, 1986 51. Goldberg RJ, Simundson S: Managing Medicare reimbursement on medical-psychiatry units. Gen Hosp Psychiatry 13:3X3-318, 1991

Psychiatry and Managed Care

52. Camara EG: A psychiatry outpatient consultationliaison clinic. Psychosomatics32304-308, 1991 53. Epstein SA, Gonzales JJ: Outpatient consultationliaison psychiatry: a valuable addition to the tmining of advanced psychiatry residents. Gen Hasp Psychiatry 15369-374, 1993 54. Rowan GE, Strain JJ, Gise LJ: The liaison clinic: a model for liaison psychiatry fundktg, training, and research. Gen Hosp Psychiatry 6:109-115, 1984 55. Schuster JM: A cost-effective model of consultationliaison psychiatry. Hosp Community Psvchiatrv 43(4):330-332,1992

277