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CONSULTATION–LIAISON PSYCHIATRY IN THE MANAGED CARE ARENA
CONSULTATION-LIAISON PSYCHIATRY
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CONSULTATION-LIAISON PSYCHIATRY IN THE MANAGED CARE ARENA Junius J. Gonzales, MD, and Lauren Randel, MD
The field of consultation-liaison (CL) psychiatry has recently attempted to define itself and promote its services. In 1994, a published series of articles described the potential cost savings by using CL services in the general hospital, the potential impact on patient outcomes, and useful models to improve mental health problems in primary care.48,52 CL services have been an integral part of standard clinical psychiatric practice in the general hospital and have been a subject of increasing research over the last decade. The nature of CL psychiatric services, however, requires carefully assessing organizational, financial, and reimbursement issues for the subsequent continuation of these services. In this era of rapidly changing health care, especially managed care, critically defining what CL services are, and knowing where the managed care movement is headed can directly impact CL psychiatry. This article briefly defines CL psychiatry-its history, goals, and clinical modelsand places it in the context of managed health care’s history, goals, and structures. Several current trends in managed care systems, such as financial arrangements and management mechanisms, are also described. We then examine the potential impact of managed care on CL psychiatry, discuss general ethical issues in managed care with relevant applications to CL psychiatry, and make recommendations for CL psychiatry to survive under managed care.
From the Department of Psychiatry (JJG, LR), Clinical Economics Research Unit UJG), and the Institute for Health Care Research and Policy (JJG),Georgetown University Medical Center, Washington, DC
THE PSYCHIATRIC CLINICS OF NORTH AMERICA VOLUME 19 * NUMBER 3 * SEPTEMBER 1996
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HISTORY, GOALS, AND CLINICAL MODELS OF CONSULTATION-LIAISON PSYCHIATRY
CL psychiatry derived its name and functions from two related movements: (1) consultation and (2) liaison work. Initially, the movements attempted to delineate and distinguish their two functions in terms of scope and focus, but the separation of these two processes has disappeared, and most CL psychiatrists function in dual capacities. Oken37described that ”the consultant . . . is called in to deal with overt aberrant behavior and to identify and treat psychiatric disorders, including the clarification as to whether physical symptoms arise from a psychiatric condition.” In contrast, liaison work was described as not direct clinical patient contact but rather working collaboratively with nonpsychiatric medical and surgical professionals in providing education on psychiatric problems and psychosocial issues. The links between these two work roles are clearly inextricable. The CL psychiatrist has more recently been defined as a practitioner who studies, evaluates, and treats psychiatric morbidity in the physically ill, psychological factors affecting physical conditions, and psychosomatic interactions. Historically, CL psychiatry has roots in mental health consultation that emerged in the 1920s via community-based child guidance clinics. At that time, diverse professional groups and individuals who came in direct contact with mental health problems were targeted as the focus of mental health consultation. These sometimes disparate providers included nurses, educators, general physicians, social welfare workers, and legal or judicial professionals. Although conceptually similar, liaison work arose somewhat later as a separate area of expertise within mental health consultation. Liaison focused on the process of linking or joining two separate disciplines with the ultimate goal of increasing awareness of mental health issues. A separation between liaison and consuhtion psychiatry existed for some years and was even the subject of published literature. CL psychiatry flourished within the conceptual framework of psychosomatic medicine and expanded with the applied use of Engel’sI3 biopsychosocial paradigm.37Even as far back as 1929, the clinical practice of psychiatric consultation was finely described by George Henryz0and, in 1934, funds were made available by the Rockefeller Foundation to introduce psychiatry departments in general hospitals.z0Consequently, CL psychiatry has a longstanding tradition of being the most direct and active psychiatric connection to the rest of medicine. Formal training for CL psychiatry grew in the 1970s and 1980s owing to National Institute of Health funding and revitalized psychiatry’s direct link to general medicine by, for example, training primary care physicians in psychosocial issues. Other mental health professional disciplines, such as nursing, social work, and psychology, were also supported through specialized fellowships. More recently, CL psychiatry has evolved by establishing its own professional organization and a proliferation of CL fellowships. Despite an initial failure to obtain official
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subspecialty status, the CL professional movement continues to pursue special certification for psychiatrists completing a fellowship. Although CL psychiatry has been connected to primary care for some time (e.g., the longstanding American Psychiatric Association Committee on CL Psychiatry and Primary Care Education), the promise of that connection has not been well fulfilled, and little attention has been paid to CL psychiatry in the outpatient sector. Recent literature has prioritized a move into the outpatient arena for CL psychiatric work.18Outpatient CL psychiatry offers many advantages, including for training, and may provide an effective survival tactic in this era of health care delivery changes. Revisiting systems models that helped inform the developing CL field may abet the contemporary organization and delivery of CL services within the greater system of managed care. General systems theory, which examines both intersystem and intrasystem factors, may need to be practically applied as managed care seeks to organize services both by integrating systems as well as by splitting systems (e.g., carve out^).^ For example, Pincus et a138proposed six models linking general medical and mental health systems of care based on three key linkage elements. The first element is contractual and consists of the nature and content of formal or informal agreements between the two settings. The second element is functional. The third element is educational and focuses on the relationship that establishes and reinforces a general health care provider’s knowledge and skills in mental health. Linkages are modified by the level of administrative and clinical participation of each sector (Table 1). For example, at one end of the spectrum is the agreement model, which is characterized by a linkage that is established in a contractual way between two separate parties in which each party renders separate services. Another model, at the other end of the spectrum, is an integrated health care team that is described as ”a fluid synthesis” of those three linkage elements and may include a mental health professional as a regular colleague. Important considerations in developing and choosing a model are (1)population served, (2) geography, (3) management, (4) financing mechanisms, (5) philosophy of care, and (6) settings and levels of care.
Table 1. LINKAGE ELEMENTS Models
Contractual
Functional
Agreement Triage Service delivery team Consultation service Supervision education Integrated health care team
+++ +++ +++ ++ + +++
+ ++ ++ +++ ++ +++
+
=
mild level;
++
=
moderate level;
+++
=
high level; -
=
Educational
not present.
+/+/-
+ ++ +++ +++
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History of Managed Care and Psychiatry
Managed care companies have been proliferating over the last few years in this country, with rapidly differing levels of regional penetration, yet they have roots in group practice from the late 1800s and health maintenance organizations (HMOs) that sprang up midcentury.* Operational definitions of managed care are predicated on the financial arrangement for the patient when obtaining health care services. At one end of the management spectrum are fee-for-service (FFS)plans with a managed component, such as utilization review; but the primary financial arrangements still have traditional FFS deductibles and out-ofpocket (percentage)payments. On the other end is fully prepaid care that represents prototypic managed care-all denoted services are covered by an annual premium but there may be small copayments for visits. By 1992, more than 50% of employees in large or medium companies received prepaid care.17 Since the inception of managed care, mental health has been included under prepaid care in a variety of ways3,30 The most common managed mental health benefit was through limited and carefully defined prepaid services focusing on crisis intervention, triage, and consultation. In the mid-1980s prepaid medical and mental health care became a growth industry and saw the industrialization of psychiatric services with aggressive development of for-profit hospitals and then companies 22 that tried to capitalize on the reputed overspending in the FFS sector.lO, The privatization and growth of private psychiatric hospitals resulted in maximized profits, increased efficiency, and the aggressive use of marketing and advertising, which increased and stimulated demand for managed care group services. The growth of companies and a corporate level of involvement in providing mental health care transformed a cottage industry to a booming multimillion dollar business. This trend resulted in increased competition between not only FFS and managed care plans but among managed care plans, insurers, and providers of care-a competition not seen even with Congressional HMO Acts.'O Given these developments, it is important for CL psychiatrists to have an understanding of contemporary managed care plans and what problems they face in order to meet the challenge posed by Durham" of "whether they can manage the care of persons with mental health needs and resist the temptation to manage only the financial risk. Organizations that successfully address this challenge will reap benefits throughout their delivery systems and reclaim the competitive advantage of managed care." Goals and Organization of Managed Care
Whereas initial directions in the managed care movement were based on providing affordable quality health care and emphasized such concepts as preventive care and health promotion, the industry has
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redefined its goals: to reduce prices, reduce variation in treatment patterns, reduce need for services, and reduce the costs of prod~ction.~, 33 The clarity and evaluation of such goals is often muddied by complex issues, such as for-profit needs and problematic definitions of demand for care, need for care, and supply of care. Data on access, costs, quality of care, and outcomes in managed care settings are emerging but, owing to study limitations, provide mixed results.33The data related to costs have focused on inpatient utilization and have demonstrated savings owing to shortened lengths of stay. These data have not been well linked, however, to patient outcomes and quality of care. Some studies on access and outcomes in FFS and prepaid care have yielded no significant differences in outcomes or use, whereas others, focusing on patients’ reports, have found differences.6 For example, a recent J A M A article45evaluated primary care performance in the two settings and found differences in six of eight indicators: organizational access, continuity of care, and accountability were highest in FFS systems, whereas coordination of care was higher in prepaid care. Communication between providers in FFS versus prepaid care has also been studied and results indicated that, from providers’ perspectives, prepaid care may impair ideal cornmuni~ation.~~ Similarly, depressed patients in the Medical Outcomes Study who had prepaid versus FFS care had more decrements in functioning over 53 Much more research is needed to tease out how the processes of care differ in the two systems and what impact these differences may have on patient outcomes. Different organizational models of managed care plans exist depending on structural and contractual arrangements (Table 2).39For example, a staff model HMO usually has its own physical facility in which providers are salaried employees who serve only those people enrolled in the plan. One longstanding well-known staff model HMO is Kaiser-Permanente, which owns many of its outpatient facilities, but the HMO may contract with community hospitals or other specific facilities to deliver certain aspects of care ( e g , specialty care). Two common models, independent practice associations (IPAs) and preferred provider organizations (PPOs), are proliferating and marketing directly to insurers. In the former, a management group markets the benefits plan, collects fees, and reimburses providers. This is a middle manager group who manages the benefits for the insurer and contracts with independent providers who agree to certain prepaid reimbursement rates for their various services. A PPO is an arrangement between a payer and a provider group whereby the latter is often an organization who can negotiate with providers for lower rates in return for a guaranteed patient volume. The PPO form of managed care is growing rapidly with variations, such as a ”point of service” plan where patients can use nonPPO providers at higher out-of-pocket costs. The goal of quality of care for managed care plans has been questioned recently given the relative absence of standards and heightened competition between for profit companies. The National Committee on
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Table 2. ORGANIZATIONAL MODELS OF MANAGED CARE Organization Structure Staff model HMO
Independent Practice Association (IPA)
Network IPA
Preferred Provider Organization (PPO)
Managed FFS Indemnity Plan with FFS
Description Traditional, prepaid multispecialty group practice housed in own facility Providers are salaried and work for the plan or group that has an exclusive contract with the plan Patients covered for care provided by the HMO Insurers send patients to providers in solo or small groups who agree to some financial risk for service provision Payment mechanisms range from discounted FFS (with or without financial incentives) or capitation Similar to IPA but often made up of network of larger group practices Payment is usually capitation to groups that then pay providers Insurer sends patients to “preferred” providers who are usually reimbursed discounted FFS The insurers, not the provider, usually accepts financial risk Full range of provider choice, FFS, but insurer uses utilization control to manage costs Total freedom of provider choice; provider reimbursed by insurer on FFS
Adapted from Rivo M, Mays H,Katzoff J, et al: Managed health care: Implications for the physician workforce and medical education. JAMA 274:712, 1995, and Moore GT: The Impact of Managed Care on the Medical Education Environment. Rockville, Council on Graduate Medical Education, November 1993, copyright 1995 American Medical Association; with permission.
Quality Assurance was created ”to promote improvement in the quality of patient care provided through managed health plans; and to provide information on quality to the public at large, consumers, purchasers, health plans and other interested parties such as governmental agencies or en ti tie^."^^ NCQA struggles, however, with differing definitions of key concepts (e.g., accountability) by the different constituencies who want input, and faces the dilemma of how ultimately to enforce those standards. Managed Care Mechanisms
The increased costs of health care (owing to recession, inflation, a more complex society, and supply and demand factors) have all contributed to the recent development of managed care. As noted previously, four common objectives exist: (1)to reduce prices, (2) to decrease variation in treatment, (3) to decrease the need for services, and (4) to reduce
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the cost of production. Some see these objectives resulting from complex economic forces that, in short, shift health care costs from insurers to patients and providers while shifting health care profits into managed care companies. Managed care organizations use several mechanisms in order to meet their goals. The first objective, price reduction, is primarily achieved through contracted payments. Providers may be reimbursed for services in the following ways: per case, per type of service, per diem, or through capitation. Often, provider fees for services are discounted in exchange perhaps for access to a potentially high volume of patients. Reimbursement for nonmedical providers heightens competition, particularly for psychotherapy services. Currently, reimbursement trends are based on the Medicare fee schedule-companies are negotiating rates with providers at some percent value above or equal to Medicare (e.g., 120%). Capitation is a mechanism whereby a fixed sum of money is allotted for the care of a population and this flexible funding is based on a negotiated price per person per annum (e.g., $3 per person/month) for mental health services. Should fewer services than anticipated be used, the provider group can profit, but the opposite occurs if service use exceeds calculations. Capitation requires having concrete and detailed information on the insured population, utilization data, charge and cost data for services, target marketing information, and competitor analyses.49It also requires being able to provide a comprehensive range of mental health services; if some services are not available, subcontracts to other providers are necessary. To meet the second goal-reducing variation in treatment patterninformation management operations abound. First, utilization review of services provided is common and uses a guiding concept of medical necessity, although the operational definitions of necessity vary with each individual managed care plan. Table 3 presents components of an ideal psychiatric review.4oOther emerging information management methods include case management; provider profiling (i.e., practice patterns); and outcome studies. Reducing the need for services, the third managed care goal, focuses on prevention, early identification, triage, telephone-assistance programs and tight links to employee-assistance programs. Reducing need involves mental health promotion efforts and those few plans that have such programs rely on the voluntary participation of members. It is precisely the group that needs, but may not access, services that needs targeting, however, because it may be that only the healthier people participate in those promotion efforts. The last goal, reduction of costs, is often achieved by benefit redesign and structuring. Mental health benefits have often not had parity with other general medical benefits but demonstrated increased use and cost escalations; therefore, some effort was made to redesign and structure mental health benefits to control those expenditures. One such administrative method has been dubbed beneficiary inconvenience whereby complex required procedures, confusing terms, slow adminis-
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Table 3. COMPONENTS OF A PSYCHIATRIC REVIEW Quality focus Professional reviewers Specialized Multidisciplinary Consultative approach Direct communications: phone based on face-to-face Criteria (specific to a company) Consensus-developed Objective scientific Review focused Functioning levels and appropriate level of treatment Indicated evaluations and treatments Treatment goals Aftercare: family, work-school, community supports Effective benefit decision communications Effective appeals mechanisms Quality control Review opinions Reviewer knowledge and actions Confidentiality Communications Adapted from Rodriguez A: Management of quality, utilization, and risk. In Feldman JL, Fitzpatrick RJ (eds): Managed Mental Health Care: Administrative and Clinical Issues. Washington, DC, American Psychiatric Press, 1992, p 88; with permission.
trative processing of claims and inquiries, and uneven communications decrease access to care.4o Managed care companies use many other mechanisms that limit services. One mechanism is a so-called carve-out program for certain benefits, such as mental health, where a managed care plan may contract with a provider group (e.g., a PPO) for general medical and surgical services, but use a separate limited provider group or managed mental health care company for delivery and administration of mental health services. The driving impetus for carve-out of any service is cost, but this mechanism results in numerous clinical and administrative obstacles for patients in these plans, which may, in the long run, be more expensive. Such important clinical process components, such as continuity of care and comprehensiveness of care (two tenets of primary care), are overlooked by carve-out programs. Carve-outs of mental health services for university or tertiary hospi~ ~ research data tals pose some unique issues for CL p s y ~ h i a t r y .First, indicate that patients with comorbid medical and psychiatric problems seen in a tertiary setting have poorer functioning and well-being than those seen in community settings.15This finding, coupled with the available expertise of providers in tertiary settings, raises the questions of continuity and quality of care for these patients. New work on the practice patterns of psychiatrists in dealing with medically ill outpatients who also have depression or anxiety show significant differences in knowledge by practice setting and that community solo practitioners
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may use more costly antidepressants more often than their counterparts in tertiary settings and have less knowledge about managing depressed patients with these medical c~morbidities.’~ Anecdotally, our institution has found that the carve-out programs have fewer psychiatrists with formal expertise in or experience with medically ill patients, and after a circuitous traverse and delay in evaluation or treatment, patients have been rerouted through special dispensation by their managed care plan back to our psychiatry department. Carve-outs pose special problems for CL psychiatry especially as the boundaries between medical and psychiatric problems and diagnoses are deliberately blurred in order to shift fiscal responsibility from one benefits sector to the other (e.g., from medical to mental health). An example on the inpatient side involves organ transplantation, which often requires a psychiatric evaluation prior to the procedure and has high risk for psychiatric morbidity, such as delirium. Should services, such as psychiatric inpatient consultation, be billed to the medical part of the patient’s benefits or mental health part, which is managed by a separate company? An outpatient example is biofeedback services in a behavioral medicine division in a department of psychiatry. Some managed care plans require approval by a nonpsychiatric physician and a nonpsychiatric diagnosis to approve biofeedback yet want it billed to mental health, but the managed mental health care company does not allow out-of-network providers to provide the service despite having gone through the aforementioned obstacles. One extreme case is that the managed care company wants the biofeedback procedure performed by the recommending physician, despite the well-known fact that physicians rarely provide this service and may not have the appropriate training to do so. The diagnostic classification of organic mental disorders has also been a problem. A patient with dementia who is functionally psychotic, by virtue of diagnosis, is to be billed under the nonmental health benefits, but the bill is rejected because the services are provided by psychiatrists. Furthermore, the carve-out mental health program does not pay the psychiatrists because they are not in the plan. In our institution it has been a difficult but successful battle to provide inpatient consultation services and be reimbursed even though we are not providers in several carve-out mental health plans. This has been done by advocating for comprehensive and continuous care for ill inpatients and using our medical colleagues to support this position. Finally, for severely medically ill inpatients who have been stabilized for psychiatric problems by the CL team (e.g., overdose recovering in intensive care unit), continuity is disrupted when the patient cannot be transferred to the inpatient psychiatric unit because it is not in the carve-out mental health network. The quality and comprehensiveness of care is also potentially compromised when someone with a chronic, lifethreatening illness (e.g., AIDS) must be transferred to a freestanding psychiatric hospital not attached to a general medical facility.
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Ethical Issues and Legal Liability in Managed Care
The change from FFS as the principal means of third-party payment for health care services to managed care has had a broad impact on the practice of medicine and on psychiatry in particular. Recent articles discuss how this change has ethical implications for all aspects of health care delivery: there are systemic or societal issues, new issues regarding the ethical obligations of the managed care organizations, and new ethical dilemmas for the physician in the context of the evolving physician-patient relationship.*,50 Psychiatry and substance abuse are areas of particular controversy in the debate on health care reform. Whether society has an ethical obligation to provide mental health and substance abuse benefits, as distinct from other medical care, is inherent in the policy decisions regarding what services managed care is required to provide. Some key questions reflecting these ethical dilemmas include: who should pay for the nonmedical aspects of treatment that are efficacious and cost effective in caring for the chronically mentally ill, should treatment for ”human misery” be covered by health insurance, and should there be parity between mental health and substance abuse benefits and those for physical illness?28 Sharfstein and Stoline5I divide psychiatric care into four tasks: (1) medical tasks that include the diagnosis and treatment of acute presentations of mental illness (people are often underinsured for these services); (2) reparative tasks that constitute the rehabilitation often required after psychiatric hospitalization (people are rarely insured for these services at all); (3) social controls that consist of treatment for actions harmful to society by the patient with a mental illness or substance abuse problem (these treatments have “patchy” funding, which may be through insurance or out of the patient’s pocket; the task of protecting society generally falls on the public sector); and (4) the humanistic tasks of fostering personal growth through psychotherapy for people who experience distress but who do not have major psychiatric illness (the funding for this is varied). The authors raise the pivotal issue of who should pay for these various tasks, and suggest that social control tasks (protecting society from intoxicated drivers, from pedophiles, and so forth) are probably most appropriately handled in the public sector. By keeping the protection of society in the public domain, treatment initiation can be legally enforced and the services can be paid for out of public program and criminal justice budgets. What Sharfstein and Stolinesl call the reparative tasks (adult day care, vocational rehabilitation, assistance with household management) are generally considered to be vital to recovery from and living with mental illness. Although the benefits of rehabilitation are not disputed, what is debated is whether these services are an obligation of health insurers. The policy question is whether we, as a society, want to ensure the provision of these services. Sharfstein and Stoline5Irecommend that
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if we value these services a separate entitlement fund may result in better provision of those services. The use of medical insurance to pay for humanistic tasks of selfactualization (i.e., as some view psychotherapy) is quite controversial. As described previously, many managed care plans have extensive outpatient coverage with some cost sharing by the patient, but the coverage is not intended for ”personal growth.” The “problems” in the patients with humanistic tasks are not acute, severe psychiatric problems, and so many object to the use of health insurance to pay for this help. Some have suggested that the patient who seeks personal growth should be called on to bear more of the financial burden than has been previously asked? The use of outpatient psychotherapy has been shown to be responsive to such cost-sharing measures. Most agree that the medical tasks of diagnostic evaluation and treatment are appropriately covered by insurance (although there remains much disagreement over what constitutes appropriate and effective treatment). Current insurance benefits, however, are often inadequate if a person develops a major psychiatric condition that often has a relapsing and remitting course and may, over a short time span, include more than one episode requiring hospitalization. Most plans include some cost sharing that can result in enormous financial burdens. In addition, because of limited lifetime benefits, the maximum benefit may be exceeded, which results in financial devastation for the patient and often his or her family. The care and its costs are then transferred to the public system, which is already o v e r b ~ r d e n e d . ~ ~ These issues spotlight the controversy of parity between mental health and substance abuse benefits and general medical benefits.31Historically, good mental health coverage included 30 to 60 days per year of inpatient hospitalization compared with unlimited days or 120 days for physical illness. In addition, many plans have maxima both on annual and on lifetime inpatient benefits. Outpatient care is generally limited either in terms of number of visits, maximum annual expenses, or a smaller covered percentage of the charge (Report of the National Advisory Mental Health The fairness of practices such as maximum annual or lifetime inpatient benefits, limited outpatient visits, or increased self payment with increased numbers of visits is being reconsidered now in the active discussion over health care reform.46,47 Some proposals seek to increase benefits for those with selected psychiatric diagnoses or with a specified degree of disability. Alternatives focus on the services provided (as with the medically ill), and try to contain costs using managed care, patient incentives, and capitation with hopes of increasing the use of efficacious, cost-effective treatment.s* 30 In addition to the ethical questions that exist for society, new ethical questions face the managed care companies, because they have an increasingly large role in determining patient care and psychiatric practice pattern^.^^ Managed care organizations historically have not had the primary, ethical obligation to the patient. The primary aim of managed care organizations has been cost containment. The managed care organi-
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zations viewed providers as retaining full clinical and ethical responsibilities to the patient. This situation, however, is being challenged in the legal system, with managed care organizations being held to bear some responsibility for poor ~utcomes.’~ Borenstein3points out that given this overriding financial aim, the standard of managed care is ”medical necessity,” which is operationally defined as ”the least costly alternative form of treatment for a given patient at that time.” This differs from the physician’s perspective where he or she has an ethical obligation and resultant aim to provide the best treatment available to a patient with a specific illness. The agendas of the managed care organization and of the individual psychiatrist are often in at least partial conflict. For the psychiatrist to provide optimal care he or she must either absorb the additional cost, pass this cost on to the patient, or ask the hospital or other treating institution to absorb this cost. Another problematic issue in managed care is the confidentiality obligation on the part of the physician? Review organizations are generally increasingly privy to inpatient charts and to the substantive content of outpatient treatment. No clear confidentiality obligation exists toward the patient on the part of the managed care organization, although recent attention has been paid to ethical dilemmas for benefit managersz1 In addition, the psychiatrist is obligated to cooperate with a review that, while necessary for treatment to be paid for by the managed care organization, may undermine the trust-partly based on confidentiality-in the physician-patient relationship. Confidentiality issues symbolize the tremendous impact of managed care on the physician-patient relationship. Emanuel and DubleP define six vital aspects of the physician-patient relationship: (1)competence, (2) compassion, (3) communication, (4)continuity, (5) absence of conflict of interest on the part of the physician, and (6) patient choice. The latter two aspects of the physician-patient relationship-the physician’s freedom from conflict of interest and the patient’s choice (in selecting a physician, a treatment setting, and from multiple treatment alternatives)-are vital to the ethical physician-patient relationship. The changes in the physician’s role cloud the physician’s ethical obligations as compared with previously when the obligation was primarily to the patient. The physician practicing in a managed care setting has been described as in a ”stewardship role” with regard to society’s resources.& In a recent report by the Council on Ethical and Judicial Affairs of the American Medical Association: the physician was described as bound by two potentially conflicting moral imperatives, that of ”gatekeeper” of society’s resources and that of advocate for the individual patient. The physician’s position is further complicated in many managed care organizations by the financial incentives for limiting the care provided, although it should be noted that FFS arrangements posed the opposite incentive? For psychiatrists, the obligation chosen as primary can determine the treatment aim: should the desired outcome be related to patient satisfaction, patient functioning, external social costs, or some other outcome measure?z4How physicians resolve these
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dilemmas inherent in their conflicting roles is unclear. Novack et a135 studied a physician’s willingness to deceive either an insurance company or the family of a patient for various reasons including: protecting the patient’s confidentiality, securing reimbursements for patients, or covering the physician’s own mistakes. One finding was that physicians were willing to deceive insurance companies to get reimbursements for patients; this may provide some clue as to how conflicting obligations are prioritized. This issue of deception on behalf of the patient is particularly relevant for psychiatric conditions that are perceived to be stigmatizing and are known to be poorly reimbursed. Rost and Smith42found that 50% of the surveyed primary care practitioners deliberately miscoded major depression in the submission for reimbursement as some nonspecific physical complaint. The three reasons most commonly cited for this were (1) uncertainty about the diagnosis, (2) problems with reimbursement for services if depression is coded, and (3) jeopardizing the patient’s future ability to obtain health insurance. The patient’s loss of choice, and thereby of autonomy, further erodes the possibility of an optimally ethical physician-patient relationship. In the absence of well-enforced regulations preventing ”cherry picking,” insurance companies and managed care organizations may try to select participants who are less likely to be ill, which may prevent some people from enrolling in the managed care organization of their choice. Without regulations ensuring transportability of coverage, many people will be forced to change physicians when they change jobs; 7 million Americans change jobs or become newly employed each month. Additionally, many employers are now offering only one health plan, and indeed which plan is offered may change frequently as managed care organizations compete on price or go out of business so that new plans are selected by the employer based on their cost savings.I2 A change to a new managed care organization generally requires that patients change physicians to those designated by the plan. Mutual consent between autonomous parties is important in all physician-patient relationships, but it is particularly significant in psychiatric treatment where the therapeutic alliance is central to treatment. Frequent changes of provider are likely to undermine the success of treatment. Ethical questions face psychiatry at many levels: the individual patient and physician, their relationships, managed care organization, and society. Does society have an obligation to those with mental illness or substance abuse that differs from the obligation to the medically ill? Do managed care organizations in their function of determining treatment and benefits take on ethical obligations to patients? If so, how are these best understood? Finally, how can the trust necessary for effective treatment be established between physician and patient, given the competing pressures on both parties? For CL psychiatry, the primary ethical dilemmas focus on the delivery of services in a timely manner and the physician-patient relationship.44On inpatient settings, CL psychiatry focuses on acute evaluation and management of psychiatric problems. This clinical service is espe-
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cially problematic when psychiatric services are carved out of a managed care plan. Traditionally, a medicine inpatient's attending physician directly requested consultation by a hospital-based CL psychiatrist. In a carve-out, preauthorization by the mental health company's reviewer or the outside primary care practitioner is typically required for psychiatric services to be provided. The services may then be provided by perhaps an outside psychiatrist who may or may not have expertise with acutely medically ill patients. The case may require immediate attention, such as delirium or emergency competency assessment, and the on-site psychiatrist is faced with the dilemma of intervening without reimbursement or declining to provide the con~ultation.~~ The ethical dilemma extends to the collegial relationship between the CL psychiatrist and the medical team asking for help in the form via the consultation. Finally, legal issues abound in this situation, and action should be predicated on doing what is best for the patient. Not doing a consultation may result in harm to the patient, but the decisions become murkier when the acuity factor is removed. Recent articles have addressed the legal issues faced by clinicians in working within managed care',19 and offer some suggestions on facing these issues. Appelbaum' writes that the physician or provider has several duties: the duty to appeal adverse decisions, the duty to disclose, and the duty to continue treatment. Similarly, the managed care organization has legal duties: the duty to review with reasonable care, the duty to disclose, and the duty to select appropriate providers with possible vicarious liability. Finally, Hall19offers 12 steps for providers dealing with managed care based on best care for the patient, detailed documentation, and appeal. RECOMMENDATIONS FOR CL PSYCHIATRY
The status of managed care in health care delivery is growing at an astounding rate and challenges-clinical, organizational, legal, and ethical-face providers as well as the managed care industry. We have reviewed the history of both CL psychiatry and managed care and detailed some relevant practical concerns for patient care. These difficulties pervade all of psychiatry, but certain situations may be more prevalent in the CL setting. Numerous articles have documented how psychiatrists can play a pivotal role in managed care at administrative, 29, 32 We also think that CL psychiatry, clinical, and training levels.l6* by virtue of its specialized expertise, can make some unique contributions to the care of medically ill populations within the managed care world, but it must work aggressively with systems infrastructures (e.g., hospital, department) targeted at managed care. First, CL psychiatrists must work closely with their departments in order to provide input on reimbursement rates for their services. They must know what a bottom-line acceptable rate is, based on all operating costs, and have an opportunity to achieve those rates and not have the 307
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department turn away contracts because certain other rates may be low. Second, working with a hospital's office of managed care is critical in order to understand clearly what is happening at both local and national levels. For example, knowing what the regional charges per current procedural terminology (CPT) code are is a critical tactic. This can position one to negotiate at lower rates if some service is underpriced by CL psychiatry compared with regional charges. Finally, bundling services may be a way of carving oneself back in. As described previously, our experience is that managed care companies who carved out the mental health services are actively negotiating to carve in certain services, such as inpatient consultations. The reasons are clear: access to comprehensive and continuous care for their patients in the general hospital. Because of decreased lengths of stay, these inpatient consultations are appealing owing to a foreseeable finite length of stay and can be bundled using an average number of visits and calculated reimbursement rates. Second, the problems of decreased lengths of stay, reimbursement rates for inpatient consults, and lack of continuity can be tackled by the movement of CL psychiatry into the outpatient sector. First, specialized outpatient services can provide a competitive advantage (e.g., behavioral medicine, pain programs) against a market filled with generalists. Second, CL psychiatry has a long tradition of liaison with primary carethis may represent a large proportion of referrals (as in our center)and this avenue may be well worth exploring. Informal and more formal liaison in primary care clinics can lead not only to referrals but to establishing a joint venture basing psychiatric services in the primary care setting. This may overcome the obstacle of patients not following through with a referral visit to psychiatry by first having the patient meet the psychiatrist briefly, at no charge, in the primary care clinic and then arrange follow up there, perhaps, at a convenient time close to another primary care appointment. In a capitated system, these linkages may ultimately provide cost savings because untreated mental disorders, such as depression, result in increased service utilization, disability, and costs. These linkages can facilitate improved detection and appropriate treatment of these disorders, especially earlier in the course of illnesses. For example, Katon and colleagues23recently described a collaborative management model using primary care physicians and psychiatrists to treat depressed patients. Intervention patients receiving this model had increased intensity and frequency of visits during the first 4 to 6 weeks of treatment. Their visits included two (at weeks 2 and 4) with a psychiatrist. The psychiatrist also reviewed pharmacy data to monitor patients' antidepressant adherence and notified the primary care physician about unexpected discontinuations. This use of shared responsibility and team functioning between primary care physicians and psychiatrists resulted in better outcomes for patients with major depression and is an example of how CL psychiatry may involve itself in caring for patients in the outpatient general health sector. The challenges facing psychiatrists in a rapidly evolving managed care environment are innumerable. Many authors16,32 think that "psychi-
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atrists should play a critical leadership role on the multidisciplinary work with the severely and chronically ill and to integrate biologic and psychological intervention^."^^ We contend that CL psychiatrists, by virtue of their special expertise, can play a similarly specialized role in the care of those people with serious concomitant physical and psychiatric comorbidity in this rapidly changing managed care arena.
References 1. Applebaum PS: Legal liability and managed care. Am Psycho1 48:251,1993 2. Bittker TE: The emergence of prepaid psychiatry. In Feldman JL, Fitzpatrick RJ (eds): Managed Mental Health Care: Administrative and Clinical Issues. Washington, DC, American Psychiatric Press, 1992, p 3 3. Borenstein DB Managed care: A means of rationing psychiatric treatment. Hospital and Community Psychiatry 41:1095, 1990 4. Boyle PJ, Callahan D Managed care in mental health The ethical issues. Health Aff (Millwood) 148,1995 5. Caplan G: The Theory and Practice of Mental Health Consultation. London, Tavistock, 1970 6. Christianson JB, Osher FC: Health maintenance organizations, health care reform, and persons with serious mental illness. Hospital and Community Psychiatry 45:898, 1994 7. Clancy CM, Brody H Managed care: Jekyll or Hyde? JAMA 273:338, 1995 8. Coleman MT, Bright K Ensuring patient confidentiality. J Fam Pract 4018, 1995 9. Council on Ethical and Judicial Affairs, American Medical Association: Ethical issues in managed care. JAMA 273 330, 1995 10. Donvart RA,Epstein S S Economics and managed mental health care: The HMO as a crucible for cost-effective care. In Feldman JL, Fitzpatrick RJ (eds): Managed Mental Health Care: Administrative and Clinical Issues. Washington, DC, American Psychiatric Press, 1992, p 11 11. Durham ML Can HMOs manage the mental health benefit? Health Aff (Millwood) 14116, 1995 12. Emanuel EJ, Dubler NN: Preserving the physician-patient relationship in the era of managed care. JAMA 273:323, 1995 13. Engel G: The need for a new medical model: A challenge for biomedicine. Science 196:129, 1977 14. Epstein S, Gonzales J, Stockton P, et a1 The functioning and well-being of outpatients in an ambulatory consultation-liaison program. Gen Hosp Psychiatry, 18:3-7, 1996 15. Epstein S, Gonzales J, et al: Practice patterns and expert opinion in the evaluation and treatment of anxiety and depression in the medically ill. Psychosomatics, in press 16. Fink PJ: Psychiatrists’ roles in managed care programs. Hospital and Community Psychiatry 44:723, 1993 17. Gable J, Rice T Is managed competition a field of dreams? J Am Health Policy 1:19, 1993 18. Gonzales J: Outpatient consultation-liaison psychiatry: An unfulfilled promise? Gen Hosp Psychiatry 15360, 1993 19. Hall RCW Legal precedents affecting managed care: The physician’s responsibilities to patients. Psychosomatics 35:105, 1994 20. Henry GW: Some aspects of psychiatry in general hospital practice. Am J Psychiatry 9:481, 1929 21. Hunter RB: Ethical dilemmas for benefit managers: Avoiding the double agent role in personal health care. Presented at the Behavioral Health Care Tomorrow Annual Meeting, Dallas, TX, September 23, 1995 22. Jellinek MS, Nurcombe B Two wrongs don’t make a right: Managed care, mental health, and the marketplace. JAMA 270:1737, 1993
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23. Katon W, VonKorff M, Lin E, et al: Collaborative management to achieve treatment guidelines. JAMA 273:1026, 1995 24. Knesper DJ: Substitution in production as the basis for research and policy relevant to mental health specialists. In Taube CA, Mechanic D (eds): The Future of Mental Health Services Research. Washington, DC, US Department of Health and Human Services, 1989, p 63 25. Koyanagi C, Manes J, Surles R, et al: On being very smart: The mental health community’s response in the health care reform debate. Hospital and Community Psychiatry 44:537, 1993 26. Lamb RH, Goldfinger SM, Greenfeld D, et al: Ensuring services for persons with chronic mental illness under national health care reform. Hospital and Community Psychiatry 44:545, 1993 27. Lazarus A Disputes over payment for hospitalization under mental health “carveout” programs. Hospital and Community Psychiatry 45:115, 1994 28. Lazarus A: Dumping psychiatric patients in the managed care sector. Hospital and Community Psychiatry 45:529, 1994 29. Lazarus A: Opportunities for psychiatrists in managed care organizations. Hospital and Community Psychiatry 45:1206, 1994 30. Lazarus A: Ten reasons why psychiatrists may dislike managed competition. Hospital and Community Psychiatry 45:496, 1994 31. Mechanic D Integrating mental health into a general health care system. Hospital and Community Psychiatry 45:893, 1994 32. Meyer RE, Sotsky SM: Managed care and the role and training of psychiatrists. Health Aff (Millwood) 14:65, 1995 33. Miller RH, Luft HS: Managed care plan performance since 1980: A literature analysis. JAMA 271:1512, 1994 34. National Advisory Mental Health Council: Health care reform for Americans with severe mental illnesses: Report. Am J Psycho1 150:1447, 1993 35. Novack DH, Detering BJ, Arnold R, et al: Physicians’ attitudes toward using deception to resolve difficult ethical problems. JAMA 261:2980, 1989 36. O‘Kane M, Rickel A: Quality and accountability as imperatives in managed behavioral health care. Behavioral Healthcare Tomorrow 4230, 1995 37. Oken D: Liaison psychiatry. Adv Psychosom Med 11:23, 1983 38. Pincus H, Strain J, Koupt J, et al: Models of mental health training in primary care. JAMA 249:3065, 1983 39. Rivo M, Mays H, Katzoff J, et al: Managed health care: Implications for the physician workforce and medical education. JAMA 274:712, 1995 40. Rodriguez A: Management of quality, utilization, and risk. In Feldman JL, Fitzpatrick RJ (eds): Managed Mental Health Care: Administrative and Clinical Issues. Washington, DC, American Psychiatric Press, 1992, p 83 41. Rogers WH, Wells KB, Meredith LS, et a l Outcomes for adult outpatients with depression under prepaid or fee-for-service financing. Arch Gen Psychiatry 50:517, 1993 42. Rost K, Smith R The deliberate misdiagnosis of major depression in primary care. Arch Fam Med 3:333, 1994 43. Roulidis ZC, Schulman KA Physician communication in managed care organizations: Opinions of primary care physicians. J Fam Pract 39:446, 1994 44. Sabin JE: A credo for ethical managed care in mental health practice. Hospital and Community Psychiatry 45:859, 1994 45. Safran DG, Tarlov AR, Rogers NH: Primary care performance in fee-for-service and prepaid health care systems. JAMA 271:1579, 1994 46. Santiago JM: The fate of mental health services in health care reform: I. A system in crisis. Hospital and Community Psychiatry 43:1091, 1992 47. Santiago JM: The fate of mental health services in health care reform: 11. Realistic solutions. Hospital and Community Psychiatry 43:1095, 1992 48. Saravay SM, Saravay MD, Levin M: Psychiatric comorbidity and length of stay in the general hospital A critical review of outcome studies. Psychosomatics 35:233, 1994 49. Sargent S: Contracting and managed care payment options. In Feldman JL, Fitzpatrick
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RJ (eds): Managed Mental Health Care: Administrative and Clinical Issues. Washington, DC, American Psychiatric Press, 1992, p 53 50. Schlesinger M: Ethical issues in policy advocacy. Health Aff (Millwood) 14:23, 1995 51. Sharfstein SS, Stoline AM: Reform issues for insuring mental health care. Health Aff (Millwood) 22:84, 1992 52. Strain JJ, Hammer JS, Fulop G: APM task force on psychosocial interventions in the general hospital inpatient setting: A review of cost-offset studies. Psychosomatics 35:253, 1994 53. Wells KB: Depression in general medical settings: Implications of three health policy studies for consultation-liaison psychiatry. Psychosomatics 35:279, 1994 Address reprint requests to Junius J. Gonzales, MD Clinical Economics Research Unit, GUMC Suite 440 2233 Wisconsin Avenue NW Washington, DC 20007
0193-953>(/96 $0.00
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CONSULTATION-LIAISON PSYCHIATRY IN THE MANAGED CARE ARENA Junius J. Gonzales, MD, and Lauren Randel, MD
The field of consultation-liaison (CL) psychiatry has recently attempted to define itself and promote its services. In 1994, a published series of articles described the potential cost savings by using CL services in the general hospital, the potential impact on patient outcomes, and useful models to improve mental health problems in primary care.48,52 CL services have been an integral part of standard clinical psychiatric practice in the general hospital and have been a subject of increasing research over the last decade. The nature of CL psychiatric services, however, requires carefully assessing organizational, financial, and reimbursement issues for the subsequent continuation of these services. In this era of rapidly changing health care, especially managed care, critically defining what CL services are, and knowing where the managed care movement is headed can directly impact CL psychiatry. This article briefly defines CL psychiatry-its history, goals, and clinical modelsand places it in the context of managed health care’s history, goals, and structures. Several current trends in managed care systems, such as financial arrangements and management mechanisms, are also described. We then examine the potential impact of managed care on CL psychiatry, discuss general ethical issues in managed care with relevant applications to CL psychiatry, and make recommendations for CL psychiatry to survive under managed care.
From the Department of Psychiatry (JJG, LR), Clinical Economics Research Unit UJG), and the Institute for Health Care Research and Policy (JJG),Georgetown University Medical Center, Washington, DC
THE PSYCHIATRIC CLINICS OF NORTH AMERICA VOLUME 19 * NUMBER 3 * SEPTEMBER 1996
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HISTORY, GOALS, AND CLINICAL MODELS OF CONSULTATION-LIAISON PSYCHIATRY
CL psychiatry derived its name and functions from two related movements: (1) consultation and (2) liaison work. Initially, the movements attempted to delineate and distinguish their two functions in terms of scope and focus, but the separation of these two processes has disappeared, and most CL psychiatrists function in dual capacities. Oken37described that ”the consultant . . . is called in to deal with overt aberrant behavior and to identify and treat psychiatric disorders, including the clarification as to whether physical symptoms arise from a psychiatric condition.” In contrast, liaison work was described as not direct clinical patient contact but rather working collaboratively with nonpsychiatric medical and surgical professionals in providing education on psychiatric problems and psychosocial issues. The links between these two work roles are clearly inextricable. The CL psychiatrist has more recently been defined as a practitioner who studies, evaluates, and treats psychiatric morbidity in the physically ill, psychological factors affecting physical conditions, and psychosomatic interactions. Historically, CL psychiatry has roots in mental health consultation that emerged in the 1920s via community-based child guidance clinics. At that time, diverse professional groups and individuals who came in direct contact with mental health problems were targeted as the focus of mental health consultation. These sometimes disparate providers included nurses, educators, general physicians, social welfare workers, and legal or judicial professionals. Although conceptually similar, liaison work arose somewhat later as a separate area of expertise within mental health consultation. Liaison focused on the process of linking or joining two separate disciplines with the ultimate goal of increasing awareness of mental health issues. A separation between liaison and consuhtion psychiatry existed for some years and was even the subject of published literature. CL psychiatry flourished within the conceptual framework of psychosomatic medicine and expanded with the applied use of Engel’sI3 biopsychosocial paradigm.37Even as far back as 1929, the clinical practice of psychiatric consultation was finely described by George Henryz0and, in 1934, funds were made available by the Rockefeller Foundation to introduce psychiatry departments in general hospitals.z0Consequently, CL psychiatry has a longstanding tradition of being the most direct and active psychiatric connection to the rest of medicine. Formal training for CL psychiatry grew in the 1970s and 1980s owing to National Institute of Health funding and revitalized psychiatry’s direct link to general medicine by, for example, training primary care physicians in psychosocial issues. Other mental health professional disciplines, such as nursing, social work, and psychology, were also supported through specialized fellowships. More recently, CL psychiatry has evolved by establishing its own professional organization and a proliferation of CL fellowships. Despite an initial failure to obtain official
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subspecialty status, the CL professional movement continues to pursue special certification for psychiatrists completing a fellowship. Although CL psychiatry has been connected to primary care for some time (e.g., the longstanding American Psychiatric Association Committee on CL Psychiatry and Primary Care Education), the promise of that connection has not been well fulfilled, and little attention has been paid to CL psychiatry in the outpatient sector. Recent literature has prioritized a move into the outpatient arena for CL psychiatric work.18Outpatient CL psychiatry offers many advantages, including for training, and may provide an effective survival tactic in this era of health care delivery changes. Revisiting systems models that helped inform the developing CL field may abet the contemporary organization and delivery of CL services within the greater system of managed care. General systems theory, which examines both intersystem and intrasystem factors, may need to be practically applied as managed care seeks to organize services both by integrating systems as well as by splitting systems (e.g., carve out^).^ For example, Pincus et a138proposed six models linking general medical and mental health systems of care based on three key linkage elements. The first element is contractual and consists of the nature and content of formal or informal agreements between the two settings. The second element is functional. The third element is educational and focuses on the relationship that establishes and reinforces a general health care provider’s knowledge and skills in mental health. Linkages are modified by the level of administrative and clinical participation of each sector (Table 1). For example, at one end of the spectrum is the agreement model, which is characterized by a linkage that is established in a contractual way between two separate parties in which each party renders separate services. Another model, at the other end of the spectrum, is an integrated health care team that is described as ”a fluid synthesis” of those three linkage elements and may include a mental health professional as a regular colleague. Important considerations in developing and choosing a model are (1)population served, (2) geography, (3) management, (4) financing mechanisms, (5) philosophy of care, and (6) settings and levels of care.
Table 1. LINKAGE ELEMENTS Models
Contractual
Functional
Agreement Triage Service delivery team Consultation service Supervision education Integrated health care team
+++ +++ +++ ++ + +++
+ ++ ++ +++ ++ +++
+
=
mild level;
++
=
moderate level;
+++
=
high level; -
=
Educational
not present.
+/+/-
+ ++ +++ +++
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History of Managed Care and Psychiatry
Managed care companies have been proliferating over the last few years in this country, with rapidly differing levels of regional penetration, yet they have roots in group practice from the late 1800s and health maintenance organizations (HMOs) that sprang up midcentury.* Operational definitions of managed care are predicated on the financial arrangement for the patient when obtaining health care services. At one end of the management spectrum are fee-for-service (FFS)plans with a managed component, such as utilization review; but the primary financial arrangements still have traditional FFS deductibles and out-ofpocket (percentage)payments. On the other end is fully prepaid care that represents prototypic managed care-all denoted services are covered by an annual premium but there may be small copayments for visits. By 1992, more than 50% of employees in large or medium companies received prepaid care.17 Since the inception of managed care, mental health has been included under prepaid care in a variety of ways3,30 The most common managed mental health benefit was through limited and carefully defined prepaid services focusing on crisis intervention, triage, and consultation. In the mid-1980s prepaid medical and mental health care became a growth industry and saw the industrialization of psychiatric services with aggressive development of for-profit hospitals and then companies 22 that tried to capitalize on the reputed overspending in the FFS sector.lO, The privatization and growth of private psychiatric hospitals resulted in maximized profits, increased efficiency, and the aggressive use of marketing and advertising, which increased and stimulated demand for managed care group services. The growth of companies and a corporate level of involvement in providing mental health care transformed a cottage industry to a booming multimillion dollar business. This trend resulted in increased competition between not only FFS and managed care plans but among managed care plans, insurers, and providers of care-a competition not seen even with Congressional HMO Acts.'O Given these developments, it is important for CL psychiatrists to have an understanding of contemporary managed care plans and what problems they face in order to meet the challenge posed by Durham" of "whether they can manage the care of persons with mental health needs and resist the temptation to manage only the financial risk. Organizations that successfully address this challenge will reap benefits throughout their delivery systems and reclaim the competitive advantage of managed care." Goals and Organization of Managed Care
Whereas initial directions in the managed care movement were based on providing affordable quality health care and emphasized such concepts as preventive care and health promotion, the industry has
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redefined its goals: to reduce prices, reduce variation in treatment patterns, reduce need for services, and reduce the costs of prod~ction.~, 33 The clarity and evaluation of such goals is often muddied by complex issues, such as for-profit needs and problematic definitions of demand for care, need for care, and supply of care. Data on access, costs, quality of care, and outcomes in managed care settings are emerging but, owing to study limitations, provide mixed results.33The data related to costs have focused on inpatient utilization and have demonstrated savings owing to shortened lengths of stay. These data have not been well linked, however, to patient outcomes and quality of care. Some studies on access and outcomes in FFS and prepaid care have yielded no significant differences in outcomes or use, whereas others, focusing on patients’ reports, have found differences.6 For example, a recent J A M A article45evaluated primary care performance in the two settings and found differences in six of eight indicators: organizational access, continuity of care, and accountability were highest in FFS systems, whereas coordination of care was higher in prepaid care. Communication between providers in FFS versus prepaid care has also been studied and results indicated that, from providers’ perspectives, prepaid care may impair ideal cornmuni~ation.~~ Similarly, depressed patients in the Medical Outcomes Study who had prepaid versus FFS care had more decrements in functioning over 53 Much more research is needed to tease out how the processes of care differ in the two systems and what impact these differences may have on patient outcomes. Different organizational models of managed care plans exist depending on structural and contractual arrangements (Table 2).39For example, a staff model HMO usually has its own physical facility in which providers are salaried employees who serve only those people enrolled in the plan. One longstanding well-known staff model HMO is Kaiser-Permanente, which owns many of its outpatient facilities, but the HMO may contract with community hospitals or other specific facilities to deliver certain aspects of care ( e g , specialty care). Two common models, independent practice associations (IPAs) and preferred provider organizations (PPOs), are proliferating and marketing directly to insurers. In the former, a management group markets the benefits plan, collects fees, and reimburses providers. This is a middle manager group who manages the benefits for the insurer and contracts with independent providers who agree to certain prepaid reimbursement rates for their various services. A PPO is an arrangement between a payer and a provider group whereby the latter is often an organization who can negotiate with providers for lower rates in return for a guaranteed patient volume. The PPO form of managed care is growing rapidly with variations, such as a ”point of service” plan where patients can use nonPPO providers at higher out-of-pocket costs. The goal of quality of care for managed care plans has been questioned recently given the relative absence of standards and heightened competition between for profit companies. The National Committee on
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Table 2. ORGANIZATIONAL MODELS OF MANAGED CARE Organization Structure Staff model HMO
Independent Practice Association (IPA)
Network IPA
Preferred Provider Organization (PPO)
Managed FFS Indemnity Plan with FFS
Description Traditional, prepaid multispecialty group practice housed in own facility Providers are salaried and work for the plan or group that has an exclusive contract with the plan Patients covered for care provided by the HMO Insurers send patients to providers in solo or small groups who agree to some financial risk for service provision Payment mechanisms range from discounted FFS (with or without financial incentives) or capitation Similar to IPA but often made up of network of larger group practices Payment is usually capitation to groups that then pay providers Insurer sends patients to “preferred” providers who are usually reimbursed discounted FFS The insurers, not the provider, usually accepts financial risk Full range of provider choice, FFS, but insurer uses utilization control to manage costs Total freedom of provider choice; provider reimbursed by insurer on FFS
Adapted from Rivo M, Mays H,Katzoff J, et al: Managed health care: Implications for the physician workforce and medical education. JAMA 274:712, 1995, and Moore GT: The Impact of Managed Care on the Medical Education Environment. Rockville, Council on Graduate Medical Education, November 1993, copyright 1995 American Medical Association; with permission.
Quality Assurance was created ”to promote improvement in the quality of patient care provided through managed health plans; and to provide information on quality to the public at large, consumers, purchasers, health plans and other interested parties such as governmental agencies or en ti tie^."^^ NCQA struggles, however, with differing definitions of key concepts (e.g., accountability) by the different constituencies who want input, and faces the dilemma of how ultimately to enforce those standards. Managed Care Mechanisms
The increased costs of health care (owing to recession, inflation, a more complex society, and supply and demand factors) have all contributed to the recent development of managed care. As noted previously, four common objectives exist: (1)to reduce prices, (2) to decrease variation in treatment, (3) to decrease the need for services, and (4) to reduce
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the cost of production. Some see these objectives resulting from complex economic forces that, in short, shift health care costs from insurers to patients and providers while shifting health care profits into managed care companies. Managed care organizations use several mechanisms in order to meet their goals. The first objective, price reduction, is primarily achieved through contracted payments. Providers may be reimbursed for services in the following ways: per case, per type of service, per diem, or through capitation. Often, provider fees for services are discounted in exchange perhaps for access to a potentially high volume of patients. Reimbursement for nonmedical providers heightens competition, particularly for psychotherapy services. Currently, reimbursement trends are based on the Medicare fee schedule-companies are negotiating rates with providers at some percent value above or equal to Medicare (e.g., 120%). Capitation is a mechanism whereby a fixed sum of money is allotted for the care of a population and this flexible funding is based on a negotiated price per person per annum (e.g., $3 per person/month) for mental health services. Should fewer services than anticipated be used, the provider group can profit, but the opposite occurs if service use exceeds calculations. Capitation requires having concrete and detailed information on the insured population, utilization data, charge and cost data for services, target marketing information, and competitor analyses.49It also requires being able to provide a comprehensive range of mental health services; if some services are not available, subcontracts to other providers are necessary. To meet the second goal-reducing variation in treatment patterninformation management operations abound. First, utilization review of services provided is common and uses a guiding concept of medical necessity, although the operational definitions of necessity vary with each individual managed care plan. Table 3 presents components of an ideal psychiatric review.4oOther emerging information management methods include case management; provider profiling (i.e., practice patterns); and outcome studies. Reducing the need for services, the third managed care goal, focuses on prevention, early identification, triage, telephone-assistance programs and tight links to employee-assistance programs. Reducing need involves mental health promotion efforts and those few plans that have such programs rely on the voluntary participation of members. It is precisely the group that needs, but may not access, services that needs targeting, however, because it may be that only the healthier people participate in those promotion efforts. The last goal, reduction of costs, is often achieved by benefit redesign and structuring. Mental health benefits have often not had parity with other general medical benefits but demonstrated increased use and cost escalations; therefore, some effort was made to redesign and structure mental health benefits to control those expenditures. One such administrative method has been dubbed beneficiary inconvenience whereby complex required procedures, confusing terms, slow adminis-
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Table 3. COMPONENTS OF A PSYCHIATRIC REVIEW Quality focus Professional reviewers Specialized Multidisciplinary Consultative approach Direct communications: phone based on face-to-face Criteria (specific to a company) Consensus-developed Objective scientific Review focused Functioning levels and appropriate level of treatment Indicated evaluations and treatments Treatment goals Aftercare: family, work-school, community supports Effective benefit decision communications Effective appeals mechanisms Quality control Review opinions Reviewer knowledge and actions Confidentiality Communications Adapted from Rodriguez A: Management of quality, utilization, and risk. In Feldman JL, Fitzpatrick RJ (eds): Managed Mental Health Care: Administrative and Clinical Issues. Washington, DC, American Psychiatric Press, 1992, p 88; with permission.
trative processing of claims and inquiries, and uneven communications decrease access to care.4o Managed care companies use many other mechanisms that limit services. One mechanism is a so-called carve-out program for certain benefits, such as mental health, where a managed care plan may contract with a provider group (e.g., a PPO) for general medical and surgical services, but use a separate limited provider group or managed mental health care company for delivery and administration of mental health services. The driving impetus for carve-out of any service is cost, but this mechanism results in numerous clinical and administrative obstacles for patients in these plans, which may, in the long run, be more expensive. Such important clinical process components, such as continuity of care and comprehensiveness of care (two tenets of primary care), are overlooked by carve-out programs. Carve-outs of mental health services for university or tertiary hospi~ ~ research data tals pose some unique issues for CL p s y ~ h i a t r y .First, indicate that patients with comorbid medical and psychiatric problems seen in a tertiary setting have poorer functioning and well-being than those seen in community settings.15This finding, coupled with the available expertise of providers in tertiary settings, raises the questions of continuity and quality of care for these patients. New work on the practice patterns of psychiatrists in dealing with medically ill outpatients who also have depression or anxiety show significant differences in knowledge by practice setting and that community solo practitioners
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may use more costly antidepressants more often than their counterparts in tertiary settings and have less knowledge about managing depressed patients with these medical c~morbidities.’~ Anecdotally, our institution has found that the carve-out programs have fewer psychiatrists with formal expertise in or experience with medically ill patients, and after a circuitous traverse and delay in evaluation or treatment, patients have been rerouted through special dispensation by their managed care plan back to our psychiatry department. Carve-outs pose special problems for CL psychiatry especially as the boundaries between medical and psychiatric problems and diagnoses are deliberately blurred in order to shift fiscal responsibility from one benefits sector to the other (e.g., from medical to mental health). An example on the inpatient side involves organ transplantation, which often requires a psychiatric evaluation prior to the procedure and has high risk for psychiatric morbidity, such as delirium. Should services, such as psychiatric inpatient consultation, be billed to the medical part of the patient’s benefits or mental health part, which is managed by a separate company? An outpatient example is biofeedback services in a behavioral medicine division in a department of psychiatry. Some managed care plans require approval by a nonpsychiatric physician and a nonpsychiatric diagnosis to approve biofeedback yet want it billed to mental health, but the managed mental health care company does not allow out-of-network providers to provide the service despite having gone through the aforementioned obstacles. One extreme case is that the managed care company wants the biofeedback procedure performed by the recommending physician, despite the well-known fact that physicians rarely provide this service and may not have the appropriate training to do so. The diagnostic classification of organic mental disorders has also been a problem. A patient with dementia who is functionally psychotic, by virtue of diagnosis, is to be billed under the nonmental health benefits, but the bill is rejected because the services are provided by psychiatrists. Furthermore, the carve-out mental health program does not pay the psychiatrists because they are not in the plan. In our institution it has been a difficult but successful battle to provide inpatient consultation services and be reimbursed even though we are not providers in several carve-out mental health plans. This has been done by advocating for comprehensive and continuous care for ill inpatients and using our medical colleagues to support this position. Finally, for severely medically ill inpatients who have been stabilized for psychiatric problems by the CL team (e.g., overdose recovering in intensive care unit), continuity is disrupted when the patient cannot be transferred to the inpatient psychiatric unit because it is not in the carve-out mental health network. The quality and comprehensiveness of care is also potentially compromised when someone with a chronic, lifethreatening illness (e.g., AIDS) must be transferred to a freestanding psychiatric hospital not attached to a general medical facility.
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Ethical Issues and Legal Liability in Managed Care
The change from FFS as the principal means of third-party payment for health care services to managed care has had a broad impact on the practice of medicine and on psychiatry in particular. Recent articles discuss how this change has ethical implications for all aspects of health care delivery: there are systemic or societal issues, new issues regarding the ethical obligations of the managed care organizations, and new ethical dilemmas for the physician in the context of the evolving physician-patient relationship.*,50 Psychiatry and substance abuse are areas of particular controversy in the debate on health care reform. Whether society has an ethical obligation to provide mental health and substance abuse benefits, as distinct from other medical care, is inherent in the policy decisions regarding what services managed care is required to provide. Some key questions reflecting these ethical dilemmas include: who should pay for the nonmedical aspects of treatment that are efficacious and cost effective in caring for the chronically mentally ill, should treatment for ”human misery” be covered by health insurance, and should there be parity between mental health and substance abuse benefits and those for physical illness?28 Sharfstein and Stoline5I divide psychiatric care into four tasks: (1) medical tasks that include the diagnosis and treatment of acute presentations of mental illness (people are often underinsured for these services); (2) reparative tasks that constitute the rehabilitation often required after psychiatric hospitalization (people are rarely insured for these services at all); (3) social controls that consist of treatment for actions harmful to society by the patient with a mental illness or substance abuse problem (these treatments have “patchy” funding, which may be through insurance or out of the patient’s pocket; the task of protecting society generally falls on the public sector); and (4) the humanistic tasks of fostering personal growth through psychotherapy for people who experience distress but who do not have major psychiatric illness (the funding for this is varied). The authors raise the pivotal issue of who should pay for these various tasks, and suggest that social control tasks (protecting society from intoxicated drivers, from pedophiles, and so forth) are probably most appropriately handled in the public sector. By keeping the protection of society in the public domain, treatment initiation can be legally enforced and the services can be paid for out of public program and criminal justice budgets. What Sharfstein and Stolinesl call the reparative tasks (adult day care, vocational rehabilitation, assistance with household management) are generally considered to be vital to recovery from and living with mental illness. Although the benefits of rehabilitation are not disputed, what is debated is whether these services are an obligation of health insurers. The policy question is whether we, as a society, want to ensure the provision of these services. Sharfstein and Stoline5Irecommend that
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if we value these services a separate entitlement fund may result in better provision of those services. The use of medical insurance to pay for humanistic tasks of selfactualization (i.e., as some view psychotherapy) is quite controversial. As described previously, many managed care plans have extensive outpatient coverage with some cost sharing by the patient, but the coverage is not intended for ”personal growth.” The “problems” in the patients with humanistic tasks are not acute, severe psychiatric problems, and so many object to the use of health insurance to pay for this help. Some have suggested that the patient who seeks personal growth should be called on to bear more of the financial burden than has been previously asked? The use of outpatient psychotherapy has been shown to be responsive to such cost-sharing measures. Most agree that the medical tasks of diagnostic evaluation and treatment are appropriately covered by insurance (although there remains much disagreement over what constitutes appropriate and effective treatment). Current insurance benefits, however, are often inadequate if a person develops a major psychiatric condition that often has a relapsing and remitting course and may, over a short time span, include more than one episode requiring hospitalization. Most plans include some cost sharing that can result in enormous financial burdens. In addition, because of limited lifetime benefits, the maximum benefit may be exceeded, which results in financial devastation for the patient and often his or her family. The care and its costs are then transferred to the public system, which is already o v e r b ~ r d e n e d . ~ ~ These issues spotlight the controversy of parity between mental health and substance abuse benefits and general medical benefits.31Historically, good mental health coverage included 30 to 60 days per year of inpatient hospitalization compared with unlimited days or 120 days for physical illness. In addition, many plans have maxima both on annual and on lifetime inpatient benefits. Outpatient care is generally limited either in terms of number of visits, maximum annual expenses, or a smaller covered percentage of the charge (Report of the National Advisory Mental Health The fairness of practices such as maximum annual or lifetime inpatient benefits, limited outpatient visits, or increased self payment with increased numbers of visits is being reconsidered now in the active discussion over health care reform.46,47 Some proposals seek to increase benefits for those with selected psychiatric diagnoses or with a specified degree of disability. Alternatives focus on the services provided (as with the medically ill), and try to contain costs using managed care, patient incentives, and capitation with hopes of increasing the use of efficacious, cost-effective treatment.s* 30 In addition to the ethical questions that exist for society, new ethical questions face the managed care companies, because they have an increasingly large role in determining patient care and psychiatric practice pattern^.^^ Managed care organizations historically have not had the primary, ethical obligation to the patient. The primary aim of managed care organizations has been cost containment. The managed care organi-
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zations viewed providers as retaining full clinical and ethical responsibilities to the patient. This situation, however, is being challenged in the legal system, with managed care organizations being held to bear some responsibility for poor ~utcomes.’~ Borenstein3points out that given this overriding financial aim, the standard of managed care is ”medical necessity,” which is operationally defined as ”the least costly alternative form of treatment for a given patient at that time.” This differs from the physician’s perspective where he or she has an ethical obligation and resultant aim to provide the best treatment available to a patient with a specific illness. The agendas of the managed care organization and of the individual psychiatrist are often in at least partial conflict. For the psychiatrist to provide optimal care he or she must either absorb the additional cost, pass this cost on to the patient, or ask the hospital or other treating institution to absorb this cost. Another problematic issue in managed care is the confidentiality obligation on the part of the physician? Review organizations are generally increasingly privy to inpatient charts and to the substantive content of outpatient treatment. No clear confidentiality obligation exists toward the patient on the part of the managed care organization, although recent attention has been paid to ethical dilemmas for benefit managersz1 In addition, the psychiatrist is obligated to cooperate with a review that, while necessary for treatment to be paid for by the managed care organization, may undermine the trust-partly based on confidentiality-in the physician-patient relationship. Confidentiality issues symbolize the tremendous impact of managed care on the physician-patient relationship. Emanuel and DubleP define six vital aspects of the physician-patient relationship: (1)competence, (2) compassion, (3) communication, (4)continuity, (5) absence of conflict of interest on the part of the physician, and (6) patient choice. The latter two aspects of the physician-patient relationship-the physician’s freedom from conflict of interest and the patient’s choice (in selecting a physician, a treatment setting, and from multiple treatment alternatives)-are vital to the ethical physician-patient relationship. The changes in the physician’s role cloud the physician’s ethical obligations as compared with previously when the obligation was primarily to the patient. The physician practicing in a managed care setting has been described as in a ”stewardship role” with regard to society’s resources.& In a recent report by the Council on Ethical and Judicial Affairs of the American Medical Association: the physician was described as bound by two potentially conflicting moral imperatives, that of ”gatekeeper” of society’s resources and that of advocate for the individual patient. The physician’s position is further complicated in many managed care organizations by the financial incentives for limiting the care provided, although it should be noted that FFS arrangements posed the opposite incentive? For psychiatrists, the obligation chosen as primary can determine the treatment aim: should the desired outcome be related to patient satisfaction, patient functioning, external social costs, or some other outcome measure?z4How physicians resolve these
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dilemmas inherent in their conflicting roles is unclear. Novack et a135 studied a physician’s willingness to deceive either an insurance company or the family of a patient for various reasons including: protecting the patient’s confidentiality, securing reimbursements for patients, or covering the physician’s own mistakes. One finding was that physicians were willing to deceive insurance companies to get reimbursements for patients; this may provide some clue as to how conflicting obligations are prioritized. This issue of deception on behalf of the patient is particularly relevant for psychiatric conditions that are perceived to be stigmatizing and are known to be poorly reimbursed. Rost and Smith42found that 50% of the surveyed primary care practitioners deliberately miscoded major depression in the submission for reimbursement as some nonspecific physical complaint. The three reasons most commonly cited for this were (1) uncertainty about the diagnosis, (2) problems with reimbursement for services if depression is coded, and (3) jeopardizing the patient’s future ability to obtain health insurance. The patient’s loss of choice, and thereby of autonomy, further erodes the possibility of an optimally ethical physician-patient relationship. In the absence of well-enforced regulations preventing ”cherry picking,” insurance companies and managed care organizations may try to select participants who are less likely to be ill, which may prevent some people from enrolling in the managed care organization of their choice. Without regulations ensuring transportability of coverage, many people will be forced to change physicians when they change jobs; 7 million Americans change jobs or become newly employed each month. Additionally, many employers are now offering only one health plan, and indeed which plan is offered may change frequently as managed care organizations compete on price or go out of business so that new plans are selected by the employer based on their cost savings.I2 A change to a new managed care organization generally requires that patients change physicians to those designated by the plan. Mutual consent between autonomous parties is important in all physician-patient relationships, but it is particularly significant in psychiatric treatment where the therapeutic alliance is central to treatment. Frequent changes of provider are likely to undermine the success of treatment. Ethical questions face psychiatry at many levels: the individual patient and physician, their relationships, managed care organization, and society. Does society have an obligation to those with mental illness or substance abuse that differs from the obligation to the medically ill? Do managed care organizations in their function of determining treatment and benefits take on ethical obligations to patients? If so, how are these best understood? Finally, how can the trust necessary for effective treatment be established between physician and patient, given the competing pressures on both parties? For CL psychiatry, the primary ethical dilemmas focus on the delivery of services in a timely manner and the physician-patient relationship.44On inpatient settings, CL psychiatry focuses on acute evaluation and management of psychiatric problems. This clinical service is espe-
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cially problematic when psychiatric services are carved out of a managed care plan. Traditionally, a medicine inpatient's attending physician directly requested consultation by a hospital-based CL psychiatrist. In a carve-out, preauthorization by the mental health company's reviewer or the outside primary care practitioner is typically required for psychiatric services to be provided. The services may then be provided by perhaps an outside psychiatrist who may or may not have expertise with acutely medically ill patients. The case may require immediate attention, such as delirium or emergency competency assessment, and the on-site psychiatrist is faced with the dilemma of intervening without reimbursement or declining to provide the con~ultation.~~ The ethical dilemma extends to the collegial relationship between the CL psychiatrist and the medical team asking for help in the form via the consultation. Finally, legal issues abound in this situation, and action should be predicated on doing what is best for the patient. Not doing a consultation may result in harm to the patient, but the decisions become murkier when the acuity factor is removed. Recent articles have addressed the legal issues faced by clinicians in working within managed care',19 and offer some suggestions on facing these issues. Appelbaum' writes that the physician or provider has several duties: the duty to appeal adverse decisions, the duty to disclose, and the duty to continue treatment. Similarly, the managed care organization has legal duties: the duty to review with reasonable care, the duty to disclose, and the duty to select appropriate providers with possible vicarious liability. Finally, Hall19offers 12 steps for providers dealing with managed care based on best care for the patient, detailed documentation, and appeal. RECOMMENDATIONS FOR CL PSYCHIATRY
The status of managed care in health care delivery is growing at an astounding rate and challenges-clinical, organizational, legal, and ethical-face providers as well as the managed care industry. We have reviewed the history of both CL psychiatry and managed care and detailed some relevant practical concerns for patient care. These difficulties pervade all of psychiatry, but certain situations may be more prevalent in the CL setting. Numerous articles have documented how psychiatrists can play a pivotal role in managed care at administrative, 29, 32 We also think that CL psychiatry, clinical, and training levels.l6* by virtue of its specialized expertise, can make some unique contributions to the care of medically ill populations within the managed care world, but it must work aggressively with systems infrastructures (e.g., hospital, department) targeted at managed care. First, CL psychiatrists must work closely with their departments in order to provide input on reimbursement rates for their services. They must know what a bottom-line acceptable rate is, based on all operating costs, and have an opportunity to achieve those rates and not have the 307
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department turn away contracts because certain other rates may be low. Second, working with a hospital's office of managed care is critical in order to understand clearly what is happening at both local and national levels. For example, knowing what the regional charges per current procedural terminology (CPT) code are is a critical tactic. This can position one to negotiate at lower rates if some service is underpriced by CL psychiatry compared with regional charges. Finally, bundling services may be a way of carving oneself back in. As described previously, our experience is that managed care companies who carved out the mental health services are actively negotiating to carve in certain services, such as inpatient consultations. The reasons are clear: access to comprehensive and continuous care for their patients in the general hospital. Because of decreased lengths of stay, these inpatient consultations are appealing owing to a foreseeable finite length of stay and can be bundled using an average number of visits and calculated reimbursement rates. Second, the problems of decreased lengths of stay, reimbursement rates for inpatient consults, and lack of continuity can be tackled by the movement of CL psychiatry into the outpatient sector. First, specialized outpatient services can provide a competitive advantage (e.g., behavioral medicine, pain programs) against a market filled with generalists. Second, CL psychiatry has a long tradition of liaison with primary carethis may represent a large proportion of referrals (as in our center)and this avenue may be well worth exploring. Informal and more formal liaison in primary care clinics can lead not only to referrals but to establishing a joint venture basing psychiatric services in the primary care setting. This may overcome the obstacle of patients not following through with a referral visit to psychiatry by first having the patient meet the psychiatrist briefly, at no charge, in the primary care clinic and then arrange follow up there, perhaps, at a convenient time close to another primary care appointment. In a capitated system, these linkages may ultimately provide cost savings because untreated mental disorders, such as depression, result in increased service utilization, disability, and costs. These linkages can facilitate improved detection and appropriate treatment of these disorders, especially earlier in the course of illnesses. For example, Katon and colleagues23recently described a collaborative management model using primary care physicians and psychiatrists to treat depressed patients. Intervention patients receiving this model had increased intensity and frequency of visits during the first 4 to 6 weeks of treatment. Their visits included two (at weeks 2 and 4) with a psychiatrist. The psychiatrist also reviewed pharmacy data to monitor patients' antidepressant adherence and notified the primary care physician about unexpected discontinuations. This use of shared responsibility and team functioning between primary care physicians and psychiatrists resulted in better outcomes for patients with major depression and is an example of how CL psychiatry may involve itself in caring for patients in the outpatient general health sector. The challenges facing psychiatrists in a rapidly evolving managed care environment are innumerable. Many authors16,32 think that "psychi-
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atrists should play a critical leadership role on the multidisciplinary work with the severely and chronically ill and to integrate biologic and psychological intervention^."^^ We contend that CL psychiatrists, by virtue of their special expertise, can play a similarly specialized role in the care of those people with serious concomitant physical and psychiatric comorbidity in this rapidly changing managed care arena.
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RJ (eds): Managed Mental Health Care: Administrative and Clinical Issues. Washington, DC, American Psychiatric Press, 1992, p 53 50. Schlesinger M: Ethical issues in policy advocacy. Health Aff (Millwood) 14:23, 1995 51. Sharfstein SS, Stoline AM: Reform issues for insuring mental health care. Health Aff (Millwood) 22:84, 1992 52. Strain JJ, Hammer JS, Fulop G: APM task force on psychosocial interventions in the general hospital inpatient setting: A review of cost-offset studies. Psychosomatics 35:253, 1994 53. Wells KB: Depression in general medical settings: Implications of three health policy studies for consultation-liaison psychiatry. Psychosomatics 35:279, 1994 Address reprint requests to Junius J. Gonzales, MD Clinical Economics Research Unit, GUMC Suite 440 2233 Wisconsin Avenue NW Washington, DC 20007