Clashing Forces Pressure Consultation-Liaison Psychiatry

October 1, 1998

The future is both bright and dark for consultation-liaison (C-L) psychiatry. It is a paradox created by a still-evolving health care system that affords unique opportunities for innovation, while simultaneously placing seemingly insurmountable obstacles in the way of access to quality care. Striving to navigate these systemic contradictions, C-L psychiatry can be seen as on the verge of either a breakthrough or a breakdown-only time will tell how things will work out for this as yet uncertified subspecialty.

The future is both bright and dark for consultation-liaison (C-L) psychiatry. It is a paradox created by a still-evolving health care system that affords unique opportunities for innovation, while simultaneously placing seemingly insurmountable obstacles in the way of access to quality care. Striving to navigate these systemic contradictions, C-L psychiatry can be seen as on the verge of either a breakthrough or a breakdown-only time will tell how things will work out for this as yet uncertified subspecialty.

"One of the biggest concerns [among C-L psychiatrists] is that there just are not going to be enough [of them] to meet the needs of patients that are currently not being treated in the primary care area," said Roger Kathol, M.D., president of the Academy of Psychosomatic Medicine (APM). While arguing that there is a significant need for C-L psychiatrists, Kathol acknowledges that enormous financial and professional barriers separate them from the patients who need their services.

Kathol is also the CEO of Cartesian Solutions, an Iowa City-based consulting firm that assists health care systems in developing programs which integrate mental health with primary care and other medical services. For him, as for many other C-L psychiatrists, "the mind and body are intimately and inextricably linked," and the goal of his firm is to shift the mindset of those health care systems that "set up inpatient and outpatient psychiatric [mind] and physical [body] services with independent practitioners in separate locations and supported by autonomous, often competing, payment sources."

The growing body of research linking mental health care with lower utilization of other medical services and better patient outcomes has caused a rethinking of these traditional models, which usually rejected paying for psychiatric interventions, said Kathol. Despite better data and increasing recognition by medical/surgical professionals of the benefits of mental health care, however, change is slow in coming.

"The whole of medicine is in transition. We are using new systems of care and new systems of finance...the old system of finance did not recognize the percentage of primary care patients who had psychiatric comorbidity and the very substantial impact that has on cost of care in the medical settings," Kathol said. "It is just now that the medical reimbursers-the managed care companies and indemnity companies, and actually the employers-are recognizing the need to include psychiatric services for patients that only show up in the primary care area."

For Thomas Nathan Wise, M.D., a past president of APM and the editor of Psychosomatics, the journal of C-L psychiatry, the holy grail of "integration"-a seamless continuum of health care for the mind and the body-will remain out of reach as long as health care systems continue to "silo," or partition, psychiatry from the rest of medicine. Eliminating mental health carveouts, therefore, emerges as the ultimate challenge for C-L psychiatry.

"There is a barrier, financially, when we talk about integration," said Wise, who is also the medical director of behavioral health for Inova Health Systems based in Fairfax, Va. "Until we have global budgeting of the total health care dollars, and mental health is not carved out financially or organizationally, integration is an illusion and a fiction."

While capitated systems of care are often vilified for providing incentives to limit or deny care, their growing acceptance and popularity has created a unique environment for promoting the types of economic and structural reforms promoted by both Kathol and Wise. In a truly integrated system, the ability of C-L psychiatrists to reduce the costs of caring for what are viewed as only physically ill patients could produce financial gains for both primary care physicians and other specialists.

For instance, data show that treating patients with irritable bowel syndrome for both the mental and physical components of the illness ultimately reduces costs and improves outcomes. "As gastroenterologists become more familiar with the psychiatric implications and the costs to their practices, they will be looking to psychiatrists who can reverse not just the symptoms but the economic outcome the patients are representing to them," Kathol said. "If you do not identify the patient who needs a mental health intervention, all you have is usual care, and that is more expensive for these patients."

For an "informal" subspecialty that has yet to achieve certification by the American Board of Psychiatry and Neurology, acceptance by health care systems and medical colleagues is a particularly pressing issue. The APM intends to reinitiate efforts to obtain certification next year. Nevertheless, the lack of official recognition has not made much difference, according to Kathol. Rather, implementing the changes that the field now recognizes as appropriate is of more concern.

"We now have sufficient data to show that psychiatry should be involved in primary care patients, but the jump between knowing it and doing it is usually a 15- to 20-year process," Kathol said. During the transition, he added, the risk is that without enough C-L psychiatrists to handle the load, patients may initially receive poor care. This could cause referring physicians to "throw up their hands and say it is not worth it."

Despite the potential pitfalls, however, the future has already arrived. The North Shore Long Island Jewish Health Systems (NSLIJHS) in New York, for instance, embarked on a cutting-edge venture last month to provide health care to 40,000 Medicare recipients. According to Steven Cole, M.D., vice president and medical director of Care Management Group of Greater New York Inc., NSLIJHS' wholly owned management service organization, the fully capitated contract will integrate mental health care with all other specialties.

In accepting all of the financial risk for providing care to patients, Cole said, NSLIJHS has control over all the dollars that are spent. Under previous administration, this population had a medical loss ratio of 120%-an economic hemorrhage that cost $5 million a month. But by betting on data showing that a fully integrated system will improve patient outcomes while reducing costs, Cole said, they hope to reach the break-even point within three years.

Under the program, all high-risk patients will be given mental health screenings and, for those who need it, early interventions that treat comorbid mental illnesses. Meanwhile, psychiatrists providing services will be given the same share of the Medicare reimbursement received by other specialists.

Although Cole said that it is too early to discuss a study design to measure the outcomes for this cohort, at some point they will be looking to quantify and document the results. But this venture is more about providing "fully integrated quality care to patients," Cole added, with the resulting financial benefits a natural consequence.For Elisabeth Kunkel, M.D., an associate professor of psychiatry and human behavior and the director of C-L psychiatry at Jefferson Medical College in Philadelphia, "It is like we are second-class citizens in the world of specialists who do consultations in the general inpatient medical/surgical hospital." While other specialists are able to freely provide services, psychiatric consults always require preautho-rization. In some cases, she said, obtaining preauthorization was such a chore for attending physicians, that they canceled the referral rather than cope with the bureaucracy.

But in one case, when the city of Philadelphia successfully negotiated a contract to provide mental health services to its Medicaid population, an effort to create a more integrated system paid off. Now, an initial mental health consultation and one follow-up visit are permitted without preauthorization.

Similar efforts nationwide will have to occur, however, if integration of C-L psychiatric services is to proliferate. "Most of us are trained to take care of patients, write articles, teach and do research," Kunkel said. "Almost none of us have really been educated in finance and approaching payers. What we are trying to do is teach people in consultation-liaison centers across the country how to take their own regional issues and go to an insurance company."

Miriam Rosenthal, M.D., the director of the division of behavioral medicine and obstetrics and gynecology at University MacDonald Women's Hospital and an associate professor of psychiatry and reproductive biology at Case Western Reserve School of Medicine in Cleveland, feels lucky that she has been able to operate in a fully integrated obstetrics and gynecology service for more than two decades. As a result, she has developed model collaborative relationships with attending physicians who quickly refer patients needing mental health care. Women undergoing treatment for a variety of reproductive and other obstetric and gynecological conditions receive a full range of psychiatric and psychological services when necessary.

What mitigates against more programs like hers, Rosenthal said, "is the stigma of psychiatry and a basic prejudice." But the fault doesn't just lie with popular opinion or with professional turf issues.

"I am not sure that psychiatrists are waiting in line for programs like this," Rosenthal said. "I am not in my own primary department. I am working amidst a group of other physicians." It is this close relationship, however, that has fostered her effectiveness as a C-L psychiatrist, and she urges other psychiatrists to rethink the manner in which they integrate themselves into the health care environment. On the other hand, she also conceded that "medicine seems to reject having psychiatrists in their midst, even in our institution."

Despite growing acceptance of C-L psychiatry, and the cost and outcomes benefits it can provide, it will still need to struggle for its position in the hierarchy of health care delivery. How well it accomplishes that task will not only be a function of evolving reforms in the marketplace, but also of psychiatry's willingness to motivate change.

In a message to its members, APM president Kathol put the challenge to C-L psychiatrists this way:
"The question is, are consultation psychiatrists going to position themselves to take an active and leadership role as service models evolve? Or are they going to let others, less knowledgeable about mental illness in medical patients, dictate their involvement because they fail to recognize the importance of defining the contribution that their psychiatric subspecialty will make in the 21st century?"