Mental Health Consult

Clinical Segment 3: Should you add a psychiatrist to your practice?


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People in this video: Whitney McKnight, cohost and producer of Mental Health Consult; Dr. Lorenzo Norris, editorial board member of Clinical Psychiatry News and cohost of Mental Health Consult, and assistant professor of psychiatry and behavioral sciences, assistant dean of student affairs at G.W. University School of Medicine & Health Sciences, and the medical director of psychiatric and behavioral services at G.W.U. Hospital, Washington; Dr. Lillian Beard, pediatrician with Children’s National Hospital Network, Washington, and a Pediatric News editorial board member; Dr. David Pickar, adjunct professor of psychiatry at Johns Hopkins University School of Medicine, Baltimore, and at the Uniformed Services University of the Health Sciences in Bethesda, Md.; Dr. April Barbour, an associate professor of medicine and the director of general internal medicine and of the primary care residency program at G.W.U. School of Medicine, Washington.

Dr. Beard: This is one of the major frustrations. You've hit it right on the head. I will take anywhere from 45-50 minutes to do this, and I will have others who are waiting in my reception area or I will have a tap on the door. It takes that kind of time and the unfortunate thing is, I am never adequately reimbursed for the time that it really takes. Often, what I do is ask my front desk to screen patients when they call. If they say it is a routine check-up, the front desk knows to ask, "Are there any particular concerns that you have this year. Anything you would like the doctor to focus on?" If they do, then what I have to do is block out three of my regular times and that is very costly.

Whitney: As we move into a world in which it is not fee-for-service—based and “I think if it’s possible to have a mental health professional on site [in your practice], it is a win-win situation.” – Dr. Lillian Beardwe have to create these new metrics, I say “we,” but the health care system is moving toward setting up new accountable care organizations or other sorts of bundle payments. When we have the new legislation take effect, the MACRA (Medicaid Access and CHIP Reauthorization Act) legislation, are you building into the metrics that you are going to be reimbursed through your third-party payers to include these 50-minute sessions or is there no way to do that?

Dr. Beard: I do not know of a way to do it. I really do not.

Whitney: How is that going to impact outcomes and reimbursement?

Dr. Beard: Well, it is definitely going to impact outcomes. One of the areas of interest that I have is the feasibility of having a mental health specialist in my actual primary care site. Even if it is for a few segments a week, it would be a tremendous help. Just having that individual present removes certain barriers. For example, there are times that, even during the primary care encounter, the mental health specialist is able to say to the patient’s parents, “We’ll be glad to make an appointment and discuss that with you at a future time, so we can go more in depth.” Just that introduction lowers the barrier. Otherwise, there is more resistance if I say, “I am going to refer you to Dr. Pickar he is an associate who…” They object, and want to know, “Well, what kind of doctor is Dr. Pickar? He is a psychiatrist?” It depends on what association they have with the word “psychiatrist.” The parents might object, “My kid’s not crazy.” I have to explain that this is a mental health disorder that we can do something about, and the psychiatrist is going to assist us with that.

Dr. Pickar: That is a great model.

Whitney: Yes but is it feasible with all the new legislation that is coming down the line?

Dr. Barbour: I think there are very dramatic differences between the pediatric model of care, which tends to be more wraparound care that you are describing; (should this be “that” or “than”?) and the adult model of care, which is more consumer driven and in which we expect a lot of our patients. We find particularly that young people transitioning to their early 20s often have a hard time understanding how to interact in the adult model of care. Particularly the patients that we have worked on have had significant health problems, many of which include mental health disorders. The program that we put in place has some psychiatric services available in the clinic. That is not feasible – I think – in our current payment structure to do that everywhere, in all adult medicine clinics.

I think these patients are particularly vulnerable. They do not understand the health care systems. They come in with these diagnoses. You bring up ADHD and that is something an internist is not as comfortable in providing care for as you are, and that I think causes a lot of roadblocks for patients to get the medicines they need. It has worked well for them, but the new doctor is not as comfortable prescribing the medicine or making the diagnosis. There are issues around that.

Dr. Norris: This is one of points of the roundtable. Who should be delivering this treatment? If you can create a team based atmosphere where what Dr. Beard illustrated, just the introduction. "I want to introduce you to my colleague so that we can start treatment." That one element, just starting that can make a huge difference, but how do you make that fiscally viable? In the George Washington University Hospital Thriving After Cancer clinic, we used resident psychiatrist in training. These are senior-level residents who are very good at that or are supervised by a psychiatrist. If you were to put a psychiatrist in the TAC clinic and bill for their hours, it just would not work, Dr. Barbour is shaking her head like no way.

Dr. Barbour: I could not afford it.

Dr. Beard: What I am thinking is that this other professional, be it a psychiatrist or psychologist, a licensed clinical social worker, whatever, will have the capability of billing for his or her services. I think if it is possible to have that professional in your site it is a win/win situation.

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