Child Psychiatry Consult

Pediatric Psychiatry Services Infiltrate Primary Care



Mean total scores on the CBCL, for example, decreased from approximately 63 to about 53 at 6 months. Mean PedsQL scores at baseline ranged approximately from 68 to 71 at baseline (depending on the age group) and increased to a range of about 77-81.

Data on diagnoses and prescriptions tracked by the program suggest that the pediatricians prescribed appropriate medications to the 2,207 patients who received at least one psychotropic medication (15% of all patients), Dr. Pliszka said.

"So, kids with ADHD got treated with a stimulant, kids with depression got an antidepressant, [and] kids with bipolar disorder got combinations of different medications. We also did not have any really bad outcomes. There were no suicides, no serious adverse drug effects. It shows that the model is a way to treat even fairly serious mental illnesses in the primary care setting," he said.

Dr. Pliszka and his associates next plan to compare outcomes for patients managed through SUPPORT and usual care (referral by primary care physicians to mental health clinics in the community).

Reimbursement Issues

Government and academic funds support these programs for now, but better funding mechanisms for collaborative care are needed for long-term sustainability, each of the physicians interviewed said.

New York’s CAP PC is a collaboration among five academic centers that is funded by a grant from the State Office of Mental Health. The SUPPORT program received Medicaid support in Texas.

While there probably are enough master’s level therapists to expand SUPPORT beyond the Medicaid population, "what’s lacking is that it’s difficult for both the pediatrician and the master’s level person to get reimbursed for that type of activity because they use completely different codes," Dr. Pliszka said. "Projects of this type would make the argument for modifying the reimbursement system to allow more integrated care."

Dr. Teresa M. Hargrave

Part of CAP PC’s education program helps New York primary care physicians get comfortable with coding for their mental health work, but there are gaps in that approach, Dr. Kaye said. "In some of our regions, docs can be paid reasonably for what they’re doing, but in lots of places, they can’t put in a code for ADHD or depression and get reimbursed" because insurers say they’re not credentialed mental health providers.

"There’s got to be a way on the payment side that Medicaid and/or the insurers figure out how to pay primary care docs to do this work, and to pay them fairly," he said. "I think this is going to be a huge part of the future of primary care. The numbers are that mental health problems are the most common chronic condition that kids get."

Even for the psychiatrists involved, the current model is not sustainable, he added. The New York grant pays each of the five academic centers for a 10-hour day of consultation each week, which is far less than the actual hours contributed.

"We’re all university based. We believe in the project, so we’ve been able to sustain that. Can we do that for 20 years? I don’t know," Dr. Kaye said.

"The major drawback is that it takes time, and insurance does not reimburse for that time. To really get such a system as this off the ground or well integrated" will require reimbursement for the time spent by all the health care providers involved, Dr. Hargrave said.

She said she hopes that in the future, all children and primary care clinicians will have access to mental health care, advice and support, "and that the clinicians – whether primary care or psychiatric – could be paid adequately for the work that we do."

Dr. Pliszka reported financial associations with Shire Pharmaceuticals and Ortho-McNeil-Janssen Pharmaceuticals. Dr. Kaye and Dr. Hargrave received research support from the New York State Office of Mental Health. Some of their coinvestigators reported financial associations with the Resource for Advancing Children’s Health Institute, American Psychiatric Publishing, Marriott Foundation, Shire Pharmaceuticals, and Ortho-McNeil-Janssen.

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