EXPERT ANALYSIS FROM AAP 16
SAN FRANCISCO (FRONTLINE MEDICAL NEWS) – Integrating pediatric mental health care into your primary care office can be an effective way to ensure your patients get the care they really need – and it’s easier than you think.
That’s the message Jay Rabinowitz, MD, MPH, a clinical professor of pediatrics at the University of Colorado at Denver, Aurora, delivered to a packed room at the annual meeting of the American Academy of Pediatrics.
“There’s more and more behavioral and mental health issues these days, and there’s not enough psychiatrists to see the children,” Dr. Rabinowitz said before rattling off the benefits of integration. “It’s quicker to get an appointment, and it’s more convenient. It reduces the stigma. It has better adherence. Our patients stick with the program almost all the time,” he said, adding that studies have shown poorer adherence and follow-through on appointments when referred out of office.
He noted that depression and anxiety are among the top five conditions driving overall health costs in the United States, and a 1999 Surgeon General’s Report found that one in five children have a diagnosable mental disorder – but only a fifth to a quarter of these children receive treatment. The rub is that treatment is highly successful; it’s just difficult to access for many families, so making it a part of a child’s medical home just makes sense, Dr. Rabinowitz said.
To drive home his point, he described a case of a depressed adolescent with cutting and suicidal ideation, and the steps he would need to take without integration: find out their insurance, get a list of covered mental health professionals, refer to someone he may or may not heard of, and then rarely receive follow-up reports, much less confirmation the patient had gone to the appointment. With integrated care, parents can make appointments on their way out, he can read the psychologist’s report immediately after the visit, and he can drop in to say hello during the child’s mental health appointment.
“Sometimes there’s a question abut a medication or something, and sometimes it’s an inopportune moment if the child is sad or crying, but generally it seems to be pretty popular,” he said.
Taking steps toward integration
If providers are interesting in exploring the possibility of integration, they need to consider and decide on several issues before taking any concrete steps, Dr. Rabinowitz said. One is the type of arrangement that would work best for your practice: hiring on mental health professionals as employees of the practice, hiring independent contractors, coordinating a space share agreement or creating an out-of-office agreement.
“In our practice, psychologists are employees of the practice, but there are other arrangements,” he said, and some may depend on what is easiest based on state law or billing procedures.
The next question is what kind of provider(s) you would hire. His office has child psychologists with a PhD and postdoctorate fellowships working with children, but other possibilities include social workers, licensed counselors, psychiatric nurse practitioners, or psychiatrists.
Another consideration is what diagnoses your office will handle because it’s not possible to see everything. His practice sees patients in-house for attention deficit/hyperactivity disorder (ADHD), depression, anxiety, drug counseling, and behavioral and adjustment disorders. They choose to refer out educational testing, autism, difficult divorce cases, and complex cases that require more than 20 sessions. They refer out divorce cases because they frequently require specialized knowledge and a lot of court time and phone calls. Aside from ADHD evaluations, his office does not see the staff’s children.
Providers also should consider options for adapting their physical space to accommodate integration. His practice converted an exam room into a consultation room, making it homier with a throw rug, soft chairs, a painted wall, and office decor.
Establishing effective protocols with integration
The next step after providers decide to integrate is to determine the office protocols that govern what forms get used, who can schedule appointments and how long they last, billing, and similar procedures.
“You need to have certain protocols, and some of these things you don’t think about it until you start doing it,” Dr. Rabinowitz said. Should mental health appointments be 50 minutes, for example, or 20 to 25 minutes? His office has gradually shrunk these appointments from 50 to 30 minutes, but they give psychologists an hour of time each day for follow-up phone calls.
Forms to consider developing include a disclosure form, notice of privacy practices, late cancel/no show policy, financial policy, and a summary of parent concerns. His office’s charting includes an extensive intake form with medical, treatment, family, and social history, an intake summary, and a progress note.
It’s with reimbursement, of course, that providers will need to do the most research, particularly with regard to their state’s laws and in looking for grants to provide funding – which is more available than many realize.
“Money is often out there if you look for it,” Dr. Rabinowitz said.” Mental health is an area where no one is really against it: You get together the NRA (National Rifle Association) and the anti-gun movement, and they are both for it.”
Planning for reimbursement challenges
Reimbursement barriers can include lack of payment if mental health codes are used instead of pediatrics ones (depending on the practice arrangement), lack of “incident to” payments, same day billing of physical and mental health appointments, reimbursement for screening, and lack of payment for non–face-to-face services. Although a concierge or fee-for-service option solves many of these, it excludes Medicaid patients and is an economic barrier for many families.
Mental health networks offer a different route, but they can involve poor reimbursement and an additional layer of administration, which makes financial integration more viable as long as providers investigate their options.
“It’s going to be a regional variation, and you need to look at state rules and regulations,” Dr. Rabinowitz said, explaining that his office then sought insurance contracts to include mental health care reimbursement through their office and then sought the same from Medicaid.
“We weren’t about to see Medicaid patients for fear of an audit unless we got written permission, but we got that,” he said. His office simply asked for it and received in writing a letter starting as follows: “Under Department policy, they (our psychologists) may submit E&M claims to Medicaid under a supervising physician’s billing ID. It is not mandatory they be credentialed into a BHO (Behavioral Healthcare Options) network…”
He also noted that his state allows inclusion of psychologists on medical malpractice insurance policies, which is far less expensive for mental health professionals, compared with medical doctors.
Ultimately, the result of mental health integration into primary care practices is greater satisfaction among patients and pediatricians as well as potentially better health outcomes, Dr. Rabinowitz said. An in-house patient satisfaction survey his office conducted found that 91% of parents felt it was convenient for their child to receive mental health services at the same location as medical care, and 90% were satisfied with their care. Only 9% cited barriers to their child seeing a psychologist at their office, and 89% found the services beneficial for their child. Similarly, providers find integration more convenient, easier for follow-up, less stressful, and more efficient while improving communication, confidence, and follow-up.
Dr. Rabinowitz reported no disclosures. No external funding was used for the presentation.