Funding consultation-liaison psychiatry via Medicare screening

Activity-based funding: implications for mental health services and consultation-liaison psychiatry

OBJECTIVE

The aim of this paper is to inform mental health professionals about Activity-based funding (ABF) and the implications for data collection and clinical practice, in particular for consultation-liaison (CL) psychiatry.

CONCLUSIONS

Activity-based funding may provide an opportunity for mental health services to be more equitably resourced, but much needs to be done to demonstrate that the funding model works in mental health. It is important to ensure that data collected is meaningful and accurate and reflects the diverse roles of mental health clinicians, including in CL. Inpatient and community services should be integrated in the model, as well as safeguards against potential abuse. Clinicians, in partnership with initiatives such as the Australian Mental Health Outcomes and Classification Network, are best placed to guide the development of an ABF system for mental health which appropriately recognises the complexity and variability between patients in different settings.

Financial impact of accurate discharge coding in a liaison psychiatry service

OBJECTIVE

Previous research has shown that patients seen by liaison psychiatry services are a complex and expensive patient group and that the psychiatric co-morbidities of hospital inpatients are poorly attested at discharge for assignment to diagnosis-related groups (DRGs). The aim of this study was to investigate the accuracy of discharge coding in a neuropsychiatry liaison population. We also aimed to establish whether or not, had the correct diagnosis been assigned, additional funding would have been allocated to the hospital.

METHODS

Diagnostic codes were retrospectively collected from the discharge diagnoses for all inpatients (n=276) referred to the neuropsychiatry liaison service in a university hospital over a 12 month period and these were compared to a consensus diagnosis. Using grouper software, codes were then changed to reflect the consensus diagnoses and DRGs were recalculated to see if the change in diagnosis led to a change in reimbursement for those patients.

RESULTS

Discharge diagnosis and consensus diagnosis were in agreement in 30% of cases. When discharge codes were corrected, patients changed to a higher paying DRG in 28/220 (12.7%) of patients. The increase in costing associated with this change in DRG was €305,349.

CONCLUSIONS

According to these results, not only is the complexity of patients seen by psychiatry consult services in general hospitals not reflected in the discharge diagnosis, but, in this sample of patients, the additional complexity would have led to a significant increase in reimbursement to the hospital. Further training of doctors should increase awareness of this important issue.

Consultation-liaison psychiatry in an Australian oncology unit

OBJECTIVE

To provide an overview of the work of a consultation-liaison (C-L) psychiatry service to an oncology unit in a university affiliated teaching hospital, with the aid of a comprehensive clinical database.

METHOD

The MICROCARES prospective clinical database system was used to record data on all oncology inpatients referred to C-L psychiatry, and the hospital clinical database was used to compare referred inpatients with all oncology inpatients.

RESULTS

Two hundred and seventy-one referrals were made in the 3 years from 1991 to 1993, a referral rate of 10.4%. The referred patients were younger but there was no bias in sex and marital status. The mean length of stay was twice that for all other oncology admissions, day cases excluded. The most frequent reasons for referral were coping problems, depression, terminal illness issues and anxiety. The most common psychiatric diagnoses were Systemic Family Problems (V codes, 24%), Mood Disorders (23%), Adjustment Disorders (16%) and Organic Mental Disorders (10%). Management involved family conferences in half of the patients and antidepressant medication in one-quarter. Concordance with pharmacological recommendations was 98%. Existential issues and family-centred care are discussed.

CONCLUSIONS

Both individual and family-centred care is required in an oncology service; a dedicated liaison attachment offers considerable staff support. Psycho-oncology is underdeveloped in Australia compared to many overseas services; there is scope for substantial growth in preventive and supportive work.

Psychiatric complications and comorbidities in medical inpatients: the inadequacy of attestation at discharge

The determination of an appropriate level of prospective payment for inpatient medical services requires consideration and documentation of psychiatric problems which impact on resource utilization. A major source of information for reimbursement planning is the list of secondary diagnoses referred to as "complications and comorbidities" (CCs) taken from the medical record. If psychiatry problems are omitted on the attestation sheet, they are unlikely to be included in any reimbursement formulae. This study was designed to look at actual hospital experience in terms of how often psychiatric diagnoses were attested to on the medical record. Of the 100 patients evaluated, 25 were found to have 33 psychiatric complications and CCs. Of the 33 psychiatric CCs, only 9 (24%) were recorded on the attestation sheet. Reasons for and implications of this low rate of attestation are discussed. The complete and accurate attestation of psychiatric problems may be the single most important priority for psychiatrists in general hospitals. Even when the DRG system is replaced by capitation payment, the importance of accurate diagnostic recording and recognition will remain paramount to making rate analyses and adjustments.

The future of consultation-liaison psychiatry and medical-psychiatric units in the era of managed care

There has been increasing recognition and documentation of the impact of psychiatric problems on the outcome and cost of medical care. Because consultation-liaison psychiatrists have the expertise to address the psychiatric aspects of medical illness, this group should be in a strong position to facilitate integration of medical and psychiatric services in managed care delivery systems. Although consultation-liaison psychiatry (CLP) has documented its ability to shorten inpatient medical lengths of stay for some disorders, a greater challenge exists in developing comprehensive systems to identify and care for patients with mental health problems in primary care settings. This paper reviews the fiscal and programmatic implications for managed medical care systems of findings from outcome-based C-L research. The future role of CLP and combined medical-psychiatric units in an era of managed care is also discussed.

Composition and funding. Consultation-liaison psychiatry services

All of the programs in the Academy of Psychosomatic Medicine directory of U.S. consultation-liaison (C-L) fellowship training (N = 49) responded to a questionnaire to document composition and funding of their staff. The mean annual budget was $324,664 (range $40,000-$550,000), with a mean of 2.4 full-time equivalents and 1.6 fellowship training positions. A significant patient cohort and C-L staff and fellows exist in these programs to launch important hypothesis-generation studies.

Maximizing clinical revenues of psychiatric consultation-liaison services. An economic commentary

Clinical revenues rarely suffice to support an academic psychiatric consultation-liaison (C-L) service. Nonetheless, the revenue provides a major source of financial support. The authors describe ten steps that can help maximize the financial return from the C-L service's clinical efforts. The steps range from establishing a reasonable fee schedule and creating an efficient charge document, through educating residents and faculty physicians about documentation requirements, to billing quickly and insisting on meaningful monthly reports from the faculty practice plan. A number of "magic phrases" (proper and key wording for reimbursement) are described in detail that can markedly reduce documentation requirements.

The impact of psychiatric comorbidity on Medicare reimbursement for inpatient medical care

Funding for psychiatric consultation-liaison (C-L) services has been a difficult problem. It has been suggested that the identification of psychiatric co-morbidities in Medicare patients on medical services could generate incremental hospital revenue by moving patients from a lower to a higher paying Diagnostic Related Group (DRG). This increased revenue could be used as a means of supporting the psychiatric C-L service. This study documents the financial impact of screening for and documenting psychiatric co-morbidities on a general acute medical service. We clinically assessed 100 consecutive Medicare admissions and found 25 psychiatric co-morbidities in 20 patients. In only one case did the psychiatric diagnosis result in moving the case to a higher DRG. However, the need for psychiatric consultation remains evident as there was significant lack of recognition and documentation of the psychiatric diagnoses by the medical team. The authors discuss both the financial and clinical implications of screening medical inpatients for psychiatric co-morbidities and propose directions for further studies in this area.

Consultation-liaison psychiatry as a subspecialty. A Canadian survey

In Canada, in recent years, there has been increased interest in the issue of subspecialization in psychiatry. One hundred and forty-four members of the Section on Psychosomatic Medicine of the Canadian Psychiatric Association responded to a survey about their opinions on teaching, training, continuing education, and designation of consultation-liaison (C-L) psychiatry as a subspecialty. Fifty-five percent of respondents agreed that C-L psychiatry should receive designation as a psychiatric subspecialty, 35% were opposed, and 10% did not give an opinion. The results also indicated that formal teaching in C-L psychiatry has increased, particularly over the past 20 years; that training in C-L psychiatry is believed by many to have been inadequate, regardless of when the training took place; and recent graduates were more likely than psychiatrists graduating more than 10 years ago to agree that C-L psychiatry should be designated as a subspecialty. Psychiatrists who devote more of their time to the care of patients with combined medical and psychiatric illness were also more likely to favor subspecialty designation. Factors unique to Canada that may influence attitudes toward psychiatric subspecialization include the number and geographic distribution of psychiatrists, their educational background, and governmental funding priorities.

The practice of consultation-liaison psychiatry in Japan

Consultation-liaison (C-L) psychiatry has been developing for the past 10 years as a new clinical service field in Japan. Although this kind of service had been practiced previously, it was not recognized as an independent clinical field. Still in the developing phase, clinical research in C-L psychiatry has been reported, although its quality has been variable. The authors describe the development and a typology of C-L psychiatry (seven types) in Japan. This article reports time spent on C-L psychiatry activity in a general hospital. Although C-L psychiatry requires much time and labor, hardly any of the C-L psychiatry services are reimbursed in the Japanese insurance system. The authors propose a "new department" as one option to continue providing C-L psychiatry service to general hospital patients and for further development of C-L psychiatry in Japan.

A new tool for consultation-liaison funding: modified DRGs to reflect psychiatric comorbidity

Funding for consultation-liaison (C-L) psychiatry remains an overriding obstacle to its implementation and practice. Several methods have been described to access funds for this subspecialty of psychiatry, but none has been enacted as a policy by third party payers to reimburse adequately for the service. In addition, although the consultation portion of the effort can be reimbursed in part in some cases through fee for services, the liaison portion is dependent on the donation of psychiatry time or the largesse of the host department. The efforts at Stanford to capitalize on the findings that psychiatric and medical comorbidity results in prolonged length of hospital stay and increased health resource utilization suggest that specific DRGs would be important patient groups to screen and charge for psychiatric services. Furthermore, DRGs that are accompanied by a high frequency of psychiatric comorbidity are a "target" for an additional funding aliquot to assess and manage the patient's psychiatric status.