Could psych services boost your income?
Could psych services boost your income?
Doing mental calculations
More practices are adding mental health services and are benefiting from cross-referrals and the ability to integrate treatment. And staff at the Institute of Behavioral Health in Tiburon, CA, say that trend will continue.
Marcia Byrnes, RN, MPA, director of primary care initiatives at the institute, says while there is limited data on just how many practices are doing this, she knows of several that are taking the first step by hiring consultants to help create mental health programs. Others are making more concrete strides by co-locating with behavioral specialists or by having them work part time in a practice.
But while offering your patients all the care they need may seem like a good idea, there are few managed care organizations that provide adequate mental health coverage. "The payer community has to catch up to the notion of not dividing patient care into psychiatric care and medical surgical care," says Doug Rammel, MHA, chief executive officer and administrator of Associated University Neurosurgeons in Peoria, IL, and president of the Assembly of Behavioral Health Care of the Medical Group Management Association (MGMA).
Even part-time services could help
Despite the lag in reimbursement, your practice may still benefit from including psychological and psychiatric services to your patients even if it is only part-time. "It’s been a great business move for us," says Bruce Hagadorn, MD, medical director of the Lewis-Gale Clinic in Salem, VA. Lewis-Gale, a 130-physician practice, brought its first behavioral health professional on board in 1985.
That counselor has since been joined by 14 other psychologists and four psychiatrists. "In the last year, they have done 80 seminars in the community," says Hagadorn. "They have a performance institute and deal with mental wellness issues. They do pre-employment evaluations; they have a contract with police force. They are out there in the community getting our name out; they bring us business."
The ability to cross-sell services for your physicians to refer to mental health professionals and receive referrals from them is one of the best reasons to consider adding behavioral health care to your practice. "Most of our people have their own patient bases in the community that they bring with them when they join," Hagadorn says. "They are known in the community, and once they are here, you do what you can to keep all the business in-house."
Hagadorn says costs of bringing the counselors and psychiatrists on staff has been minimized by using existing space. "We didn’t have to create a new office for them," he says. And although salaries for the new staff members were guaranteed for the first year, after that, they would be tied to the same productivity requirements as other physicians in the practice, Hagadorn adds.
Allen Daniels, EdD, CEO of Alliance Behavioral Care, a Cincinnati-based managed care organization for behavioral health, says a push toward truly integrated health care delivery will make practices that have mental health services look more attractive to payers in the future.
"It happens as a way to meet needs for patients, and also as a way for primary care practices to deal with chronic behavioral conditions," says Daniels, who is also executive director of University Psychiatric Services at the University of Cincinnati and the president of the Council of Behavioral Group Practices, a part of the Institute for Behavioral Health. "You get people coming in repeatedly with a problem that needs more specialized care than a family doctor can provide."
Hagadorn says any practice may benefit from adding psychologists and psychiatrists whether primary care or multispecialty. His practice tried initially to send the psychologists to the primary care practices on a part-time basis. "We thought that patients would feel less of a stigma if they were going to their regular doctor’s office than if they were waiting in the behavioral health department waiting room."
In the end, patients actually preferred the latter method. "But that doesn’t mean it can’t work for a single specialty primary care setting," he says. "It just didn’t work for us."
Making it work
Making such a relationship a success takes work. There are issues of turf, says Daniels. For instance, where a nurse once dealt with behavioral concerns in an office, now that role is being delegated to a counselor. "And there are no treatment protocols around for when a physician can handle this and when a psychologist or psychiatrist is needed. You just have to play it by ear."
There are also payment concerns. Hagadorn says there are often situations when a payer will agree to pay for three visits to a counselor, but what is needed are nine. Often, the providers will continue seeing the patient without payment.
The benefits are clear, however. Daniels recalls one case when a teen-age patient with diabetes was not managing his disease well. "There was family conflict, too. So we had a collaborative visit with the family, the primary care physician, and the counselor to talk about the disease and how it exacerbated family conflict."
Start with referrals
Daniels says the best way to start is to form a collaborative referral relationship. If after a few months, it is working and both your physicians and your patients are happy, then you can explore the idea of having a counselor on site one day per week.
"It can be an opportunity for satellite expansion for the counselor," he says. "If you have a psychiatrist with a downtown practice and a primary physician in the suburbs, then having [the psychiatrist] come to your office one day a week is a way for him or her to expand."
One thing to keep in mind, however, is that the behavioral health provider will be paying two rents for that day. "You might want to have a system that takes that into account," says Daniels. "Don’t view this as just a way to sublet extra office space."
Move a counselor in next door
In most cases, there is not enough work for a counselor or psychiatrist to be a full-time member of a primary care practice, Daniels says. "But you can have side-by-side operations. If you have a common approach to patient care, this can be a great thing for you."
As payers reduce the amount they pay for inpatient psychiatric care, outpatient options look more attractive, says Hagadorn. "We do pretty well from this section in our fee negotiations. We have two or three or four of our practitioners in one plan, and three or four in another. They are carveouts. But we have leverage in our community, and it works for us."
• Doug Rammel, MHA, CEO, Associated University Neurosurgeons, Peoria, IL. Telephone: (309) 676-0766.
• Allen Daniels, EdD, CEO, Alliance Behavioral Care, Cincinnati. Telephone: (513) 475-8710.
• Bruce Hagadorn, MD, Medical Director, Lewis-Gale Clinic, Salem, VA. Telephone: (540) 772-3400.
• Marcia Byrnes, RN, MPA, Director of Primary Care Initiatives, Institute of Behavioral Health, Tiburon, CA. Telephone: (415) 435-9821.
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