Today’s post looking at financial practices influencing children’s mental health care is the second in a series on Hot Topics in Children’s Mental Health we’re offering in recognition of Mental Health Month, National Children’s Mental Health Awareness Week (May 6-12), and National Children’s Mental Health Awareness Day.
Parents and families are appropriately concerned when they have reason to believe that treatment recommendations they receive from mental health professionals are influenced by anything other than the best interests of their child. An important component of the professionalism we’re expected to demonstrate as physicians is “a responsiveness to the needs of patients and society that supersedes self-interest.” Increasingly, professionals are being placed smack in the middle of a variety of competing interests in our role as advocates for kids and families…our personal economic interests, the interests of the practices, agencies or healthcare systems where the professional is employed, the insurance company providing benefits to the family, the pharmacy benefit manager contracted by the family’s insurance company, the government and the school the child attends.
Lots of attention has been paid to reports of drug companies lavishing gifts, trips, dinners and speaking engagements to physicians in attempts to influence prescribing habits. It’s absolutely true that abuses occurred, especially prior to 2008, but the combination of very costly legal settlements exacted from pharmaceutical companies for “off-label” promotion of medication prescribed for patients on Medicare and Medicaid, self-serving regulatory guidelines propagated by the large pharmaceutical companies, requirements for public disclosure of payments made to physicians by industry and a serious crackdown on ethics and conflict of interest policies by professional societies and medical schools, perceived or real conflicts of interest from payments or gifts provided clinicians by pharmaceutical companies are, in my opinion, of minimal impact on the care provided to kids today. I suspect that the extensive media coverage may be distracting attention from far more serious practices that greatly impact the quality of, and manner in which most U.S. families access mental health care. We’ll look at some of these practices in what is rapidly expanding into a multi-segment post, spotlighting their immediate impact on access to care and the quality of care received:
The design of fee schedules used by insurance companies to reimburse hospitals, clinics, physicians and other mental health professionals for care
The networks of hospitals, clinics, physicians and mental health services available to families seeking care and the timeliness with which care can be accessed.
The process through which families are able to access prescription medication
The impact of direct-to-consumer advertising of pharmaceuticals
We’ll start today by looking at the impact of insurance company fee schedules on the care kids receive and tackle the other topics in a future post(s).
Most physicians are paid on the basis of how many procedures they complete (surgeons, anesthesiologists, gastroenterologists, obstetricians) or on the basis of the clinical complexity of their office visits (primary care physicians…internists, pediatricians, family physicians). Unlike our other physician colleagues, psychiatrists are (with a notable exception) paid on the basis of how much time they spend with patients. They can’t make more money by working faster…as a surgeon or another physician can do who performs procedures.
A financial disincentive exists for the busy psychiatrist (or psychologist/counselor) able to fill all of their scheduled time. Any time you spend delivering a service that you’re not compensated for constitutes a loss in personal income. Remember…they can’t work faster to make up for the lost time. We’ll come back to this later.
Commercial insurance companies typically develop fee schedules based upon CPT (Current Procedure Terminology) codes, originally developed for the Medicare program.
The most commonly used billing codes reimbursed through private insurance are:
Psychiatric diagnostic interview/evaluation (generally assumed to be 60 minutes by most insurance companies). In our area, insurance would typically pay $140-$175 for this service, including the family’s co-payments.
45-50 minutes of psychotherapy by a physician with medication management (insurance plus copay $75-$100)
45-50 minutes of psychotherapy by a psychologist or independently licensed counselor, social worker, marriage and family therapist (insurance plus copay $50-$80)
20-30 minutes of psychotherapy by a physician for medication management (insurance plus copay $50-$75)
Pharmacologic management, including prescription, use and review of medication with no more than minimal medical psychotherapy (insurance plus copay $50-60)
The medication management code is an untimed code. The physician can generally bill as many of these as they want without triggering allegations of billing fraud. Four 10-15 minute medication visits can easily produce twice the income or more seen from longer appointments!
Talk doesn’t pay. Physicians, hospitals and clinics have a tremendous financial incentive to see lots of kids for relatively brief appointments. Here’s the problem…are the appointments sufficient for the physician to ascertain all of the information they need…interview the child, question the parent, inquire about the child’s functioning at school, with friends and in extracurricular activities, ask appropriate questions about medication side effects, discuss the course of treatment and available treatment options and answer questions from the parent and the child, and write/update any necessary prescriptions? Does the quality of care suffer when all of these tasks need to be accomplished in a 15 or 20 minute appointment? Does agreeing to practice this way with kids constitute a potential conflict of interest?
Let’s look at initial evaluations. Most general psychiatrists can do a pretty thorough assessment of an adult patient in 60 minutes. But what about a child or teen?
Here’s a link to the American Academy of Child and Adolescent Psychiatry’s practice parameters on the psychiatric evaluation of a child or teen. For me to interview a child at length without the parent(s) in the room, take a complete history from the parent(s) without the child in the room, review records from other treating professionals, review the child’s school records, obtain and review rating scales from the child’s parents and teachers (when applicable), discuss my clinical impressions and treatment options with the parents, review my recommendations in a developmentally-appropriate manner with the child/teen and answer questions, I usually spend a minimum of three hours, often broken up into two office visits, taking more time when I need to.
So…what happens when a clinician or a hospital agrees to a contract that pays them for evaluations under the assumption (as with adults) a complete evaluation can be conducted in an hour? Some insurance companies will pay for a second evaluation hour for a child or teen if the doctor or a staff member obtains a prior authorization…resulting in an expenditure of time. Does scheduling longer evaluations reduce the number of appointment slots available for more lucrative medication management visits and create a potential financial conflict? Does agreeing to complete evaluations within the time allocated by the insurance company increase the potential for an assessment less thorough than what the child or family really need?
Insurance companies typically don’t pay for time spent on tasks essential for clinical care that occur outside of office-based appointments…returning phone calls and e-mails, coordinating care with other clinicians, writing and phoning in prescriptions, attending team meetings at school, writing reports and letters, completing forms from schools, completing paperwork required by the insurance company. These tasks consume an increasing percentage of the clinician’s time. Huge financial disincentives exist for clinicians to do more than the minimum required from a medical-legal standpoint.
I’d like to make absolutely clear that by raising these issues, I don’t mean in any way to impugn the integrity or professionalism of the clinicians who participate in insurance networks (Our practice does not). In my experience, most of them either work for hospital systems or clinics that require them to see a specific number of patients per hour or day with administrators who determine the length of scheduled appointments, or feel they have no choice because the families they serve would have no other means to pay for services.
I do think that conflict of interest guidelines developed by professional societies need to consider all manner of clinician compensation with the potential to compromise care. Insurance contracts that provide huge financial incentives for very brief appointments and employment relationships that impact the autonomy of mental health professionals to spend the time they deem necessary with kids and families are at least as large a concern as relationships with drug companies.
Next: Money, Insurance Networks and Access to Care
I haven’t personally received any payment from a pharmaceutical company since 2007. I chose to stop doing promotional lectures for pharmaceutical companies in 2006. Our practice is part of a research network (CAPTN) originally funded by the National Institute of Mental Health (NIMH) and organized through the Duke University Research Institute. All of the research I’ve participated in over the past five years had funding originating from the NIMH…although we plan to participate in a long term medication safety study through the CAPTN network required by governmental authorities in Europe. Funding for that study will originate from Pfizer…We will begin recruiting in the next few months. Our practice will be paid through Duke University, but their funding will have originated from Pfizer.
Key Ministry received donations in 2008 and 2009 from Shire U.S. The ministry hasn’t received any corporate grants from a pharmaceutical company since 2009.
Our practice adheres to the guidelines on conflict of interest for child and adolescent psychiatrists of the American Academy of Child and Adolescent Psychiatry. I served as a member of AACAP’s Consensus Building Panel on Conflict of Interest that developed the guidelines in February, 2008.