APM President James Rundell, MD, FAPM, asked the three candidates for 2018 President-Elect of the American Psychiatric Association to respond to six issues of concern to the Academy of Psychosomatic Medicine. The questions and their responses are below, which are intended to help you be as fully informed as possible about the candidates’ views on these matters as you make your choices in the election.
The six issues of concern to the Academy involve:
The three candidates are:
APA members are reminded that voting closes at 11:59pm ET Wednesday, January 31, 2018. For more information about the election and the candidates, see 2018 APA Election on the American Psychiatric Association’s website.
Maintaining the Gains with Collaborative Care: The past year has seen significant progress in terms of defining and supporting the roles of psychiatrists in integrated care settings, especially collaborative care (e.g., the new collaborative care payment codes). Our members are uniquely trained to be successful in practicing in primary care settings, but are also active in integration of behavioral health services into specialty medical settings (e.g., transplant, oncology, rehabilitation settings). What are your thoughts on how APA can maintain and extend the gains made in supporting the roles of psychiatrists in integrated care settings?
MARTIN: I would like to see a day where the term “integrated care settings” disappears because almost all settings, as a matter of course, provide integrated care. The focus to date has been on primary care, and the implemented billing code changes are certainly a crucial step in allowing the growth of integrated care to continue. If the available codes or existing RVU valuations need to be expanded or tweaked to promote integration in specialty settings, the APA should work with the AMA to address that issue. Of course, with the passage of the new tax legislation, the fear is that Medicare and Medicaid will be cut, the numbers of uninsured will rise again, and simply ensuring care, integrated or not, will once again become a major challenge. Clearly the APA has to focus on this larger picture too, and supporting integrated care in all appropriate settings must be a part of this effort.
SCHWARTZ: I have worked at Montefiore Medical Center since 1985 which has a very robust C-L Service under the direction of Mary Alice O’Dowd. Montefiore has additional psychiatrists funded to provide dedicated care in our Transplant Programs (heart, liver, lung, etc.) and Cancer Center. We have one of the largest collaborative care and co-location programs in the U.S. These initiatives are partially funded through a CMMI grant. I recently published a chapter which addresses the history and financing of these programs (Schwartz BJ, Stein G, Wetzler S. Financing Integrated Care Models. In Feinstein R, Connelly J and Feinstein M, eds. Integrating Behavioral Health and Primary Care, New York: Oxford University Press, 2017: 76-89). I believe the new CPT Collaborative Care codes offer inadequate reimbursement to support these initiatives. As you can see from the above, I have been instrumental and supportive of these types of initiative. APA has its own SAMHSA grant to fund training in Integrated/Collaborative care and should continue to do so. APA as well needs to monitor the adequacy of the reimbursement under the CPT Collaborative Care codes.
STRAKOWSKI: As you can see on my website (https://stevestrakowski.com/), continued strong attention to integrating psychiatry into the health care continuum is a high priority of mine. For the first time in a very long time, if ever, payers, health systems and the government are beginning to understand the high costs and poor outcomes associated with failing to attend to mental health across all medical conditions. Here at Dell Medical School (UT-Austin), we are specifically committed to embedding mental health, typically but not exclusively, through collaborative care models. In addition to actively working with our Population Health Department to embed collaborative care into primary care structures, we are working to co-locate our psychiatry ambulatory programs across a variety of primary care and specialists offices. Additionally, we have recently launched two specialty integrated practice units (IPUS; musculoskeletal, women’s health) in which we are testing/modifying a collaborative care model within these subspecialties. By demonstrating better outcomes and reduced cost through these models, we hope to create a platform that can be advanced nationwide. I believe the APA needs to continue to be in the forefront of integrating psychiatry solidly into the healthcare discussion and continuum through these types of projects and negotiations with payers. Working with APM seems like a natural component of this activity.
APM Collaboration with APA. The APA Council on Psychosomatic Medicine (COPM) has been very active in APA affairs and APM/ACLP has recently collaborated with APA on a successful monograph on dissemination of integrated care. There is a strong relationship created when APA’s size and advocacy experience is combined with subspecialty subject matter expertise. What do you see as the future role of APM and C-L psychiatrists in APA’s ongoing initiatives to advance the field of Psychiatry? Are there any specific ideas, positions or projects that you can see as an opportunity for continued collaboration between our organizations?
MARTIN: The relationship of the APA council and the Academy has been a productive one and I am sure that collaboration will continue to generate ideas and work products of benefit to the field. The APM/ACLP is also an allied organization with a representative in the Assembly of the APA, who for the moment is also chair of the Council. This allows for the Assembly to have direct access to the expertise that the APM/ACLP brings to bear on all relevant discussions. It also allows for the issues of the C-L psychiatrists to gather the support of the larger body of psychiatrists that can influence policy and resource allocation at the level of the board of trustees. In sum, I see the current state as quite good and I will work to maintain this forward momentum.
SCHWARTZ: The APA is the leading advocacy organization and needs to continue to work with the APM and Council to push our mutual agenda. It is important that APM members belong to the APA as well and to help direct and participate in those advocacy efforts as well as to actively play a role in ongoing educational efforts at the Annual Meetings and IPS. Publications and columns in Psych News need to be encouraged to further the education of our membership.
STRAKOWSKI: If elected president, I would plan to engage with APM as soon as you would have me! As noted in the answer to question 1, I think that continued integration into healthcare in general is perhaps the greatest opportunity psychiatry has had in a long time. Additionally, we have contact with APM through one of my department leaders, Lowell McRoberts, who also heads up our affiliated physician group (Ascension Texas) and runs our Psychosomatics Fellowship. As we develop our new models, I would very much appreciate ongoing engagement with APM regardless of the results of the election (although still would appreciate your votes).
Psychiatric Fellowship Training. Our organization is deeply committed to psychiatric education, at the medical school, residency, and fellowship level. What is your opinion of the value of fellowship training for psychiatry as a field, and what is your philosophy on the role of subspecialists in Psychiatry?
MARTIN: I think fellowships are valuable, as are sub-specialties. With the continuing expansion of knowledge, and certainly the publications that report it, focused training in subparts of our filed becomes even more important. The risk of course is promoting silos, diminishing the perceived competence of general psychiatrists who are perfectly capable of treating many “specialty” conditions, and ultimately becoming the punchline of the old joke…an expert (or a specialist) is someone who knows more and more about less and less. It would be ironic that as we move to integrate psychiatry and the rest of medicine that we move in the opposite direction within our own field.
SCHWARTZ: We started one of the first accredited C-L Fellowship Programs. Several years later we began the first Child-Adolescent C-L Fellowship program to train child-adolescent psychiatrists to provide C-L services to our Children’s Hospital at Montefiore (CHAM). Under my tenure here we have added Addiction, Forensic and Autism and O-C Spectrum, all of which I highly support.
STRAKOWSKI: We have a psychosomatics fellowship here at Dell Medical School in partnership with our affiliate Ascension Texas. We are committed to continuing to train subspecialists in CL/integrative medicine pathways. In fact, coupled with our current effort to embed psychiatry across the medical spectrum in our system, we are taking a one-year hiatus from recruiting to completely redesign the fellowship in order to train the next generation of leaders in CL. In particular, we want to move from traditional inpatient bound models to training across the entire spectrum of health care, using the integrated practice unit (IPU) approach of Porter and Teisberg (Elizabeth Teisberg is here at Dell Medical School in fact). I am a strong supporter of developing strong subspecialty programs and then working with health systems and payers to demonstrate their value. Again, please refer to my website.
Subspecialty Training Fast-Tracking. There has been discussion of expanding the concept of “fast-tracking” fellowship training (overlap with residency) from child and adolescent psychiatry to other subspecialties. What are your thoughts about that concept?
MARTIN: It is clear that all of education from medical school through residency is experimenting with new models, and the whole concept of years is getting fuzzy as specific milestones are tracked more than the completion of specific didactic activities. I do not see why child fellowships should be treated significantly differently than other fellowships in only requiring three years of general residency rather than 4. I think appropriately designed and monitored fast tracking is a viable option that should be more widely available.
SCHWARTZ: We have been very successful at attracting our graduates to our C-L Fellowship. While I recognize the advantages of fast-tracking, Adult Residency Programs have concerns. The PGY4 year of residency provides opportunities for leadership experiences, electives and consolidates the knowledge base for many residents. I support incentives and opportunities to recruit C-L fellows and I’m not opposed to fast-tracking but we need to determine whether it is detrimental to the development and training of residents.
STRAKOWSKI: This question is an interesting one. For many years, I have strongly encouraged trainees looking to abbreviate the training process (i.e., eliminate the fourth year) in order to start a fellowship early (usually child) to reconsider and take the time to enjoy their fourth year. In my career, it was a defining opportunity to clarify my interests and it typically remains unstructured enough to still do so. There is no other time in life (except perhaps retirement) when this opportunity to have some time to actually think and try things out is embedded within the job. Additionally, those of us who have been around awhile, recognize that one year is not very long and taking this opportunity pays back far more that rushing ahead because of short-term concerns about finishing training early, paying off loans, etc. That said, I believe everyone I have so counselled has essentially ignored me and proceeded anyway! So, with that background, my view is that we should develop the possibility to offer this option (i.e., starting fellowship in year 4), encourage people not to do so, but leave it to the residents to make the decision, since, in the end, it is their career.
APM Name Change. As mentioned above, our field’s name has been changed to C-L Psychiatry and our organization’s name is changing to Academy of Consultation-Liaison Psychiatry. Do you have thoughts about how APA might assist with education and branding for Psychiatry as a whole?
MARTIN: I recall in my hospital in the 80’s the battle was C-L vs L-C with psychosomatics a distant third. The APA should adopt the “new” name in its publications and correspondence. I don’t see the APA focusing on this change as a separate goal. I do see fighting prejudice and discrimination towards those with mental illness and those who treat it as key responsibility of the APA. The fact that C-L psychiatry is a valuable and essential part of the field is something that can be promoted within that context.
SCHWARTZ: I supported the change from Psychosomatic Medicine to C-L. I don’t know why the name originally was changed to PM but C-L is both historically and descriptively appropriate. APA needs to make sure our communications all reference C-L. I’m not sure how much education is needed as C-L services are becoming ubiquitous and desirable in all medical settings. The biggest issue is the shortage of psychiatric providers to work in almost all settings where our expertise is needed.
STRAKOWSKI: Again as mentioned in my website, I believe rebranding psychiatry is critical and the integrative work that APM members provide is central to that effort. We, as a profession, have allowed ourselves to remain mysterious to the general population and frankly other physicians. We have been vague about what we can and cannot do and where we fit in the continuum of healthcare. We are therefore, incorrectly defined by others. I am leading an effort to better define psychiatry through an integrative workgroup of APA, Society of Biological Psychiatry, and the American College of Neuropsychopharmacology (ACNP). I would appreciate APM’s help in these efforts.
Financial Models. C-L psychiatrists have traditionally been of financial value to health care organizations a) by adding overall value to health care outcomes, and b) by driving cost savings. These factors often far outweigh the ability of our members to bring in substantial reimbursements. APA has conducted benchmarking activities and other advocacy-related activities to help with efforts to support financial positions of psychiatrists. Do you have thoughts about how APA’s experience might help with our Academy’s efforts to be more effective in developing credible financial models for C-L psychiatrists in their organizations?
MARTIN: The expertise of the APA when it comes to reimbursement and coding issues is superb. As a result of advocacy and the hard and tedious work of working on committees and workgroups in the federal bureaucracy we have been quite successful. Changes in coding and changes to policies and regulations have certainly lead to better reimbursement of our activities. As reimbursement continues to move to global payments rather than for specific services provided the struggle to assure that members of the team get their fair share within the local organization becomes the focus of attention. Facts are frequently helpful in making progress on issues and the APA is very good in getting the facts, and of course the APA experience expertise in modeling payment systems will also come to bear. So this is another area where collaboration of our two organizations areas of expertise should generate innovative ideas that can be jointly promoted.
SCHWARTZ: I address these questions in my chapter. The discriminatory reimbursement for psychiatric services has to be rectified. Whether we do it through litigation, regulation or legislation it is vital to the financial viability of C-L services. APA has to take the lead in these efforts and support state district branches and specialty societies in their efforts.
STRAKOWSKI: My approach in my various psychiatry and leadership positions has been to work very closely with hospital and healthcare systems to specifically identify how embedded mental health assessments and care can improve outcomes and costs. Here, we are experimenting with several models of proactive consults, recognizing that 60-80% of all medical and surgical admissions have mental health issues that will negatively impact outcomes if not addressed. As we establish the value of these integrations, we have then been successful developing contracts to provide care rather than simply trying to survive on reimbursements (which can be turned over to the health system). I am hoping to then engage health systems to work with CMS and other payers to demonstrate the value of embedded mental health care to increase reimbursement. I think the APA and APM can naturally collaborate in these efforts and, if president, would hope to work with your organization toward that end.