ACLP president Michael Sharpe, MD, FACLP, asked the three candidates for the APA’s 2020 President-elect elections to respond to five issues of concern to the Academy. 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 five issues of concern to the Academy involve:
The three candidates are:
APA members are reminded that voting closes at 11:59pm ET Friday, January 31, 2020. For more information about the election and the candidates, see 2020 APA Election on the American Psychiatric Association’s website.
Maintaining the gains already achieved with Collaborative and Integrated Care. The past several years has seen significant progress in defining and supporting the roles of psychiatrists working in general medical settings. This include integrated care system and especially collaborative care (e.g., the new collaborative care payment codes) and also proactive inpatient C-L (which is increasingly being adopted by major hospitals). Our members are uniquely trained to be working in these services. What are your thoughts on how APA can maintain and extend the gains made in supporting the roles of psychiatrists in integrated care? How can the APA promote collaboration with non-psychiatric medical organizations to achieve awareness of the value of these innovations in integrated care?
HENDERSON: I have been impressed with the gains made in collaborative and integrated care. I have used these models for more than two decades in much of my global work. These approaches are critical for us to increase the capacity of health systems to care for patients. I have been a strongly supportive of this and have worked within our health system to implement and expand collaborative and integrated care- while also working with hospital leaders to help them understand what this means and develop financial models that allow our psychiatrists to do the work without constantly worrying about RVUs. The APA can play an important role in extended current efforts, educating health systems, and working with community health centers to develop a blueprint for implementation. APA can also help these organizations establish partnerships with psychiatric experts to educate and implement collaborative and integrated care.
NASRALLAH: I believe the APA must emphasize the medical identity of psychiatrists by inserting the term “physicians” in its name to become: American Psychiatric Physicians Association (APPA). I have already discussed this initiative with the APA CEO, Dr. Levin, and he expressed his support. This is not just a name change: it is a strong signal about psychiatry being an integral part of the House of Medicine, collaborating with other physicians across multiple specialties. I will also strongly support the APA’s ongoing efforts to partner with primary care physicians’ associations [Family Medicine, Internal Medicine, Pediatrics, OBGYN and Osteopathic Physicians].
PENDER: C-L Psychiatry has grown remarkably since being granted official subspecialty status 15 years ago. Not only has the traditional consult model become more ubiquitous around the country, a variety of liaison approaches are increasingly accepted. C-L psychiatry has proven very useful to our non-psychiatric colleagues, for more than just compliance to prescribed treatments or surgery. Integrative care and proactive inpatient C-L have several things in common: they are useful and acceptable to patients; they allow the primary clinicians to more effectively perform their work; they have been shown to be cost effective to sponsoring institutions; they provide care to patient populations that have been historically underserved (the medically ill and other disenfranchised groups); and they allow for fulfilling careers for psychiatrists and other mental health professionals.
ACLP’s collaboration with APA. The APA Council on Consultation-Liaison Psychiatry (CoCLP) has been very active in APA affairs and ACLP has recently collaborated with APA on a successful monograph on dissemination of integrated care. The combination of APA’s size and advocacy experience combined with the subspecialty subject matter expertise is very powerful. What do you see as the future role of ACLP 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 see as an opportunity for continued collaboration between our organizations?
HENDERSON: The collaboration between the ACLP and the APA must continue to be strengthened in order to improve access to mental health care in the US. Due to a shortage of psychiatrists and psychiatric nurse practitioners, collaborative care seems to be the best approach to meeting the demands. The question is always, how to get health care leaders and medical providers to understand the value in C-L psychiatry and collaborative care models. I have conducted research on primary care clinicians confidence in conducting mental health evaluations and treatment in several countries.In my current position,I have been aware that educating hospital leaders is a critical step in the success of integrated care- as most believe that co-location is integrated care. I believe the APA should partner with, if not already done, organizations, local and national meetings that hospital administrators/leaders attend and the ACLP/APA can provide seminars/lectures regarding the models of care as well as present financial data that demonstrates the value to the system.
NASRALLAH: There is no doubt in my mind that the best way to underscore the medical identity of the APA and its psychiatrist members is to strongly support C-L psychiatry through the Council on Consultation-Liaison Psychiatry (CoCLP) and the ACLP. In addition to the name change and partnerships I mentioned earlier, and having served for 6 years on the ACGME/ RRC for Psychiatry, I will urge the RRC to require that residents and their supervisors be co-localized within primary care clinics so that collaborative care is inculcated into the residency training before graduation. This will very likely increase the likelihood that newly-minted psychiatrist will practice collaborative care after residency.
PENDER: As President of the APA I would plan to work with ACLP leadership to develop programs, projects and evidence that could be used by individual C-L services around the country as they negotiate with larger organizations such as medical schools, hospitals and government. Positions endorsed by the APA would stand alongside those of the ACLP, and, in so doing, would strongly affirm the efforts of the ACLP. Grand rounds presentations for other specialties should be encouraged. I recently co-authored a journal article (submitted to the BMJ) with anesthesiologists on the topic of perception of pain in traumatized patients. I am also a co-investigator on an intramural innovative Department of Internal medicine grant on experiences of victims of trafficking in healthcare settings. The APA has a good relationship with CMS that can be a foundation for improving the status and work of C-L psychiatrists. Another entry point for C-L training is for international psychiatrists. The APA can extend its resources to encompass global psychiatry, an endeavor that is especially linked to C-L psychiatry.
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?
HENDERSON: I am a strong supporter of fellowship training in psychiatry. C-L psychiatry fellowships provide a unique training and skills that can be utilized anywhere. Four years of residency is often not adequate to prepare trainees for critical areas such as C-L, addiction psychiatry, and geriatric. As I have been the Co-Director of a Global Mental Health fellowship for many years, where we often use and study integrated care models, I am aware that additional training is necessary for trainees to become competent in these areas. Subspecialists are critical in psychiatry, just like in medicine.
NASRALLAH: I believe fellowship training will elevate the quality of psychiatric clinical care. Just consider the various subspecialty fellowships in Internal medicine which produces superb subspecialists who provide advanced care and are more likely to conduct research as well. I am eager to see a high proportion of psychiatry residents choose to go into one of the ABPN subspecialties, especially C-L, where we have far less than the country needs. As APA President, I will emphasize how C-L training is at the core of a good psychiatrist, who can also practice general psychiatry.
PENDER: Having completed residency training in internal medicine before training in psychiatry, I understand the dual nature of our roles as physicians treating both physical and mental health. As a first-time attending at Cornell, I worked in the geriatric division for four years where I learned a great deal about diagnosing and treating patients as well as working with other specialty physicians. Many psychiatrists work in this way of evaluating patients, first medically, then neurologically, then primary mental illness, and then personality, in that order. APA must make a robust effort to promote psychiatrists’ roles as professional physicians. Psychiatrists are uniquely trained to be successful in practicing in primary care settings. Psychiatrists frequently suspect that a ‘functional’ disorder can be more properly diagnosed and treated as a psychiatric disorder. As a practicing clinician, I fulfill a primary care need for patients in monitoring their medical care, for example, flu shots, routine colonoscopies, cardiac and other meds? Some of my colleagues are also active in integrating behavioral health services into specialty medical settings, for example, weight management, transplant, oncology, and rehabilitation settings. It is time that psychiatrists accrue the respect and collaboration they deserve in filling this crucial gap in clinical care. Psychiatrists are first and foremost physicians.
Workforce Development. ACLP, similar to other psychiatry subspecialties faces a critical workforce shortfall. ACLP is working with other psychiatry subspecialty organizations and APA Councils in consultation-liaison psychiatry, geriatric, and addiction psychiatry to address this workforce shortage. One idea being discussed is expanding the concept of “fast-tracking” fellowship training (overlap with residency), as organized in child and adolescent psychiatry, to other subspecialties. What are your thoughts about this proposal? What other ideas do you have to address the workforce shortage in psychiatry and its subspecialties?
HENDERSON: While I have not previously thought of this, I like the idea of fast tracking into fellowships such as C-L and addictions. This may not only increase the number of psychiatrists getting specialty training, but could increase the number of slots available. I understand that psychiatric nurse practitioners are also part of the work force development, and our hospital utilizes psychiatric NPs to handle certain cases with supervision. Defining the scope of practice and requiring supervision is essential with this approach.
NASRALLAH: I agree that a 5th year (post-residency fellowship) is a hurdle to attracting more graduating residents into a subspecialty training. Having mentored numerous residents over the year in a 4th year elective, I am convinced that fast-tracking fellowships by converting the PGY4 year into a subspecialty training is a good solution to the shortage of psychiatric subspecialists, such as C-L, Geriatrics, Addictions and Child/Adolescent psychiatry. Interestingly, in my discussion with various Division Directors, only the Forensic Directors were opposed to fast-tracking.
PENDER: With scientific advances and improvements in chip technology medical education is changing. Through innovation in teaching, first year students in some medical schools now receive iPads loaded with textbooks and other medical apps. I would welcome the concept of overlapping fellowship training in C-L with residency training. In general, the APA must work to increase GME residency positions and thereby fellowship slots as well. I believe this can be accomplished by the APA and other subspecialty organizations in collaboration with the ACLP. It will require decreasing paperwork, consolidating insurance reimbursement and eliminating elaborate authorizations by insurance companies.
Financial Models. C-L psychiatrists have traditionally been of financial value to health care organizations by: (a) adding overall value to health care outcomes, and (b) 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 support the financial positions of psychiatrists. How do you think APA’s experience might help with the Academy’s efforts to be more effective in developing credible financial models for C-L psychiatrists?
HENDERSON: This is great news regarding the APAs efforts in conducting benchmarking activities and to support the financial positions of psychiatrists. For each institution/health care organization, the most compelling information is actual data from their own health system. We were able to get access to hospital data, which was normally not available to us, and patient and financial outcomes with our C-L psychiatrists and our integrated behavioral health team. The data was compelling and lead to a substantial investment by the hospital that continues to grow. The APA can provide models to examine data or lead a large multi-center study examining the health outcomes and financial data in different systems- which would be more powerful. Emphasizing these outcomes will lead to a shift in resources, particular as many institutions are moving towards an ACO model.
NASRALLAH: C-L psychiatrists do need a viable financial model equivalent to private practice psychiatrists. Hospital support for C-L salary lines is vital for inpatient C-L, but a private practice fee-for-service model is feasible for outpatient C-L [such as in a multi-specialty group practice]. One important corollary of C-L psychiatry is the creation of Med-Psych Inpatient units for patients with dual medical and psychiatric diagnoses. Such units are in high demand around the country, and C-L psychiatrists are perfectly equipped to work on such units along with an Internist. The bottom line is that hospitals must provide a healthy salary line for inpatient C-L, while outpatient C-L can be compatible with a fee-for-service model.
PENDER: Neither integrative care nor proactive inpatient C-L is economically viable under a traditional fee for service system. In addition, delivering hospital-level services to patients at home is becoming more common. Embedded hospitalists, tele-psychiatry (whether for direct patient care or for consultation to clinicians), and liaison work to medical and surgical specialists are increasingly utilized around the country, however it is my impression that the ACLP and individual C-L clinicians have had to work too hard to present their financial arguments. When busy clinicians try to negotiate with large health care facilities, multinational insurance conglomerates, and the federal government, the results may go well, but they do not always go in the direction of excellent patient care. In particular, external administrators and funding sources often fail to take into consideration such non-compensated activities as informal consults, attendance in rounds, phone availability, and service to the underinsured. This failure to appreciate the activities and talents of C-L psychiatrists must be corrected.