Collaborative and Integrated Care: Dr. Lori Raney, M.D.

This is another perspective on the integrated care vs collaborative care definitions by an expert in the field, Dr. Lori Raney. Her perspective tend to simplify the issue.

Dr. Raney was also one of those offering constructive tips on the Frequently Asked Questions (FAQ) section of a recent Psychiatric News Alert about Integrated Care FAQs.

If integrated care is the wave of the future for psychiatrists, I wonder what form it will take in different parts of the country. In some primary care clinics, there will certainly be a role as long as psychiatrists can figure out how they’ll get paid and won’t be marginalized. It’s a little hard for me to see how psychiatrists can take a leadership role in the collaborative arrangement if they’re not actually seeing the patients and the primary care physicians are doing the prescribing and behavioral health specialists are implementing the non-pharmacologic psychosocial interventions.

I think what might lead to a sense of isolation for the psychiatrist is the part about going over the care manager’s case load once a week or once a month by telephone. Even the psychiatrist’s note will have to contain language which makes it clear that he or she did not actually do a face-to-face assessment. A disclaimer might read like the following:

My treatment observations and suggestions are based on telephone consultation with the mental health care manager and chart review only. All pharmacologic and behavioral treatment recommendations should be carried out with the patient’s current clinical status in mind and include the patients preferences when possible.

It raises questions about liability and whether the primary care physician or the psychiatrist is actually in the best position to be the team leader.

Payment for psychiatric consultation could be problematic, as Dr. Jurgen Unutzer, MD admits in the FAQ. if someone could explain to me how the system would work with insurers currently in our state’s Health Insurance Marketplace, I’d feel more confident about collaborative care. Our largest insurers, Wellmark Blue Cross and Blue Shield,  and United Healthcare, are not yet enrolled in the Health Insurance Marketplace, yet serve more than 85% of the Iowa market. I’m not sure how or if Wellmark would pay for a collaborative care arrangement. And I’m unsure if the other 10 carriers who filed plans in the marketplace would either. This information about the players in the market comes from a previous post.

That said, I think there’s potential for improvement in the care of populations of patients, probably focusing on primary care. I sometimes wonder how it might work in our newest outlying clinic, the Iowa River Landing (IRL).

As it is there is no psychiatrist for emergencies and one would have to call 911, similar to most outlying medical clinics in many communities. Would a collaborative care approach help cut down on the stress and confusion of psychiatric emergencies, say suicide ideation? If a team-based model were applied and higher risk patients were being monitored by a care manager and a consulting psychiatrist, this might be achievable.

On the other hand, I get a little worried about the reliance on checklists like the PHQ-9 as the main outcome measure. I’ve always thought of psychiatric rating scales, especially self-rating instruments, as points of departure rather than the whole journey. I tend not to think of screening tools as diagnostic instruments. Very often, I’ve found them to be inaccurate, often overestimating depression. The best diagnostic instrument is an experienced, thoughtful, and methodical clinician who is able to see and talk with the patient.

However, in the world of the physician shortage, which will probably worsen with the Affordable Care Act as more people obtain insurance coverage and the number of patients exceeds the supply of doctors who can provide care–a population based care model in which a psychiatrist could reach more people through the care manager might make sense.

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Comments

  1. I keep wondering how the primary care docs feel about this. I mean, if I were in their shoes, I think I would feel like I already have too much to do, especially with more patients expecting treatment via the affordable care act, so why am I doing the psychiatrist’s job for him/her, while he/she is just waiting around to be called to participate in care.

    And it seems a waste to train people to be psychiatrists, who spend more time learning how to listen to patients than most specialties, when they’re going to be kept from direct patient contact.

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    • I could not have said it better. I routinely teach Family Medicine residents who rotate through the general hospital psychiatry consultation service. I hope they’re reading this.

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