Special Articles Consultation-Liaison Psychiatrists How Many Are There and How Are They Funded? M.D. THOMAS N. WISE, M.D. JOHN R. HAYES, M.D.
RUSSELL NOYES, JR.,
C
onsultation-liaison (C-L) psychiatry is vigorously pursuing formal recognition as a subspecialty. The process involves ongoing interaction with the American Psychiatric Association's (APA) Commission on Subspecialization. In July 1991, this commission requested information on how many psychiatrists are presently engaged in C-L psychiatry and how practice of the subspecialty is funded. These pertinent questions had no immediate answers. Previous surveys had shown that a substantial proportion of APA members have some interest in C-L psychiatry, but they provided little quantitative data. Because one criterion for subspecialty status is an adequate pool of psychiatrists to meet the needs of a particular patient group-in this case, patients with coexisting medical and psychiatric illnesses-it seemed important to obtain such data. This report addresses two questions: are there presently enough C-L psychiatrists, and is their work adequately funded such that the foundation for an officially recognized subspecialty exists. To answer these questions the Academy of Psychosomatic Medicine surveyed 1,000 members of the APA selected randomly from the more than 6,000 members who indicated in the membership directory that C-L psychiatry was an area of interest. A one-page questionnaire, developed by the authors, was sent to the 1,000 and 395 were returned. The response (39.5%) was acceptable and forms the basis for this report. 1 VOLUME 33· NUMBER 2· SPRING 1992
RESULTS Based on questionnaire responses, we extrapolated the level of C-L activity for the APA membership as a whole. The estimated time devoted to C-L activities is shown in Figure 1; it shows that over 2,700 members (7.5% of the membership) spend at least 25% of their practice time in C-L work and that nearly 1,200 (3.2%) spend 50% or more of their time in this fashion. The number of APA members devoting 25% of their time to C-L psychiatry was estimated as follows: 79 36,740 395 x 6,283 x 16,878 = 2,736 where 36,740 was the number of APA members and 16,878 was the number of members for whom area of interest information was available. A total of 6,283 indicated that they had an interest in C-L psychiatry. Psychiatrists practicing in general hospitals (mean = 23%) and academic settings (mean = 18%) reported devoting Received January 6. 1992; accepted January 6. 1992. From the Department of Psychiatry. University of Iowa. Iowa City; the Depanment of Academic Affairs. St. Vincent Hospital and Health Care Center. Indianapolis. IN; and the Depanment of Psychiatry. Fairfax Hospital. Falls Church. VA. Address reprint requests to Dr. Noyes. Dept. of Psychiatry. University of Iowa. 500 Newton Road. Iowa City. IA 52242. Copyright © 1992 The Academy of Psychosomatic Medicine.
123
Consultation-Liaison Psychiatrists
more time to Col psychiatry than psychiatrists in private practice (mean = 13%). Figure 2 shows the number of inpatient consultations seen annually. Over 1.000 members (2.8%) see at least 200 consultations and almost 500 (1.3%) see 300 inpatient consultations yearly. Inpatient consultations make up the majority (62.5%) of consultations performed. Similarly, we estimate that 5.9% of APA members generate at least one-quarter of their income from Col work and 2.4% earn at least half of their income in this manner. Major sources of direct funding for C-L work include patient fees (54%), hospital salary (17%), medical school salary (7%), and grants (2%). The proportion of time spent often exceeds the proportion of income generated by consultation work; for 51 % of those surveyed, the two proportions were equal, but for 43% time was greater than income. Also, on the basis of questionnaire responses, we estimate that 3,800 (10.5%) of the APA's members are affiliated with a Col service, 4,300 (11.6%) are involved in some type of C-L teaching, and 600 (1.7%) are engaged in Col research.
DISCUSSION The results of this survey are clear. They show that about one-quarter of psychiatrists have some involvement in Col psychiatry. However, most devote a relatively small proportion of their time to such activity, leaving about 1,000 (3%) for whom Col psychiatry is a major professional focus. Most of these psychiatrists, who devote at least half of their time to consultation work, are to be found in general and university hospitals. Such hospitals have psychiatric consultation services with which they are affiliated. A survey conducted by the American Hospital Association in 1984 found that nearly 900 hospitals throughout the country had such services. 2 These figures demonstrate that a cadre of subspecialists already exists to treat the psychiatric disorders found in physically ill patients. As with most subspecialties, the majority of uncomplicated cases and follow-up care are handled by general psychiatrists. Col psychiatrists are needed to deal with the more difficult problems. There is clearly a need for more Col psy-
FIGURE I. Percent of time devoted to consultation-liaison psychiatry. Values are taken from the responses (N =395) to a survey of 1,000 randomly selected members of the American Psychiatric Association who indicated that consultation-liaison psychiatry was an area of interest.
7.000 1,500 1,200
Number of Psychiatrists
900 600 300
o
o
100
200
300
400
500
600
Number of Inpatients
124
PSYCHOSOMATICS
Noyes et al.
chiatrists in general hospitals. Thirty to 60% of patients admitted to these hospitals have diagnosable psychiatric disorders, yet only I % are currently being seen.3.4 This is especially unfortunate in view of the evidence that psychiatric consultation reduces morbidity, shortens length of stay, and decreases the cost of hospitalization. 5- 8 Medical and surgical patients need the attention of psychiatrists who are trained to differentiate biological, psychological, and social causes of abnormal behavior. However, because of the limited presence of consultation psychiatrists, other mental health professionals have become increasingly involved in consulting work. While there are roles for many disciplines in this area, it is important that psychiatry be represented. Other professionals are not medically trained nor do they appreciate the complexities involved in managing mental disorders in acute and seriously ill patients. Too often their involvement limits access to patients who need psychiatric evaluation, treatment, and follow-up. C-L psychiatrists, where they exist, are readily available and capable of dealing
with complex medical problems. Their presence serves to increase recognition of psychiatric illness and improve the quality of medical care. Two-thirds of those who responded to our survey indicated that they see a need for increased C-L services in the communities where they practice. It is also clear from the survey results that C-L work can pay for itself, contrary to what some outside the field may have thought. Patient fees remain the chief source of direct funding, but salary support in general hospitals and medical schools is the principal means of compensation for one-quarter of those doing a substantial amount of consultation work. The survey makes clear, however, that this type of activity is not as well-funded as some others. Many respondents estimated that the proportion of time spent exceeded the income generated, and 9% indicated that no funding was available. This lack of financial compensation may deter some from practicing CoL psychiatry. A variety offunding models exist that support full-time C-L work in hospitals around the country. The traditional academic model uses
FIGURE 2. Number of inpatient consultations in the past year. Values are taken from the responses (N =395) to a survey of 1,000 randomly selected members of the American Psychiatric Association who indicated that consultation-liaison psychiatry was an area of interest. 3,000
r--;::::==;-------------------..,
1,800 1,500
Number of Psychiatrists
1,200
900 600
300
o
o
10
20
30
40
50
60
>75
Percent of Time
VOLUME 33· NUMBER 2· SPRING 1992
125
Consultation-Liaison Psychiatrists
combined salary and grant support together with a practice plan. Of course. this model relies on psychiatric trainees for much of the service delivery. but these combined financial and manpower resources have formed the basis for C-L services in medical schools nationwide. Unfortunately. grant and salary support for fellowships and research has been threatened because there has not been formal recognition of the subspecialty. It is presumed that in academic settings. official recognition would improve access to traditional forms of funding. Several other funding models have proved successful in community hospitals. Because there is good evidence that psychiatric consultation reduces length of stay for managed-care patients. many hospitals have funded one or more C-L positions. A combination of recovery from billing and financial gain from reduced length of stay make these positions viable. Also. C-L psychiatrists make referrals to psychiatric inpatient units in hospitals where they exist. Recognition of this referral pattern has prompted many community hospital administrators to enthusiastically support the addition of salaried C-L psychiatrists. Where community hospitals have graduate medical education programs. they have access to other support for C-L services. Such hospitals may elect to pay the salary of a C-L psychiatrist who provides behavioral science teaching to primary care trainees. In so doing. the hospital meets accreditation requirements and recovers direct and indirect Medicare reimbursement for medical education. This reimbursement helps to offset the salary and. in addition to teaching. the C-L psychiatrist provides all the service benefits mentioned above. Some general hospitals have entered into joint ventures to avoid the political and economic pitfalls that sometimes impede good C-L in a community hospital. Such ventures involve risk-sharing and may avoid alienating the existing psychiatric staff. In this model, C-L psychiatrists relate to the hospital and to established general psychiatrists as independent contractors. partially supported employees. contractors for a group. or employees of such a group. A 126
salary can be guaranteed for the C-L psychiatrist. allowing him or her the economic freedom to do C-L work. Mutually agreed upon limits on the C-L psychiatrist's general practice assures referrals to other psychiatrists for follow-up and inpatient care. With this arrangement. hospital programs as well as private practices benefit from referrals. Consult billings may be done by the hospital or the physician group, with collections offsetting direct costs. A relatively new model involves group practice. A group of C-L psychiatrists may wish to do consultation work exclusively and market their services in hospitals or nursing homes. Because the group commits itself to doing only consultation work and to referring patients to other psychiatrists for follow-up care. they usually overcome initial resistance within the psychiatric community. Practices of this kind have demonstrated the financial viability of practicing the subspecialty on a fee-for-service basis. CONCLUSION This survey of psychiatrists who cited an interest in C-L psychiatry indicates that an adequate pool of subspecialists exists. It also indicates that funding for subspecialty practice is available through a variety of sources and models. These data answer the APA Commission on Subspecialization's query and further support C-L psychiatry's quest for formal subspecialty recognition. However, the number of C-L psychiatrists must be increased and the training of these psychiatrists must be enhanced if the needs of the physically ill population with coexisting psychiatric disorders are to be met. Our reason for seeking official recognition is that, by strengthening and expanding the subspecialty. we may better serve this relatively neglected group of patients.
References I. Cartwright A: Professionals as responders: variations in and effects of response rates to questionnaires. 1961-77. 8M} 2:1419-1421. 1978 2. Lipowski ZJ: Consultation-liaison psychiatry: the first
PSYCHOSOMATICS
Noyes et al.
half century. Gell Hosp PsvchiaTry 8:305-315.1986 3. Lipowski Z1: Review of consultation psychiatry and psychosomatic medicine. II. Clinical aspects. Psycho.mm Med 29:201-224. 1967 4. Strain JJ: Needs for psychiatry in the general hospital. Hosp CommlilliTy PsychiaTry 33:996-1002.1982 5. Levitan S1. Kornfeld DS: Clinical and cost benefits of liaison psychiatry. Am} PsychiaTry 138:790-793.1981 6. Cassem NH. Hackel! TP: Psychiatric consultation in a
VOLUME 33· NUMBER 2· SPRING 1992
coronary care unit. AIIII/mem Med 75:9-14. 1983 7. Strain JJ. Hammer 1. Levin C. et al: The evaluation of a literature search schema for consultation-liaison psychiatry: the database and its computerization. Gell Hosp P.nchiaTry 12: 1-53.1990 8. Strain JJ. Lyons 1S. Hammer 1S. et al: Cost offset from a psychiatric consultation-liaison intervention with elderly hip fracture patients. Am} PsychiaTry 148: 10441049. 1991
127
RUSSELL NOYES, JR.,
C
onsultation-liaison (C-L) psychiatry is vigorously pursuing formal recognition as a subspecialty. The process involves ongoing interaction with the American Psychiatric Association's (APA) Commission on Subspecialization. In July 1991, this commission requested information on how many psychiatrists are presently engaged in C-L psychiatry and how practice of the subspecialty is funded. These pertinent questions had no immediate answers. Previous surveys had shown that a substantial proportion of APA members have some interest in C-L psychiatry, but they provided little quantitative data. Because one criterion for subspecialty status is an adequate pool of psychiatrists to meet the needs of a particular patient group-in this case, patients with coexisting medical and psychiatric illnesses-it seemed important to obtain such data. This report addresses two questions: are there presently enough C-L psychiatrists, and is their work adequately funded such that the foundation for an officially recognized subspecialty exists. To answer these questions the Academy of Psychosomatic Medicine surveyed 1,000 members of the APA selected randomly from the more than 6,000 members who indicated in the membership directory that C-L psychiatry was an area of interest. A one-page questionnaire, developed by the authors, was sent to the 1,000 and 395 were returned. The response (39.5%) was acceptable and forms the basis for this report. 1 VOLUME 33· NUMBER 2· SPRING 1992
RESULTS Based on questionnaire responses, we extrapolated the level of C-L activity for the APA membership as a whole. The estimated time devoted to C-L activities is shown in Figure 1; it shows that over 2,700 members (7.5% of the membership) spend at least 25% of their practice time in C-L work and that nearly 1,200 (3.2%) spend 50% or more of their time in this fashion. The number of APA members devoting 25% of their time to C-L psychiatry was estimated as follows: 79 36,740 395 x 6,283 x 16,878 = 2,736 where 36,740 was the number of APA members and 16,878 was the number of members for whom area of interest information was available. A total of 6,283 indicated that they had an interest in C-L psychiatry. Psychiatrists practicing in general hospitals (mean = 23%) and academic settings (mean = 18%) reported devoting Received January 6. 1992; accepted January 6. 1992. From the Department of Psychiatry. University of Iowa. Iowa City; the Depanment of Academic Affairs. St. Vincent Hospital and Health Care Center. Indianapolis. IN; and the Depanment of Psychiatry. Fairfax Hospital. Falls Church. VA. Address reprint requests to Dr. Noyes. Dept. of Psychiatry. University of Iowa. 500 Newton Road. Iowa City. IA 52242. Copyright © 1992 The Academy of Psychosomatic Medicine.
123
Consultation-Liaison Psychiatrists
more time to Col psychiatry than psychiatrists in private practice (mean = 13%). Figure 2 shows the number of inpatient consultations seen annually. Over 1.000 members (2.8%) see at least 200 consultations and almost 500 (1.3%) see 300 inpatient consultations yearly. Inpatient consultations make up the majority (62.5%) of consultations performed. Similarly, we estimate that 5.9% of APA members generate at least one-quarter of their income from Col work and 2.4% earn at least half of their income in this manner. Major sources of direct funding for C-L work include patient fees (54%), hospital salary (17%), medical school salary (7%), and grants (2%). The proportion of time spent often exceeds the proportion of income generated by consultation work; for 51 % of those surveyed, the two proportions were equal, but for 43% time was greater than income. Also, on the basis of questionnaire responses, we estimate that 3,800 (10.5%) of the APA's members are affiliated with a Col service, 4,300 (11.6%) are involved in some type of C-L teaching, and 600 (1.7%) are engaged in Col research.
DISCUSSION The results of this survey are clear. They show that about one-quarter of psychiatrists have some involvement in Col psychiatry. However, most devote a relatively small proportion of their time to such activity, leaving about 1,000 (3%) for whom Col psychiatry is a major professional focus. Most of these psychiatrists, who devote at least half of their time to consultation work, are to be found in general and university hospitals. Such hospitals have psychiatric consultation services with which they are affiliated. A survey conducted by the American Hospital Association in 1984 found that nearly 900 hospitals throughout the country had such services. 2 These figures demonstrate that a cadre of subspecialists already exists to treat the psychiatric disorders found in physically ill patients. As with most subspecialties, the majority of uncomplicated cases and follow-up care are handled by general psychiatrists. Col psychiatrists are needed to deal with the more difficult problems. There is clearly a need for more Col psy-
FIGURE I. Percent of time devoted to consultation-liaison psychiatry. Values are taken from the responses (N =395) to a survey of 1,000 randomly selected members of the American Psychiatric Association who indicated that consultation-liaison psychiatry was an area of interest.
7.000 1,500 1,200
Number of Psychiatrists
900 600 300
o
o
100
200
300
400
500
600
Number of Inpatients
124
PSYCHOSOMATICS
Noyes et al.
chiatrists in general hospitals. Thirty to 60% of patients admitted to these hospitals have diagnosable psychiatric disorders, yet only I % are currently being seen.3.4 This is especially unfortunate in view of the evidence that psychiatric consultation reduces morbidity, shortens length of stay, and decreases the cost of hospitalization. 5- 8 Medical and surgical patients need the attention of psychiatrists who are trained to differentiate biological, psychological, and social causes of abnormal behavior. However, because of the limited presence of consultation psychiatrists, other mental health professionals have become increasingly involved in consulting work. While there are roles for many disciplines in this area, it is important that psychiatry be represented. Other professionals are not medically trained nor do they appreciate the complexities involved in managing mental disorders in acute and seriously ill patients. Too often their involvement limits access to patients who need psychiatric evaluation, treatment, and follow-up. C-L psychiatrists, where they exist, are readily available and capable of dealing
with complex medical problems. Their presence serves to increase recognition of psychiatric illness and improve the quality of medical care. Two-thirds of those who responded to our survey indicated that they see a need for increased C-L services in the communities where they practice. It is also clear from the survey results that C-L work can pay for itself, contrary to what some outside the field may have thought. Patient fees remain the chief source of direct funding, but salary support in general hospitals and medical schools is the principal means of compensation for one-quarter of those doing a substantial amount of consultation work. The survey makes clear, however, that this type of activity is not as well-funded as some others. Many respondents estimated that the proportion of time spent exceeded the income generated, and 9% indicated that no funding was available. This lack of financial compensation may deter some from practicing CoL psychiatry. A variety offunding models exist that support full-time C-L work in hospitals around the country. The traditional academic model uses
FIGURE 2. Number of inpatient consultations in the past year. Values are taken from the responses (N =395) to a survey of 1,000 randomly selected members of the American Psychiatric Association who indicated that consultation-liaison psychiatry was an area of interest. 3,000
r--;::::==;-------------------..,
1,800 1,500
Number of Psychiatrists
1,200
900 600
300
o
o
10
20
30
40
50
60
>75
Percent of Time
VOLUME 33· NUMBER 2· SPRING 1992
125
Consultation-Liaison Psychiatrists
combined salary and grant support together with a practice plan. Of course. this model relies on psychiatric trainees for much of the service delivery. but these combined financial and manpower resources have formed the basis for C-L services in medical schools nationwide. Unfortunately. grant and salary support for fellowships and research has been threatened because there has not been formal recognition of the subspecialty. It is presumed that in academic settings. official recognition would improve access to traditional forms of funding. Several other funding models have proved successful in community hospitals. Because there is good evidence that psychiatric consultation reduces length of stay for managed-care patients. many hospitals have funded one or more C-L positions. A combination of recovery from billing and financial gain from reduced length of stay make these positions viable. Also. C-L psychiatrists make referrals to psychiatric inpatient units in hospitals where they exist. Recognition of this referral pattern has prompted many community hospital administrators to enthusiastically support the addition of salaried C-L psychiatrists. Where community hospitals have graduate medical education programs. they have access to other support for C-L services. Such hospitals may elect to pay the salary of a C-L psychiatrist who provides behavioral science teaching to primary care trainees. In so doing. the hospital meets accreditation requirements and recovers direct and indirect Medicare reimbursement for medical education. This reimbursement helps to offset the salary and. in addition to teaching. the C-L psychiatrist provides all the service benefits mentioned above. Some general hospitals have entered into joint ventures to avoid the political and economic pitfalls that sometimes impede good C-L in a community hospital. Such ventures involve risk-sharing and may avoid alienating the existing psychiatric staff. In this model, C-L psychiatrists relate to the hospital and to established general psychiatrists as independent contractors. partially supported employees. contractors for a group. or employees of such a group. A 126
salary can be guaranteed for the C-L psychiatrist. allowing him or her the economic freedom to do C-L work. Mutually agreed upon limits on the C-L psychiatrist's general practice assures referrals to other psychiatrists for follow-up and inpatient care. With this arrangement. hospital programs as well as private practices benefit from referrals. Consult billings may be done by the hospital or the physician group, with collections offsetting direct costs. A relatively new model involves group practice. A group of C-L psychiatrists may wish to do consultation work exclusively and market their services in hospitals or nursing homes. Because the group commits itself to doing only consultation work and to referring patients to other psychiatrists for follow-up care. they usually overcome initial resistance within the psychiatric community. Practices of this kind have demonstrated the financial viability of practicing the subspecialty on a fee-for-service basis. CONCLUSION This survey of psychiatrists who cited an interest in C-L psychiatry indicates that an adequate pool of subspecialists exists. It also indicates that funding for subspecialty practice is available through a variety of sources and models. These data answer the APA Commission on Subspecialization's query and further support C-L psychiatry's quest for formal subspecialty recognition. However, the number of C-L psychiatrists must be increased and the training of these psychiatrists must be enhanced if the needs of the physically ill population with coexisting psychiatric disorders are to be met. Our reason for seeking official recognition is that, by strengthening and expanding the subspecialty. we may better serve this relatively neglected group of patients.
References I. Cartwright A: Professionals as responders: variations in and effects of response rates to questionnaires. 1961-77. 8M} 2:1419-1421. 1978 2. Lipowski ZJ: Consultation-liaison psychiatry: the first
PSYCHOSOMATICS
Noyes et al.
half century. Gell Hosp PsvchiaTry 8:305-315.1986 3. Lipowski Z1: Review of consultation psychiatry and psychosomatic medicine. II. Clinical aspects. Psycho.mm Med 29:201-224. 1967 4. Strain JJ: Needs for psychiatry in the general hospital. Hosp CommlilliTy PsychiaTry 33:996-1002.1982 5. Levitan S1. Kornfeld DS: Clinical and cost benefits of liaison psychiatry. Am} PsychiaTry 138:790-793.1981 6. Cassem NH. Hackel! TP: Psychiatric consultation in a
VOLUME 33· NUMBER 2· SPRING 1992
coronary care unit. AIIII/mem Med 75:9-14. 1983 7. Strain JJ. Hammer 1. Levin C. et al: The evaluation of a literature search schema for consultation-liaison psychiatry: the database and its computerization. Gell Hosp P.nchiaTry 12: 1-53.1990 8. Strain JJ. Lyons 1S. Hammer 1S. et al: Cost offset from a psychiatric consultation-liaison intervention with elderly hip fracture patients. Am} PsychiaTry 148: 10441049. 1991
127
