The new morbidity: Where the rubber hits the road or the practitioner's guide to the new morbidity.

Abstract

The American Academy of Pediatrics (AAP) policy statement entitled “The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of Pediatric Care”1 from the Committee on Psychosocial Aspects of Child and Family Health is found in this month's issue ofPediatrics. Few experienced pediatric practitioners would disagree with this description of our life's work. Most embrace this “renewed commitment” to relevant and comprehensive care for our children and families. It is not hard to look past the examination room and appreciate the struggles, tensions, and morbidities that this complex world presents our patients as they grow and develop. But what about the complex world of our practices? We are well-intended, but are we well-trained, and are we able to follow through on our “commitment”?The rate of psychosocial problems identified by primary care physicians in the children they care for has increased from 7% to 18% in the past 20 years. Information accumulated by the Pediatric Research in Office Settings (PROS) group3 confirmed what practicing pediatricians already know: the children we see for earaches bring with them symptoms of their behavioral health. These children may have attentional difficulties, conduct issues, or significant problems of mood. They may suffer acute adjustment difficulties or evidence posttraumatic stress from physical, emotional, or sexual abuse, and may experience family poverty, family divorce, or a host of other intrinsic or situational problems that impact on their health and the ability of their family and caregivers to provide for their health.We are seeing more problems and, lacking referral sources, often have to provide more care.Skills needed to address the new morbidities are part of our training. Pediatrics has always been a science of development; now pediatric trainees have increased experience in child development, both normal and abnormal. Residency programs must provide specific training in normal and abnormal behavior and child development from infancy through young adulthood. “The program must educate their residents in the intrinsic and extrinsic factors that influence behavior to enable them to differentiate behavior that can and should be managed by the general pediatrician from behavior that warrants referral to other specialists.” Components of this required training can be found at the Accreditation Council for Graduate Medical Education Web site.4Developmental pediatric skills among experienced, board-certified pediatricians varies. Although experience is an important teacher, quality measures in behavioral health care in primary care practices are lacking. Clinical guidelines are a recent development, and they are not widely known, consulted, or used. For example, the AAP's guidelines for the diagnosis of attention-deficit/hyperactivity disorder5 were published in the May 2000 issue ofPediatrics, and the companion treatment guideline appears in the October 2001 issue.6 Will they be used? An AAP working group has been convened to encourage adoption of and adherence to the new guidelines, seeking to impose a higher community standard of care. Clinical guidelines useful to pediatricians have not yet been developed for other behavioral health disorders, such as depression in childhood and adolescence, obsessive compulsive disorder, and the disorders of oppositionality and conduct.Consistent with its “renewed commitment” to behavioral and developmental morbidities, training in this area is a key and essential part of the AAP's continuing education efforts. This reflects the AAP's core values, but also responds to practicing pediatricians, who know they need these skills and desire to provide treatments that are sensitive to child and family needs and that have good outcome. And, in the near future, the American Board of Pediatrics will bestow subspecialty board status in Developmental and Behavioral Pediatrics to those pediatricians who complete a 2-year postresidency fellowship and demonstrate certain competencies.We are trained, our training is improving, and opportunities for additional training are many. But will we be paid for our efforts, and will we have the help of consultants available to us?The pediatric office today should provide behavioral health screening and anticipatory guidance in the context of every well-child and sick visit. The pediatrician must be prepared to uncover and effectively address psychosocial issues at every encounter: some earaches are complicated by parental divorce. Although a sick call visit does not usually include the necessary time to address the child's and family's adjustment to this or other significant psychosocial stressors, there is time for identification, perhaps brief patient education and anticipatory guidance, and certainly an opportunity to make arrangements for a meeting later on.But, if primary care providers are not reimbursed for their services, behavioral health care will not find a home in primary care. Fee schedules for well-child care or sick care are not adequate to compensate time spent in training for, consulting on, or providing care for the behavioral and psychosocial problems uncovered in those visits.A significant minority of children's mental health services are accessed only through state Medicaid systems. Nationally, almost 20% of children are insured by Medicaid, but the rate of coverage varies widely by state.Primary care providers struggle with reimbursement for mental health in the Medicaid system. State Medicaid programs vary in the services or codes they will allow primary care physicians to bill, limiting the provision of mental health services that will be reimbursable. Billing for primary care services, including mental health, requires both a diagnosis and a procedure code. Specific diagnosis is essential to patient care, and an improperly applied diagnosis could be considered fraudulent. State Medicaid offices often limit providers both in the diagnoses they might be allowed to care for and in the procedures that they will be allowed to provide.For example, a pediatrician may always bill under Current Procedural Terminology7 codes 99211 to 99215 for evaluation and management of a problem, but they might be restricted in using codes 90804 and 90806 for counseling services. Or although a diagnosis code of 311.x indicating clinical depression might be allowed, services provided under the diagnosis of mood problem, v40.3, will be rejected. Yet, the problem to child and family is significant to the family regardless of the diagnosis, and the services provided are of value.Third-party coverage for health care and mental health care may take many forms, ranging from traditional fee-for-service to varied levels of care management. Managed care contracts vary in their restrictions, from the lenient preferred provider contracts to the more stringent capitated systems. The system of reimbursement is essential in the consideration of providing mental health services in a primary care office.With fee-for-service, services billed are paid at published rates. Limitations might exist on fees allowed or on allowable diagnoses based on provider credentials. Procedure codes might also be limited by provider type, as described previously. But fee-for-service provides reimbursement for specific work done for the individual patient.Managed care contracts may use a modified fee-for-service reimbursement mechanism or rely on capitated reimbursement, where a practice receives a small monthly capitation to provide all primary care services for a patient over the length of the insurance contract. Practitioners receive the same amount per month for high service utilization as for nonutilizers. Consequently, there is no financial incentiveto take the extra time to deliver mental health services; indeed, there is a disincentive. Capitation inadvertently rewards the practitioner who ignores psychosocial issues.Recognizing the importance of behavioral health services in primary care, the American Psychiatric Association in collaboration with the American Academy of Pediatrics, the Society for Developmental and Behavioral Pediatrics, the American Psychology Association, the Society for Pediatric Psychology, the American Academy of Child and Adolescent Psychology, the National Institute for Mental Health, and the Maternal and Child Health Bureau of the US Department of Health and Human Services developed the Diagnostic and Statistical Manual for Primary Care (DSMC-PC).8 TheDSM-PC utilizes diagnoses consistent withDSM-IV9 and the International Classification of Diseases, Ninth Revision10 and includes diagnostic descriptors. Each diagnostic category is considered from normal variant, through problem behaviors, to full diagnosis. In addition to diagnostic criteria, each category is described, exemplified, and differential diagnoses and comorbidities are noted. The DSM-PC is useful not just for coding, but also as a reference source.The DSM-PC now provides primary care pediatricians with the diagnostic codes necessary to bill for the psychological services they provide in their practices. Although insurers may continue to reject claims from primary care physicians for certain diagnoses, types of services, or supplementary situational morbidities, a schema for demonstrating the breadth of psychosocial service problems cared for and time spent in the provision of services is an important first step. Proper diagnostic coding allows the assessment of outcome and justification that effective services were provided. It allows the primary care physician to more fully describe their interventions than could be accomplished with simply medical diagnoses. A new standard of care can be established and documented. Now the insurance companies may argue “pediatricians don't do that.” If primary care pediatricians would simply tell insurance companies what they do, the basis for reimbursement is established. If it is consistently billed, a new standard is defined and reimbursement must follow.An important contribution of DSM-PC to primary care pediatrics is its inclusion of both normal variant and problem level diagnostic criteria and codes. In addition, a series of situational codes are included, allowing consideration of environmental factors that impact on the child and family's mental health, for example, marital discord and family divorce or homelessness. TheseInternational Classification of Diseases codes are “v codes,” characterized as “supplementary classification of factors influencing health status and contact with health services: a problem is present that influences a person's health.” Yes, many pediatricians are convinced that the “v” stands for “very unlikely to be reimbursed.” But adding a second “v” code diagnosis to the primary medical diagnostic code of the patient encounter may justify “upcoding” to a higher procedure code for reimbursement for the office visit.What can be done in the meanwhile? In the fee-for-service system a number of special codes, which are poorly used, are allowed to primary care physicians (see Table 1). These specific codes reimburse for some of the medical minutia, but they are often forgotten.In the managed care environment, primary care pediatricians who provide developmental and behavioral services should be encouraged to negotiate special contracts for these services. Two options are proposed. The argument can be made that pediatricians with expertise in psychosocial problem management could be seen as both primary care physicians and subspecialists. This is a familiar model that has been used by gynecologists who provide primary care general medical services for women as well as specialty obstetric and gynecologic care. Although insurance companies will not welcome this proposal, properly credentialed and experienced pediatricians should draw attention to their special skills that make them different from all other primary care providers who receive the same capitation or negotiated reimbursement, but do not provide the developmental and behavioral pediatric services.An alternative (although not mutually exclusive) argument has to do with the cost of consultants. Experienced pediatricians might argue that it is less costly to the insurer for the experienced pediatrician to care for children with attention-deficit/hyperactivity disorder, family adjustment problems, or uncomplicated depression than it would be to refer that child to a specialist. One argues that the long-term relationship with the child and family provides a more cost-effective opportunity for intervention.In addition to contracting, pediatricians providing special services must be prepared to defend and challenge denied claims. An example of such a defense is found in Table 2.Just as generalists may need to call on subspecialists for assistance with their patients' medical problems, generalists must have access to mental health professionals for assistance in management of behavioral and psychosocial problems. Although it is important that general pediatricians take a more active role in these frequently occurring morbidities, they cannot be expected to provide this type of service without appropriate backup. Will consultants be available?In recent years, primary care physicians have taken on an ever-increasing role in prescribing psychotropic medications. This is a complex and ever-expanding pharmacology, often with only subtle differences between agents but perhaps remarkable differences in appropriate use and outcomes. Noting our expanding understanding of brain function on the cellular and molecular levels, one managed care company medical director has noted, “In ten years all mental health will be pharmacology” (personal communication). Although few would agree with his assessment, the source and impact of this attitude are clear. Psychopharmacology will be a treatment standard, and primary care physicians will be expected to expand their treatments with these agents.Primary care doctors will need help. They will need to stay current with a new literature. They will need to assure themselves and their patients that they are providing up-to-date treatments of the highest quality, so that primary care pediatrics does not become the second balcony of children's psychopharmacology.Difficult cases need be discussed with other pediatricians or with specific mental health consultants. Consultation might include discussion of the pediatrician's own management, with specific recommendations and direction in the use of psychopharmacological agents.Select cases will need to be referred, and referral sources must be available. The American Academy of Child Psychiatry notes that 30 000 child psychiatrists are needed, but only 6300 are available. There is a maldistribution in child psychiatric services, and rural areas as well as areas of low socioeconomic status have the least access. Traditional Medicaid programs, that is, programs not enhanced by specific waiver, limit mental health providers to psychiatrists, psychologists, and other mental health providers only when supervised on site by a psychiatrist. Thus, access to clinical social workers or other masters level professionals, key providers for children, is limited. In this era of Medicaid expansion and the State Child Health Insurance Program, many states have included new provisions for mental health care access in their Medicaid expansion programs, increasing the availability of services.Access to providers in the Medicaid system continues to be limited by reduced reimbursements, often a fraction of the state's already low Medicare rates. It is common for mental health providers to limit the number of Medicaid referrals they will accept to preserve a mix of practice reimbursements.Managed care Medicaid is found in some states. Although these programs are designed to improve access to medical services, mental health services may be handled differently, similar to the private insurance programs.In other third-party contracts, the “carve out” of mental health coverage has resulted in limitations on services that are provided by a family's health insurance, and often a reduction in provider reimbursement. The extra out-of-session and unreimbursed time spent talking with parents, teachers, and others in the child patient's life is an additional disincentive to mental health providers for children. Managed care health insurance can complicate this process. Is the needed consultant in the same network as the primary care physician? If in a different network, can the patient be referred to that consultant? Is the referral process uniform, and does it ensure ready access, or is it cumbersome with delays and restrictions?The Surgeon General's report on children's mental health11 notes, “Mental health is a critical component of children's learning and general health.” Eight goals for addressing the mental health needs of all of America's children are proposed. Although all 8 goals are in the purview of primary care pediatrics, goal 7 deserves special mention: “Train frontline providers to recognize and manage mental health issues.”The medical model of our training can and will work for us as we provide these broader services addressing the new morbidities of our patients' behavioral health needs. We must take thorough histories and, to do so, enhance our interviewing skills. Pediatricians must become familiar with tested screening tools and checklists, assisting in developing appropriate differential diagnoses, and assessing the presence of comorbidities. Additional effective primary care interventions are needed, and primary care pediatricians will learn to use them. Each generalist must develop his or her own network for case discussion, consultation, and referral. New models for the collaborative practice of primary care and mental health practitioners working side by side must be developed that are community-based and not limited only to universities or training centers.Commitment to confronting the new morbidities of psychosocial problems is intrinsic to our pediatric identity, and the systemic changes necessary to allow this new standard of care are within our reach.