Access to Quality Care: Psychosomatic Medicine

Recently I had the opportunity to participate in a critical discussion aimed at addressing a key priority: access to quality psychosomatic medicine for our patients. The Center for Mental Health Services (CMHS) and Treatment Effectiveness Now (TEN), a policy action consortium focusing on access to care for patients for co-occurring psychiatric and other types of medical disorders, sponsored a daylong meeting of psychiatric thought leaders from APA and the Academy of Psychosomatic Medicine to discuss the work of the New Freedom Commission and more specifically its Subcommittee on Mental Health Interface with General Medicine. The subcommittee helped shape several specific goals and recommendations that were included in the commission's final report. (The subcommittee's report can be accessed at the New Freedom Commission's Web site at<www.mentalhealthcommission.gov/subcommittee/MHInterface_010803.doc>.)

The purpose of the retreat was to review the commission's findings and recommendations and begin to develop an action plan to address barriers to patients' receiving integrated care.

Through the leadership of Mel Haas, M.D., of CMHS, Anita Everett, M.D., of the Substance Abuse and Mental Health Services Administration (SAMHSA), and Carol Alter, M.D., of TEN, the group focused on the report recommendations that further research be conducted in psychosomatic medicine; that support be continued for demonstrations of effective models of care; that collaborative care models be reimbursed; and that the federal government address ways that Medicare, Medicaid, and other federal programs and private insurers can better coordinate and provide care for patients with psychiatric and other medical needs.

Jurgen Unutzer, M.D., the author of the subcommittee's report, discussed evidence supporting the use of collaborative care models in primary care settings. Dr. Alter, a member of APA's Council on Psychosomatic Medicine and executive director of TEN, reviewed the complex nature of reimbursement for psychiatric care of medically ill patients, noting that current reimbursement practices resulted from the carveout of mental health care from insurance benefits and the inadequacies inherent in segregating mental health from physical health.

Others in attendance included Drs. Constantine Lyketsos, Philip Muskin, and Steven Epstein, members of APA's Council on Psychosomatic Medicine. They discussed the role that APA can play in addressing barriers to integrated care. It was helpful to have the viewpoints of two residents from the George Washington University department of psychiatry, Drs. Kimberly Humann and Niku Sing. From my perspective, a critical issue that needs to be addressed is psychiatry residency training in psychosomatic medicine and its funding.

It was clear the group felt that the New Freedom Commission's recommendations provide an important opportunity to support the work that those of us in psychosomatic medicine have already begun and need to build on. The group felt strongly that we need to support current efforts to build a research agenda with the National Institutes of Health, Centers for Medicare and Medicaid Services, and other federal agencies. This will drive the field to answer critical questions about the relationship of psychiatric illness to other medical illnesses and to support additional inquiries of large demonstration projects focusing on chronic medical illness. Drs. Haas and Everett felt strongly that CMHS and its parent organization, SAMHSA, will continue to play a role in helping with this process.

Finally, the group felt that there was a critical need to focus on the issues of cost of care for co-occurring psychiatric and other medical disorders, training, and the need to build an advocacy base within the larger medical community.

While there was a great appreciation of the complexity of the reimbursement landscape, there was also an understanding that we need to use APA's resources and power to ensure that answers to questions about reimbursement and access are identified quickly. APA's Council on Psychosomatic Medicine, under the leadership of Dr. Muskin, will begin to prioritize those projects, and Sam Muszynski and Becky Yowell of APA's Office of Healthcare Systems and Financing will address the reimbursement issues.

We have long struggled with the issues of access to and reimbursement for psychiatric care for medically ill patients, but the current confluence of factors including burgeoning clinical, economic, and research evidence regarding the impact, causes, and interventions for psychiatric symptoms occurring in chronically ill people creates an important opportunity for us to address barriers to receiving integrated care.

I commend Dr. Alter for her continued efforts to focus our attention on addressing barriers to access and the leadership and support of Drs. Haas and Everett. ▪