Prepaid Psychiatric Services from Family Physicians in Canada

Prepaid Psychiatric Services From Family Physicians in Canada

Alex Richman M.D., M.P.H. Professor, Departments of Psychiatry and Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada

This paper discusses the implications for National In addition, these questions remain to be Health Insurance of paying primary practitioners answered: for psychiatric services. Canadian data are used 1. What defines medical necessity? What cir- to detail the extent and distribution of such cumstances affect whether the patient’s services. symptoms, social predicaments and self con- The generally high cost of psychiatric treatment, cerns are diagnosed as a mental disorder? limited insurance coverage and the major costs Which conditions require care from physi- of inpatient care all act as barriers to the use of cians, rather than from other practitioners? specialized mental health services in the United States (1, p 7). Economic incentives and dis- 2. Could primary physicians, with training in incentives have a significant effect on the kind the requisite diagnostic and case manage- and extent of mental health services provided in ment skills, largely absorb the functions of fee-for-service settings (1, p 8). the psychiatrist? (1, p 188). The President’s Commission on Mental Health 3. Should the current role of psychiatrists be (2) in 1978 recommended that mild to moderate revised, redefined or perhaps expanded? (1, emotional distress become a major responsi- pp 188, 190). Could psychiatrists put their bility of primary practitioners. The Commission expertise to better use by providing specialist concluded that many of the financial barriers to consultation services to primary physicians, psychiatric care would be alleviated through rather than by providing continuing direct changes in health insurance coverage and care to relatively few patients? reimbursement. Insurance benefits for treatment 4. Does increased mental health care by pri- of mental disorders are sharply limited compared mary physicians decrease the use of general with reimbursement for other kinds of illness. medical services? (1, p 11). Often there is no provision for out-patient Categorization of Mental Disorders and treatment (1, p 196). Lack of reimbursement Psychological/Emotional Responses deters the involvement of primary care practitioners in mental health care (1, p 197). The majority of persons with psychiatric diagnoses seen by primary practitioners are suffering Improvements in diagnosis, treatment methods from relatively minor aliments which include and facilities have changed the picture of mental ’problems of living’, rather than the major mental illness. Whereas 40 years ago major mental illnesses (4). Clinicians are often unable to illness was apt to involve long-term hospitali- distinguish between emotional reactions, minor zation, present day prognosis is more favourable. mental disorders and major mental illness. Re- Minor mental illnesses can be treated with psycho- liable methods are still needed for differentiating therapy and/or drugs on an ambulatory basis. the spectrum of psychological disorders, situa- It is increasingly recognized that mental illness tions, behaviours and reactions, some of which comprises a major part of the disability and are not mental illnesses. distress seen by primary practitioners. However, there is wide variability in the reporting of mental It is as yet difficult to define syndromes for which disorder in the routine clinical records of general there is good clinical consensus on their natural practitioners, with a range of 1.3 to 6.3% (3). It history and severity, as well as the type and has been suggested that these differences in amount of therapeutic intervention needed. We physicians’ assessments reside not in the patients, are not yet able to specify the required duration but in the physicians’ concepts of psychiatric and frequency of treatment or the necessary disorder, and the thresholds adopted for case level of training and experience of the provider identification (1, p 9). Furthermore, a widely (psychiatrists, primary physicians or non- recognized and acceptable concept for cate- physicians). There is little consensus on the gorizing which patients or conditions can and medical necessity for treatment of: should be treated by primary practitioners does a) Everyday personal reactions to everyday not exist (1, p 188-9). problems, and temporary and appropriate

13 adaptations to the stress, Provincial medicare programs did not change b) Problems of ’emotionality’, personality the delivery of clinical services, which continued traits, culturally determined behaviour, and to be provided mainly by private practice phy- subjective perceptions of suffering, sicians working on a fee-for-service basis. The patient has a choice of physician, who submits a c) Transient psychological and behaviour- claim for the individual patient. There are no al symptoms and signs, and, limitations within the medicare system which d) Minor mental disorders. restrict the amount or duration of treatment for mental illness. Psychotherapy: Treatment and Personnel Post-Medicare Trends in Utilization of Prepaid Psychotherapy is defined in many Provincial fee Psychotherapy. Figure 1 shows the use of pre- schedules as "... any form of treatment for paid psychotherapy and counselling services mental illness, behavioural maladaptions and/or (excluding consultations and hospital visits) in 3 other problems that can be assumed to be of an Canadian regions over an 8-year period, 1972- emotional nature in which a physician deliber- 1980. During 1980-81, the population of 22.6 ately establishes a professional relationship with million used 6.5 million psychiatric services a patient for the purposes of removing, modifying costing $140 million. There were 270 services or retarding existing symptoms, of attenuating or (costing $5,872) per 1,000 population. Two-fifths reversing disturbed patterns of behaviour and of (40.4%) of these were provided by general prac- promoting positive personality growth and devel- titioners. Excluding pathology, radiology and opment. Accordingly, a psychotherapeutic pro- certain specialized services, psychiatric services cedure may be charged for if one-half hour, or amounted to 5.5% of the total costs of insured major part thereof, has been spent in such physician services, with an inter-regional range treatment of the patient". of 4.6% to 6.0%. Professionals other than psychiatrists (both medi- In comparison with 8 years earlier (1972-73), the cal and non-medical) are capable of providing absolute number of family practitioner psycho- appropriate counselling and psychotherapy ser- therapy and counselling services in 1980-81 had vices; there are thus broad variations in types of increased by 140% (from 1.2 to 2.9 million); the treatment and in providers’ skills. With the increas- cost by 341% (from 12.8 to 56.9 million); and the ing fuzziness of psychiatric boundaries and high services per 1,000 population by 117% (from 57 levels of apparent mental disorders in the general to 123). population, detailed data on utilization become increasingly essential. FIGURE 1 National Health Insurance in Canada CANADA: MEDICAL CARE INSURANCE PROGRAM PSYCHIATRIC SERVICES FROM GENERAL PRACTITIONERS In 1960, half of the provincial health insurance RATE PER 1,000 POPULATION programs did not include psychiatric services. In 1972-73 to 1980-81 the plans with limited coverage, psychiatric 140" services comprised 0.4 - 1.7% of the total costs. There was relatively little provision for psychiatric care by family physicians5. In Canada today 120- there is a comprehensive system of National Central Provi~ Health Insurance (NHI) for all age groups. This 100- system attempts to abolish discrimination and distinction between physical and mental illness. The method by which the provincial costs are 80- financed varies from province to province: in Western Provinces Ontario, there is an annual premium, and in Nova Scotia there is a sales tax. Each province has its own standard fee schedule for clinical proce- ~ dures. These fee scales are established by the 40- Medical Society, and negotiated with the provincial medicare commission. Currently, physician satisfaction with medicare varies, and is highest 20- in the Maritime Provinces. In February 1979, family physicians we are paid from $10.00 to $21.60 for a half-hour of psychotherapy (the median was $14.03). The variation in fee sched- FISCAL YEAR ules between provinces (co-efficient of variation) was similar for psychotherapy (20.7%) and other Figure 2 shows psychiatric services provided by types of procedures (23.2%). general practitioners as a percentage of total

14 medicare payments made to general practitioners comprehensive community care systems. in Canada. In this province, the proportion of the general FIGURE 2 population in contact with the specialized psychia- CANADA: MEDICAL CARE INSURANCE PROGRAM tric services remained relatively stable between PSYCHIATRIC SERVICES FROM GENERAL PRACTITIONERS AS A PERCENTAGE OF TOTAL PAYMENTS TO GENERAL PRACTITIONERS 1969-1974n (about 2% per year). During the 1972-73 to 1980-81 same period, the proportion recorded as having 6- a mental disorder by general practitioners progres- sively increased from less than 5% to nearly 7%6. During that 6-year period, approximately 250,000 individuals (out of Saskatchewan’s average population of 920,000) were recorded as having a mental disorder by private physicians or by the specialized psychiatric services. Patients with a recorded mental disorder used 17% more general medical services during the year of contact than persons not given an ICD Chapter V diagnosis. These figures show the high frequency of mental disorders routinely recorded in a total insured population. However, the picture of chronic disorder or continuing long drawn-out psychiatric care is not evidenced in the over-all experience of the total Saskatchewan population. 19=73 19’74 19’75 19=76 1~77 19’78 19’79 19~80 19~81 45% of a sample given a medical diagnosis of FISCAL YEAR mental disorder at some time during the 6-year period were not seen by a psychiatrist, were not The Experience of Two Canadian Provinces. hospitalized, and were recorded as having a Saskatchewan. Saskatchewan has been an inter- neurosis only during 1 or 2 calendar years. This national leader in changing its psychiatric services, group received an average of 2 medical services which are no longer based in mental hospitals, for mental disorder during the 6-year study but in regional hospital psychiatric units with period.

Percentage Distribution of Medical Services By Major Diagnostic Group

Diagnostic Group Age Group ALL 0-14 1544 45-64 65-74 75-84 85+ Mental Disorders 6.2 1.2 8.3 7.7 4.7 4.5 4.8 Respiratory 13.4 27.8 11.8 9.8 10.0 8.9 9.2 Circulatory 12.2 0.3 3.3 18.9 27.4 3O.3 32.1 Nervous System & Sense Organs 11.2 18.1 10.1 10.5 9.5 8.8 6.6 All Diagnoses 100% 100% 100% 100% 100% 100% 100%

Nova Scotia. In 1982, payments for mental per 100 male subscribers. In one city, 15.8% of disorders (to all physicians, including special- the females aged 20-34 and 6.4% of the males aged ists) made up 7.2% of medical expenditures. The 35-64 received psychiatric services from family proportion of medical costs spent on psychiatric physicians. Figure 3 shows the percentage services varied among the different demographic of the population with psychiatric services pro- sub-groups, and was highest for those aged 35- vided by family physicians in 1981-82. 44 -- 12.1% for males and 14.1% for females. 18% of the 494 full-time general practitioners did Similarly, the distribution of services by diagnosis not submit any claims for psychotherapy during also varied among the different age groups. 1982. One-third of the physicians (full-and part- In 1981, 2.2% of males and 5.6% of females time) submitting claims for psychotherapy re- received psychiatric services from family physi- ceived less than $500 during the year. The cians. Provision of services was highest for majority of psychotherapy and counselling in females aged 20-34 (9.7%) and males aged 35-64 general practice was provided by a minority of (3.6%); psychiatric services amounted to 10.7 practitioners: 54 (9.9%) claimed 55.6% of the hours per 100 female subscribers and 3.4 hours costs for general practitioner psychotherapy; for

15 FIGURE 3 changes in the patterns of practice or altered PERCENTA6E OF POPULATION WITH PSYCHIATRIC SERVICES billing. These changes include: FROM FAMILY PHYSICIANS a) Additional services which were not Nova Scotia, 1981,1982 previously provided, b) New patients who were not previously Dartmouth being seen, c) Increased supply of physicians with more time for psychiatric services, d) Services previously billed as office visits which, because of their time and nature, are afterwards billed as psychotherapy, or

0-14 15~19 20~34 35’-64 65+ e) Services previously billed as minoroffice AGE GROUP procedures being billed afterwards as these phys=cians, psychotherapy comprised involving psychotherapy. 21.4% of their medicare income. CONCLUSIONS Trends In Billing For Psycffiaffic Se~i~s What are the implications for National Health The marked variabili~ among general practi- Insurance of paying primary practitioners for tioners in the recording and recognition of psychotherapy? From the Canadian experience, mental disorders is well documented. One of the it can be predicted that: concomitants of NHI is the reduction of this 1. Primary practitioners will use a significant variabili~. In Nova Scotia, geographic variabili~ portion of the insurance payments for in general practitioner psychiatric se~ices medical psychotherapy. decrease. 2. The frequency of recorded mental illness will Psychotherapy, Counselling and Hypnothempy greatly increase. Se~i~ by Family Physicians, ~r 1,~ Patient, by Communi~ Size 3. At least 8-12% of the total medical costs for 1974 and 1~2 some age groups will be for the care of mental illnesses. Over one-fifth of some demographic groups will be recorded as Community Size Services per 1,000 Patients "mentally ill" during a 12-month period. 1974 1982 Under 2,000 23 45 4. Primary practitioners are responsive to provi- 2,000 - 9,999 24 42 ding more psychotherapy services when 10,000 - 35,000 13 61 levels of payment increase. Nevertheless, the Cape Breton (urban) 26 39 supply is still skewed, with a small number of Dartmouth 58 143 physicians providing the majority of all Halifax 106 163 services. Geographic differentials in billing for psycho- 5. The current general impression of mental therapy persist, even with universal reimburse- illness having a long duration and needing ment for psychiatric services by primary prac- persistent psychiatric care will be supple- titioners. Economic incentives are not suf- mented by recognition of many acute, short- ficient by themselves. Fiscal changes must be term disorders not requiring prolonged accompanied by mechanisms for integrating the psychiatric care. primary practitioner into the network of psy- 6. Geographic differentials in utilization will chiatric services, and into the spectrum of early persist, with higher rates of psychiatric ser- recognition, crisis stabilization, and the provision vices in metropolitan areas. of continuing support and care for the long term mentally ill. 7. Within any National Health Insurance program in the United States, current definitions The Number of Psychotherapy Services is of ’psychotherapy’ can not be used to dif- Correlated with Level of Payment. ferentiate the work of non-psychiatrist physi- The mechanism for the correlation between cians from that of psychiatrists. Better definitions of the clinical indications and psychotherapy services and levels of payment is medical necessity for psychotherapy will not clear. In the procedure schedule there are enable more effective methods and criteria very few charges for office procedures which are for quality assurance and utilization review based on time (or portion thereof). Increased psychiatric services, in response to fee schedule than now exist. changes for psychotherapy, may represent either 8. Without more specific definitions of psycho-

16 therapy and the medical necessity for treat- U.S. Government Printing Office, Washington, DC 20402, ment, psychotherapy under National Health 1980: 39-48. Insurance may not provide increased care Richman A, Brown MG. Reimbursement by medicare for for persons with major mental illnesses. mental health services by general practitioners: Clinical epidemiologic and cost containment implications of the Payment for psychotherapy under National Canadian experience. In: National Institute of Mental Health Insurance in the United States may be Health, Series DN No. 2. Mental health services in primary sought in the future for a burgeoning range care settings: Report of a conference, April 2-3, 1979. DHHS Publication No. (ADM) 80-995. Superintendent of Docu- of psychological and interpersonal interven- ments, U.S. Government Printing Office, Washington, DC tions performed by physicians, although 20402, 1980:122-150. they are not closely related to current Richman A. Psychiatric care in Canada: Extent and results. medical practice. A study prepared for the Royal Commission on Health Services. Ottawa: Queen’s Printer, 1966. References D’Arcy C. Patterns in the delivery of psychiatric care in Saskatchewan, 1971-1972: Service interface study interim National Institute of Mental Health, Series DN No. 2. Mental report. Applied Research Unit, Psychiatric Research Di- health services in primary care settings: Report of a con- vision, University Hospital, Saskatoon, Saskatchewan, 1976. ference, April 2-3, 1979. DHHS Publication No. (ADM) 80- 995. Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402, 1980. Acknowledgements President’s Commission on Mental Health. Report. The assistance of P.-P. Bellerose (National Health Washington, D.C.: U.S. Government Printing Office, 1978. and Welfare, Ottawa), Dr. H. Bland (Maritime Regier D. Nature and scope of mental health problems in Medical Care Inc., Halifax), V. Hicks, M.A. primary care. In: National Institute of Mental Health, Series (Maritime Medical Care Inc., Halifax), and J. DN No. 2. Mental health services in primary care settings: Report of a conference, April 2-3, 1979. DHHS Publi- Bagnall, B.A. (Dalhousie University)is acknow- cation No. (ADM) 80-995. Superintendent of Documents, ledged.