*Common Abbreviations: PMCs = psychiatrists for the medically complex; PH =
physical health; MH/SUD = mental health/substance use disorder; MBHO = managed
behavioral health organization; CIU = complexity intervention unit
Psychiatrists for the Medically Complex:
Bringing Value at the Physical Health & Mental
Health/Substance Use Disorder Interface
Roger G. Kathol, MD
University of Minnesota, Internal Medicine and Psychiatry
Elisabeth J.S. Kunkel, MD
Thomas Jefferson University, Psychiatry
Joseph S. Weiner, MD
Albert Einstein College of Medicine, Psychiatry and Internal Medicine
Robert M. McCarron, MD
University of California Davis, Psychiatry and Internal Medicine
Linda L.M. Worley, MD
University of Arkansas, Psychiatry and Obstetrics/Gynecology
William R. Yates, MD
Laureate Research Center, Psychiatry and Family Practice
Paul Summergrad, MD
Tufts University, Psychiatry and Internal Medicine
Frits J. Huyse, MD
University Medical Center Groningen, General Internal Medicine
Correspondence Address: Roger Kathol, M.D., 3004 Foxpoint Road, Burnsville, MN
55337; phone: 952-426-1626; email: firstname.lastname@example.org
Word Count: 3177
Keywords: integrated care, medical psychiatry, complexity, service delivery
In their current configuration, traditional consultation-liaison services: a) see a
suboptimal percentage of general hospital inpatients that could benefit from their care, b)
are poorly reimbursed, and c) bring limited value in terms of clinical improvement and
reduction in health service use. During the last twenty years, newer models of cross-
disciplinary integrated health services for complicated patients in the medical setting
have been shown to promote health and lower cost. Such complicated patients have “high
health complexity” with costly admixtures of physical, mental, social, and health system
difficulties. This article discusses clinical and financial arguments that psychiatrists for
the medically complex can use in leading a change from traditional consultation models
to innovative value-added programs. Core components include partnering with others
who benefit clinically and economically from program creation and billing for services
from a single pool of medical and behavioral insurance dollars.
The ability of psychiatrists for the medically complex (PMCs) to improve the health of
medical and surgical patients has grown tremendously over the past two decades. Studies
now demonstrate improvements in clinical and economic outcomes when patients with
concurrent physical health (PH) and mental health/substance use disorders (MH/SUDs)
receive evidence-based psychiatric interventions that are tightly coordinated with
treatment of physical disorders in the medical setting.1 These patients tend to have
elevated health complexity and high service use. Despite this documented possibility for
improvement, we must still ask, “Are general medical patients with comorbid psychiatric
conditions currently receiving better care than they have in the past?” In 2008, the short
answer to this question appears to be no. This paper explains why and offers an
innovative conceptual model for health care delivery.
PMCs include psychiatrists with psychosomatic medicine expertise (with and without
subspecialty board certification) and/or with residency training in a second non-
psychiatric specialty, e.g. internal medicine, family practice, pediatrics, or neurology.
This article is intended to challenge basic assumptions that PMCs have about their
clinical services and the way that they are delivered. The authors also hope to stimulate
thought about alternative modes of care and suggest innovative approaches to obtaining
revenue for the services they provide. An analysis of traditional consultation programs
sets the stage for understanding the importance of moving toward value-added programs,
i.e. those that predictably improve clinical outcomes for patients with elevated health
complexity in a high quality, fiscally responsible way.
Do Traditional Consultation Programs Consistently Bring Value to Patients?
In 1996, Hall and Frankel published an article extolling the clinical and financial value
that PMCs bring to patients with comorbid conditions through traditional consultation-
liaison services.2 Unfortunately, few traditional consultation services have the
characteristics that lead to the value they described, such as early and appropriate referral,
timely response, and consistent implementation and follow through on consultant
recommendations by qualified practitioners. In fact, inherent limitations of traditional
consultation programs (Table 1) mitigate against improved outcomes for most patients.3-7
(insert Table 1 about here)
As a consequence of these limitations, PMCs see few patients with high health
complexity in which they truly could make a difference. In the patients they do see,
inadequate staffing and time constraints, often resulting from poor financial support for
PMC services, obstruct the mechanics of assessment and intervention. Recognizing the
shortcomings described in Table 1, PMCs should consider designing programs with
better performance metrics.
Patients with Health Complexity
Patients with high health complexity, defined as those with suboptimally addressed
physical, psychological, social, and health system factors, should be the priority for most
PMC programs.1 Complex patients are of major concern to health systems, nationally and
internationally, largely because their multifactorial treatment resistance increases health
service utilization and total health care costs. Importantly, in 50% to 80% of complex
patients, psychiatric morbidity contributes to: a) poor medical disease outcomes; b)
persistent, excessive healthcare cost burden; c) healthcare resource utilization; d)
disability; and e) use of public entitlement programs.10
Magnitude of the Challenge for PMCs
In order to implement valued-added PMC programs, one first must grasp the magnitude
of the challenge for PMCs. Currently, national agendas encouraging assessment and
intervention in patients with MH/SUDs focus on disparities of care seen in the MH/SUD
sector of the health system. The majority of MH/SUD resources go to only 10% of all
patients with MH/SUDs (Figure 1).11-13 Of these, many with severe psychiatric illness
have excessive rates of medical illness and associated mortality, but limited direct
medical care in the specialty MH/SUD sector.14 Ninety percent of patients with
MH/SUDs, however, are seen in the general medical health sector, but only about 30%
receive treatment for their MH/SUDs.13, 15-17 In short, a small number of PMCs are
expected to pick up the MH/SUD treatment burden for the majority of those with
MH/SUDs in an environment with limited reimbursement.
(insert Figure 1 about here)
Collaboration with MH/SUD professionals by other disciplines in the development of
PMC programs is crucial. Existing research demonstrates that collaboration among
providers can deliver services resulting in clinical improvement and health care cost
reduction in a variety of conditions (Table 2). This would also support primary and
specialty medical clinicians. Since medical clinicians typically receive only marginal
training in the diagnosis and treatment of MH/SUDs,18, 19 it is necessary to augment the
limited number of psychiatrists available with other MH/SUD clinicians to support
primary and specialty medical physicians, preferably working in concert with PMCs.
(insert Table 2 about here)
Models of PMC Programs That Add Value
In the current health system, which segregates PH from MH/SUD care,10, 36 over two
thirds of complex patients with psychiatric illness remain undiagnosed and untreated for
their psychiatric conditions,16 yet effective MH/SUD treatment is necessary to reduce
adverse medical and psychiatric outcomes. This creates an opportunity for PMCs to
Table 3 lists several value-added PMC programs, which target patients with high health
complexity. While the list is not comprehensive, the programs included serve as
examples of those with evidence demonstrating clinical and economic value to patients
and to the health system.
(insert Table 3 about here)
Specific Inpatient Value Added Programs
Proactive Case-Finding Consultation Services Using Empirically Validated Tools
To improve outcomes for the majority of patients who need MH/SUD attention in the
medical setting, we propose the development of proactive PMC consultation programs
(insert Table 4 about here)
In the proactive consultation model, there is an active process used to uncover complex
patients at admission to the medical setting and to automatically involve the PMC team
when a predetermined level of complexity is found. Complexity indicators (red flags)41
generated from clinical and administrative data and assessment tools, such as the
INTERMED,59 can be performed as a part of the admitting nurse assessment in selected
high-risk patients.57, 58, 60 Patients referred through the traditional referral system will
decrease, while those uncovered early after admission will increase and produce the
greatest value for patients.
Delirium Prevention Programs
Delirium has high morbidity, mortality, and associated costs, both during and after acute
hospitalization.61-64 A natural activity for a proactive consultation service would be
delirium prevention. The development of delirium can be prevented in about a third of
those at risk.23-27, 65 Surprisingly, few hospitals support delirium prevention programs
despite the tremendous value that they could bring in terms of lowered morbidity,
mortality, cost, and staff burnout. In those cases where delirium occurs despite
prevention efforts, handy PMCs can contain the morbidity and mortality associated with
delirium by providing guidance for acute treatment to the patients’ clinical unit staff.66, 67
Complexity Intervention Units
Traditionally, we have used the term Medical Psychiatry Unit (MPU) to refer to an
inpatient clinical location capable of addressing both general medical and psychiatric
symptoms in the same setting. In this article we propose the adoption of a new name,
“Complexity Intervention Units,” or CIUs, which emphasizes the need for high and
integrated PH and MH/SUD service capabilities in the general medical hospital setting.
In essence, CIUs refer to previously described Type III and Type IV MPUs with
additional organizational expectations (Table 5).42, 68
(insert Table 5 about here)
While core components, which allow assessment and treatment of all medium to high
acuity PH and MH/SUDs are inherently present, CIUs also contain capabilities that more
effectively and efficiently enable staff to address barriers to improvement in the social
and health system domains, e.g. nursing home placement of patients with physical and
mental health post-discharge needs, resolution of the competing medical and behavioral
insurance company non-payment debate, etc. Several of the core characteristics of CIUs
are mandatory. Without these features, CIUs put patients at safety risk from either PH or
MH/SUD adverse events. Non-mandatory characteristics are encouraged but have
greater capacity for customization as specific programs are developed for health delivery
CIUs add value through their ability to institute aggressive, full range, and combined
treatment for patients with complicated PH and MH/SUDs. Their focus is on providing
care for the 1% to 2% of complex patients who account for a quarter to a third of
healthcare resource utilization. Since CIUs provide efficient, effective PH and MH/SUD
intervention from the first day of hospitalization and improve comprehensive post-
discharge planning; clinical outcomes can be improved; hospitalizations can be
shortened; and the admission-readmission cycle can be broken. Symptom control in
patients with acute and concurrent but discrete PH and MH/SUDs, in those with delirium,
in polysubstance abusing patients with medical complications, in malingering and
factitious disorder patients, and in non-adherent patients with chronic medical illness and
personality disorders, amongst others, is easier to achieve when the full range of PH and
MH/SUD services is coordinated in a single setting.
Indirect benefits brought by CIUs include: 1) reduction in the burnout of nurses who have
to deal with these complex patients on other units that are poorly equipped for such care;
2) better relationships between MH/SUD and PH physicians and staff through a focus of
mutual assistance; 3) improved ability of staff in other areas of the general hospital to
handle psychiatric comorbidity due to nurse to nurse in-services and communication; and
4) excellent training for many health professionals (staff physicians, medical students,
residents, nurses, pharmacy students, social workers, etc.) in integrated care techniques.
Outpatient Value-Added Programs
Outpatient programs are necessary to sustain and augment gains achieved during
inpatient admissions of those with high health complexity. They also integrate care for
complex patients who otherwise would be seen sequentially in the general medical and/or
psychiatric outpatient settings.
Primary and Specialty Medical Clinician Training in Physical Symptom “Reframing”
For patients with PH concerns that are exaggerated by psychiatric issues, primary and
specialty medical practitioners often order unnecessary tests, obtain unnecessary
consultations, and give unnecessary medications.69-71 It is important for these clinician to
learn how to recognize and conservatively manage such patients. This will limit the
development of iatrogenic illness and to curb the overuse of health care resources.
The health systems, which have done the most to assist primary and specialty medical
physicians in this regard, are found in Denmark72 and in the United Kingdom.31, 73 Both
have active campaigns to train general and specialty medical practitioners to reframe their
own and their patients’ perceptions of somatic symptoms so that unnecessary test
ordering, medication prescribing, and specialist referrals can be avoided. Such training
programs help the physician link conservative medical work-ups with the identification
and treatment of psychiatric illness that often leads to and/or exacerbates the expression
of multiple unexplained physical concerns.
Integrated MH/SUD-Primary and Specialty Medical Clinics
There are now several research groups that have shown value in co-locating PH and
MH/SUD professionals in medical settings to enhance the treatment of depression,40, 50, 74-
77 anxiety,78-80 and chemical abuse/dependence22, 52, 81 (Table 2). Through proactive case
finding of those with higher health complexity and coordination of PH and MH/SUD
services, in part through the use of case management, the value of such services is further
enhanced.1, 40, 57, 58, 60, 82 Integrated outpatient organizational attributes are summarized in
(insert Table 6 about here)
By introducing integrated practices, it is possible to identify at risk patients early; to
support, reassure, diffuse crises, and/or give medication for emotional and behavioral
issues in the medical setting; to refer for more sophisticated MH/SUD interventions, such
as formal psychotherapy; and to limit aggressive medical testing and intervention in those
with unexplained physical complaints because reframing techniques are used and
assistance with MH/SUDs is available. PH and MH/SUD integrated capabilities also
facilitate the introduction of primary care-based clinical programs such as depression
screening and treatment,86, 87 screening and brief interventions for alcohol abuse,88
buprenorphine clinics,89 and SUD rehabilitation for the medically compromised,22, 81 all
of which have been shown to improve clinical outcomes and lower total health care costs.
Realistically, financial viability is the most important issue to hospitals and clinics and
cost savings is most important to insurers. It influences whether they will support new
program development or replace ineffective or unprofitable programs with alternatives.
For this reason, program proposals must be framed in the context of the value that would
be brought to each stakeholder as well as to the system as a whole.
In today’s world, billing for traditional consultation services through managed behavioral
health organizations (MBHOs) and public payors that use MBHO payment business
practices typically does not lead to incomes that cover traditional consultation PMCs
salary needs. MBHOs, which pay based on segregated behavioral health risk/cost
projections, have a vested interest in shifting costs for MH/SUD services delivered in the
medical setting to medical benefits—benefits for which PMCs are not network providers
and for which they cannot bill. This is a “no win” situation.90
PMCs cannot rely on psychiatric administrators to take care of finances for them since
they have little knowledge of billing through medical benefits and have little incentive to
advocate for PMCs since MBHOs pay so little for the services that PMCs provide.
Further, it is unrealistic to ask psychiatry department chairs or hospital administrators to
underwrite traditional consultation services that have limited value to patients and
hospitals and when they are nearly or actually financially insolvent. They also cannot be
asked to approach insurers for increased funding for services when clinical outcome
improvement and cost savings are not a part of the equation.
The development of programs with demonstrable value in terms of total health (PH and
Mh/SUD) and cost is the only way for PMC to effectively alter current funding
challenges. PMCs must create the vision and then market their services to public and
private payors. But how can PMCs move toward adequate reimbursement for their
work? Since MBHOs have a disincentive to pay for MH/SUD services outside the
behavioral health setting, it is necessary to identify alternative sources for funding.
Logically, PMCs should approach funding partners who would benefit from the value-
added services that PMCs provide. The most obvious potential partners are:
1) General medical care delivery systems (hospitals/clinics)—It is possible to
generate arguments for financial support because delirium prevention programs,
proactive consultation services, integrated general medical clinics, and CIUs can
decrease facility costs for one-on-one nursing care, can shorten lengths of stay
(thereby improving DRG-related profits and reducing per diem financial losses in
non-paying patients), can reduce nursing burn-out on other medical and
psychiatric units, can reduce liability for adverse MH/SUD-related events in the
medical setting, and can lessen clinical demand by low or non-paying patients
who achieve better control of both medical and psychiatric symptoms.
2) Non-psychiatrist provider groups—If non-psychiatrist physicians partner with
PMCs for payment through medical benefits by coordinating and collaborating in
contract negotiations, the incentive for internal medicine and family medicine
departments to add psychiatrists to their onsite staff may become more
pronounced. This is because such psychiatrists would be able to improve the care
of time consuming complex patients and also “pay their own way” due to
reimbursement levels comparable to their own.
3) General medical health plans—Value-based PMC activities save general medical
health plans money by indirectly reducing non-behavioral claims costs far in
excess of the cost of PMC services provided.91 By paying PMCs through medical
benefits to see patients in the medical setting in value-based programs, of which
behavioral benefits would be an integral part, medical health plans would: a)
support better care, b) lower claims costs, c) look good to their purchasers
(potentially increasing their market share), and d) be able to offer more
competitively priced products. Interestingly, they would do this by supporting
services that provide better care to their members, not through medical necessity
There is now indisputable evidence that complex patients with concurrent PH and
MH/SUDs: 1) are common yet, in most, MH/SUDs remain under or untreated; 2) have
worse PH outcomes; 3) manifest high health care service utilization; 4) are identifiable
using standardized patient complexity identification tools; 5) commonly become
disabled; 6) can predictably improve if given evidence-based treatment; and 7) show
reversal or improvement of adverse outcomes when effectively treated for both their
general medical and psychiatric problems in the medical setting.36
Therefore, PMCs should encourage development of programs in which existing evidence
shows improved health outcomes for patients with complex problems. Because these
programs bring clinical value to patients and economic value to health care delivery
systems and medical health plans, they offer creative alternatives as PMCs seek financial
support for the services they provide.
Such program proposals need to come from PMCs. To do this effectively, PMCs must
become conversant in the value that they can bring. They need to introduce the
program(s) for consideration using both data and patient examples to bring across their
points. Finally, they must have thought through the clinical and financial components
needed to transition to a new approach to care in their setting, i.e. personnel needs, space
requirements, physical plant changes, administrative involvement, billing and collections,
start-up costs, and anticipated breakeven point. They must present their plans to
stakeholders with the potential to benefit, including non-psychiatric medical colleagues,
general hospital administrators, and medical health plan medical directors and executives.
The ability to replace marginally effective approaches to care with quality and cost
saving alternatives make the investment and eventual return on investment acceptable.
The recommendations in this article are radical. In fact, many would describe them as
unreasonable. They will not lead to immediate funding to support the addition of PMCs,
nurse clinicians, or social workers for existing traditional consultation services. They
will not lead to increased reimbursement for existing consultation programs by managed
behavioral health companies. In fact, this article argues that we should not even be trying
to accomplish support for traditional consultation through existing reimbursement
structuresh. Rather, our future lies in the development of value-added programs within
the general medical reimbursement system, in which MH/SUD is considered just one of
the paid components of health.
Significant challenges exist in bringing the programs described to fruition. We strongly
encourage marketing, debate with decision-makers in care delivery systems, and lobbying
for support of such programs. Initial discussions will likely meet with resistance for a
variety of reasons, such as person-power shortages, reimbursement issues, and
interdisciplinary leveraging. With time, receptivity will improve and action will be
taken, small step by small step.
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Table 1: Traditional Consultation Program Limitations
o Financial support for fewer PMCs than needed, based on the prevalence
and clinical needs of patients with psychiatric comorbidity in the general
o Lack of inclusion of other mental health disciplines in PMC programs
and/or availability of specialized assessment and intervention capabilities
by professionals from these disciplines
o Poor coordination of PMC services with those provided by other mental
health disciplines, such as psychiatric nurses and psychologists, who often
offer competing PMC-like services
o Inefficient use of time for office-based PMCs traveling for occasional
consultations to general hospitals or medical clinics
• Patient referrals
o Reactive, not proactive, involvement with patients, i.e. based on referral
by non-psychiatric physicians who may not fully recognize the impact of
psychiatric comorbidity on physical health outcomes
o Referral of only 0.5% to 3% of general hospital admissions8, 9 when
outcome improvement could occur in 20 to 30% of general hospital
admissions with prevalence-based aggravating MH/SUD comorbidity5
o Frequent referral of patients in low need of psychiatric consultation
• Consultation mechanics
o Crisis-oriented with few preventive and/or active identification programs,
e.g. delirium prevention and proactive complex case finding
o Short, problem-focused assessments with little collateral information
o Performed late in hospitalization
o Few, if any, follow-up visits due to timing of consultation requests,
staffing constraints, and/or fiscal limitations
• Treatment delivery
o Often dictated more by the lack of availability of personnel needed to
deliver treatment than the appropriateness of the treatment recommended,
e.g. substance use disorder specialists for alcohol or drug-related
interventions, psychiatric nurse specialist to assist with limit setting in the
o Lack of integrated PH and MH/SUD electronic medical records
o No action on consultation recommendations in >50% of patients by
referring physicians or post-discharge clinicians3, 5-7
o Medical unit staff with limited comfort and/or capabilities in following
through on MH/SUD intervention recommendations, e.g. limit setting,
administration of intravenous haloperidol
o Lack of programs to transition patients from inpatient to outpatient
Figure 1: Physical and Mental Health Treatment Location and Allocation of Health Care
Table 2. Health Care Delivery-Based Integration Improves Outcomes and Lowers Cost
• Depression and diabetes: 2 months fewer days of depression/year; projected
$2.9 million/year lower total health costs per 100,000 diabetic members20
• Panic disorder in primary care: 2 months fewer days of anxiety/year; projected
$1.7 million/year lower total health costs per 100,000 primary care patients21
• Substance use disorders with medical compromise: 14% increase in
abstinence; $2,050 lower annual health care cost per patient in integrated
• Delirium prevention programs: 30% lower incidence of delirium; projected
$16.5 million/year reduction in inpatient costs per 30,000 admissions in 2005
• Unexplained physical complaints: no increase in missed general medical
illness or adverse events; 9% to 53% decrease in costs associated with
increased healthcare service utilization28-35
Table 3: Value-Added PMC Programs
o Proactive complex case finding consultation services37-41
o Delirium prevention programs25, 26
o Complexity Intervention Units (CIUs) with dedicated PH and MH/SUD
capabilities in general hospitals42-44
o Primary and medical specialty physician training in the use of the physical
symptom reframing for unexplained physical symptoms45-47
o Integrated MH/SUD in primary and specialty medicine clinics20, 21, 48-50
o Co-location of cross-disciplinary PH and MH/SUD clinicians with
proactive complexity case finding40
o Funded integrated case manager support51
o Screening and brief intervention for alcohol abuse52, 53
o Primary care buprenorphine and integrated SUD rehabilitation programs54,
Table 4: Proactive PMC Consultation Programs—an Updated Model of Care Delivery
Proactive Case Finding
• Admission screening for the top 5% with “red flags” for complexity41, 56
• Unit nursing staff use of a complexity assessment tools, such as the
INTERMED, to quantify the level of complexity and actionable steps to
change outcomes1, 39, 40, 57-59
• PMC team involvement in all (most) admissions with high complexity
through an automated referral process, upon or immediately after admission
• Adequate consultation team staffing to meet clinical demands
• PMC led multidisciplinary MH/SUD teams to assist with assessment and
psychiatric intervention, e.g. nurses, social workers, physician assistants, and
• Active communication with unit staff and physicians regarding assessment
and intervention; unit staff training when necessary, e.g. limit setting
Long-term Chronic Disease Perspective
• Use of case and disease managers when available, either in the hospital or
through the patients’ health plans or outpatient clinics
• Regular follow-up throughout the hospital stay until symptom stabilization or
maximum benefit is achieved
• Continuous outcome measurement with disease-focused measurement tools,
e.g. PHQ-9, HbA1c
• Assistance with transfer to an inpatient complexity intervention unit (CIU)
when appropriate and with discharge referrals into integrated outpatient
Table 5: Core Complexity Intervention Unit Characteristics
• Administered through a primary care and psychiatric alliance
• Location: general hospital under “medical bed” licensure,* yet with
“psychiatric bed” licensure attributes
• Physical structure: both PH and MH/SUD safety features and capabilities,
based on anticipated patient acuity*
• Facility coding and billing: to general medical health plans (with ability to bill
behavioral health plan when needed)
• PH and MH/SUD professional coding and billing: same day reimbursement
regardless of billing procedures
• Admission focus: patients with high health complexity
• Consolidated general medical and psychiatric policies and procedures*
• Moderate to high PH & MH/SUD acuity capabilities*
• Physicians coming from combined residencies or primary care and psychiatry
co-attending physicians with consistent communication and coordination of
PH and MH/SUD care*
• Enhanced use of double boarded (medicine, family medicine, pediatrics or
neurology and psychiatry) physicians for clinical care and leadership
• Nurses and other staff cross-trained in PH & MH/SUD assessments and
• Administered through general medicine nursing
• Strong social service support
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Table 6: Core Integrated Outpatient Care Organizational Attributes
• Administered by general medicine with PMC team members in the PH clinic
setting20, 48, 83
• Active collaboration and communication of co-located PH and MH/SUD
practitioners20, 48, 83
• Proactive complex case identification, such as with INTERMED technology40, 57,
• Nurse case managers assist in complex patient care using integrated PH and
MH/SUD case management methodology57, 58, 60, 85
• Nursing staff with basic PH and MH/SUD cross-training
• PH and MH/SUD accountability for all clinicians working with patients
• Outcome orientation