1.

BRENDEL: APA is a critical partner for ACLP in maintaining and extending the roles of psychiatrists in integrated and collaborative care settings and can work with ACLP in a number of ways to advance this work. As president of ACLP, I worked with the Board to strengthen our relationship with APA by becoming the first subspecialty organization to hold our midyear board meeting at APA headquarters, an important opportunity to meet face-to-face with APA to foster collaboration. As President-Elect of APA, I would continue to foster this relationship. APA is doing important grant-funded work on integrated care models in collaboration with ACLP members and is a key partner in disseminating knowledge about and data showing the important positive outcomes of integrated care. Now, especially with the mental health sequela of the COVID-19 pandemic in public view, APA is well positioned to continue its advocacy for policies and programs that center mental health as part of general medical care. APA’s work at the AMA is also critical to promoting the value of integrated care to medical and surgical colleagues. Because of this important relationship, during my presidency of ACLP, the Board voted to seek membership in the AMA House of Delegates for ACLP, and currently has secured a three-year provisional membership as part of the larger psychiatry delegation to AMA. ACLPs presence at the policy-making meetings of AMA alongside APA has the potential to engage medical and surgical colleagues in advancing strong policy for integrated care. I would welcome the opportunity to continue advocacy for integrated and collaborative care as President-Elect of APA.

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FELDMAN: The APA most assuredly should support the ongoing efforts of including psychiatrists in integrated settings. Broadening and strengthening the reach and impact of psychiatry in integrated settings rests on three pillars: the skills-set and comfort level of the psychiatrist, the acceptance of consultative services by the integrated care setting, and maximization of reimbursement for services provided. 

Skills-set development and development of ease in these practice settings should begin in residency training, and carry across all 4 years; opportunities for integrated care clinic placement and supervision for advanced residents combined with sophisticated, nuanced curricula would enhance that trajectory. GME/RRC requirements for such training is somewhat generic; enhancing and promulgating specific training curriculums by the APA Council of CL Psychiatry would be incredibly useful and productive. Already this year that Council has sponsored webinars, Psychiatric News articles, and a position statement on Medicaid reimbursement; further efforts along these lines would be helpful.

The acceptance of psychiatric consultative services by integrated care settings is an on-going challenge; while many clinics have embraced these practices (which research has shown can effectively enhance remission and reduce recidivism), increasing use of this model is imperative, because there simply are not enough psychiatrists to see every patient that needs prompt mental health access.  Perhaps the APA Council on CLP and ACLP can work in conjunction to develop report-card/quality metrics that clinics can use to self-evaluate their (and patient) satisfaction with access to mental health care.

Ultimately, psychiatric services cannot continue to be provided without either insurance reimbursement or contractual payment by clinics who realize consultative (and often preventative) services reduce patient care costs. The APA must continue its efforts (see the Council on CL Psychiatry position paper on Medicaid services extended for one-year post-deliver y care) in terms of defining, quantifying, and educating insurers of the efficacy of such delivery systems; barring that, we should use the threat of Wit v United Behavioral Health, or the resultant level of care/utilization of services tools to insist on appropriate care with appropriate cost-reimbursement.

The APA should develop and promulgate models of collaboration, and offer curriculum, didactics, webinars for non-psychiatric medical organizations. Requirements that residents training in internal medicine and family practice spend part of their training (1-2 months) in a psychiatric training opportunity might go a long way to diffusing stigma around treating those living with mental illness. There are combined internal medicine/psychiatry and family medicine/psychiatry residencies and fellowships; encouraging funding of said programs (or perhaps lobbying for student loan forgiveness for those who participate) might accelerate the growth of the skills set, ease with the collaborative care model, and ultimately reimbursement for said services.

2.

BRENDEL: As systems of healthcare continue to evolve, CL psychiatrists and ACLP are more important than ever before in shaping and implementing psychiatric care within medical settings given our unique understanding of and experience at the intersection of psychiatry and medicine. I imagine ACLP working closely with APA on models of integrated care and collaborative care, on implementation strategy and benchmarking to adequately fund psychiatric care and reimbursement on par with other medical care, and on closing the gaps in care for persons with comorbid medical and psychiatric conditions. This work would include advocacy for psychiatric treatment for patients with medical illness and also focusing attention on the medical and general health needs of persons with chronic mentally illness, who have a significantly reduced life-expectancy compared to the general population.

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FELDMAN: I believe that models of integrated care/collaborative care clinics are the wave of the future, as there is simply not enough of us to treat everyone who needs treatment. As a field, we have to be ready to provide support and consultation to our “other” medical brothers and sisters. As the APA strives to carry the profession into the future, it translates into needing a firm alliance with the ACLP and CL psychiatrists to ensure we have a cadre of psychiatrists trained and willing to offer collaborative/integrated services. As well, the APA should utilize the ACLP and CL psychiatrists to teach the rest of us about these services..most of us do not go into CL psychiatry, and yet we are called on, time and again, to provide this kind of care. Would it be helpful for the ACLP/CL psychiatrists to develop a 2-3-hour curriculum that can be utilized by DBs as part of their state CME meetings, or as webinars, so that non-CL psychiatrists can achieve at least an understanding and some level of competence/confidence in the CL/collaborative arena? I know in the past Dr. Raney et al offered courses at the APA meetings which were very helpful and always well-attended.

3.

BRENDEL: With advances in psychiatric care, increasingly specialized knowledge and practice have led to advances in effective treatment for mental illness. A two-pronged approach to preparing psychiatrists for practice is required. First, general residency training must include core knowledge and skills in CL psychiatry, as well as other subspecialty areas, to ensure a competent and prepared general psychiatric workforce. In addition, fellowship training is critical to ensure that there are subgroups of psychiatrists with advanced training in specialized practice domains, including CL psychiatry. For CL psychiatry in particular, fellowship training is needed more than ever because of the rapid growth in novel therapeutics with psychoactive properties (both direct and related to disease and treatment effects), the healthcare needs of the aging population, the promise of integrated and collaborative care models in improving outcomes, and the importance of research to advance the psychiatric care of the medically ill.

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FELDMAN: Given the incredible advances in Psychiatry over the last two decades, I absolutely endorse the role of subspecialists. There is an enormous amount of material that must be learned in psychiatry, as well as specific skills-sets, that subspecialties only make sense.  Dealing with geriatric patients whose lives might be challenged by cognitive and physical decline, social isolation, financial and housing stress will be vastly different than working with a 6-year-old female traumatized by sexual abuse whose behavior has become disruptive. The capacity to perform a competency exam on a person scheduled to be executed and commenting on it during a court hearing requires a different knowledge and skills set than coordinating care for an agitated, confused patient with a history of opioid use disorder. There are fellowships that enhance the capacity to receive more complete and rigorous training for special populations, and opportunities to practice services under supervision (and then to role model and practice teaching these skills to regular psychiatry residents and medical students); these are imperative. There should be more, they should be funded (again there should be consideration of funding from government sources if recipients “pay back” with service to underserved areas).

Please don’t misconstrue my message. Many localities cannot support subspecialties (or subspecialists don’t want to live in areas without supports for their services), and general psychiatrists are called upon to provide services for everyone. Many physicians enjoy treating patients across the age and diagnostic spectrum. The challenge is being up-to-date on all the relevant information that is necessary to provide quality care.

4.

BRENDEL: There are not enough psychiatrists at present and the need for psychiatrists, including subspecialty trained psychiatrists, is growing. Workforce development is one area that ACLP has begun to make progress through a collaborative workgroup including the APA Councils and subspecialty organizations for geriatric, addiction, and CL psychiatry. As president-elect of ACLP, I worked alongside then-ACLP President Jim Rundell to establish this workgroup in order to develop innovative approaches to ensure that psychiatry has a prepared workforce for the future. Fast-tracking that allows for completion of core general psychiatry training requirements with time reduction to allow overlap for subspecialty training is one idea. Other possibilities include a range of monetary incentives for fellowship training to balance the financial burden of an added year of training that is generally not accompanied by commensurate post-training increase in salary. Proposals could range from educational loan payment forgiveness or credits to bonuses or higher reimbursement for subspecialty-trained psychiatrists. Data regarding the clinical effectiveness of and cost savings from integrated and collaborative care programs could help advance these financing programs for CL psychiatry, in particular. Finally, a third path to workforce development could include new part-time subspecialty training opportunities for early and mid-career psychiatrists already in practice.

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FELDMAN: I know many folks who used their 4^th year of residency as their first year of their Child and Adolescent fellowship, and feel they had adequate training in both arenas (typically reflected by passing boards in both). Often, depending on how psychiatry residencies are structured, much of the 4^th year is spent in electives, or focusing on skills development that the individual seeks to use when they launch their career. I believe fast-tracking fellowship training should be adopted for other subspecialties in psychiatry.

The workforce shortage in psychiatry is profound, and having huge untoward consequences. Patients are delayed in seeking care, or simply cannot even access it if providers don’t exist or have no openings. These deficits often result in costly Increased utilization of emergency services, inpatient services, the criminal justice system, or increased morbidity and mortality. It simply cannot continue. This is one of my major platform issues. We need to address it on multiple levels: increase medical student interest and recruitment into psychiatry, expand the number of psychiatry resident trainees (and please can we make sure we are recruiting a diverse population of trainees?). Of course, this means we need to have additional funding to pay for these slots (from the federal government, again perhaps some can come in the form of student loan repayment for service in under-served areas). In addition, we need to work with insurers (including CMS Medicaid and Medicare) to provide sufficient reimbursement so that practitioners can make an adequate living. How can we entice residents to choose to work in hospitals, state hospitals, jails, prisons, community mental health centers, and FQHCs if their compensation is significantly smaller than a practice that is cash-based? We need to ensure their training in those settings is fulfilling, supported, exciting, and well-compensated. I would make workforce development a Presidential Task Force issue if elected.

5.

BRENDEL: APA’s experience in reimbursement policy, relationships with other medical organizations, and government advocacy are all important areas in which APA can work with ACLP in developing and seeking implementation of sustainable financial models for CL services and psychiatrists across systems of care. In particular, amidst the COVID-19 pandemic’s escalating mental health toll, APA will have the opportunity to contribute to the public discourse about the importance of psychiatric care on par with other medical care in both access and funding, setting the stage for a reimagining of reimbursement and care delivery models.

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FELDMAN: I am hopeful the APA can work in concert with the ACLP to continue to produce research results that underscore the financial value of CL services. Perhaps the extrapolation of the results of Wit v United Behavioral Health to establish parity in the value of psychiatric services will be helpful. For example, using the metrics of, say, a tool like LOCUS (level of care utilization of services) may result in demonstrating the usefulness and cost-effectiveness of CL psychiatry. Unfortunately, it appears that legitimate positive results of the impact of CL psychiatry (or any of psychiatry) services has rarely been sufficient to incentivize insurance companies to pay for said services.  Perhaps with the change in the federal administration, more nuanced means of assessing (and paying for) efficacy of services will evolve.