1.

TRESTMAN: It has taken a lot of dedicated work to develop and implement integrated and collaborative care in primary and specialty care settings. For these efforts to grow, we need to demonstrate the value provided in terms of improved patient outcomes and overall cost impact. We also need to continue and expand advocacy for payment reform and innovative models of care. Each environment of care brings distinct challenges and opportunities. We can and should evaluate and establish the parameters for successful implementation to guide and support broader dissemination and sustainment. One specific opportunity is in the acute medical inpatient setting. While data has existed for years supporting a more proactive approach to psychiatric consultation (e.g., Desan et al 2014), there is still limited implementation of such protocols. Making use of health systems and implementation science approaches (Bauer and Kirchner 2020) provide a framework to expand access to these valuable services. The APA can support this work through a range of educational products and consultation to members and their organizations to assist in targeted implementation. This kind of initiative is critical for the field. The APA has the skills and resources to expand our efforts in close collaboration with the ACLP. There are also many opportunities for our organizations to partner in grant submissions to evaluate the impact and outcomes of this work.

VISWANATHAN: I am a consultation liaison psychiatrist. I have been a Fellow of ACLP (formerly known as the Academy of Psychosomatic Medicine) since 1996. Our tagline “Advancing Integrated Psychiatric Care for the Medically Ill” is a principle I live by. I have been providing integrated psychiatric care in SUNY Downstate’s world-renowned HIV Clinic since 1989. I was fortunate to have been mentored by pioneers in integrated care. I was a member of the APA’s Committee on Consultation-Liaison Psychiatry and Primary Care Education in the years 1992 to 1998. I have been active in the APA in several leadership positions, including as Minority and Under-Represented Groups (MUR) Trustee on the Board and as a long-standing member of the APA Assembly. I am a member of the AMA. These experiences will help me lead the APA to advance integrated care. There is plenty of robust data published in prestigious journals showing how integrated and collaborative care lead to better physical and mental outcomes, and are cost-efficient. For example, there are studies showing that for every $1 spent on collaborative care in diabetes patients with depression the cost saving is $6, and collaborative and integrated care with pregnant patients are associated with better neonatal outcomes. Integrated care has been successful in patients with substance use disorders also. ACLP has done a wonderful job of collecting this literature and disseminating it. Due to input form ACLP and the APA Council on C-L Psychiatry, the APA has been at the forefront in developing and promoting integrated care including collaborative care, has developed excellent educational and training materials, and has provided training opportunities. With telepsychiatry, integrated and collaborative care have become even more feasible. While we have been successful in developing CPT codes for collaborative care and getting payers to reimburse, we need to do more advocacy work for better and easier payment by health insurers. 

TRESTMAN: The APA has worked for well over a decade to support integrated care innovations. In 2014, the APA received a grant from CMS as part of the Transforming Clinical Practice Initiative. This Support and Alignment Network program functioned for years as part of practice transformation initiatives, partnering with practices around the country. It has worked with multiple organizations to support the implementation and funding for the Collaborative Care Model. In this context, the existing APA Committee on Integrated Care, chaired by Dr. Ben Druss, and the Council on Consultation-Liaison Psychiatry (CoCLP), currently chaired by Dr. Maria Tiamson-Kasab, work collaboratively on building internal resources and growing collaborations. In 2021, the APA worked closely with the American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists (ACOG), American College of Physicians (ACP), American Medical Association (AMA) and others to support the federal Collaborate in an Orderly and Cohesive Manner (COCM) Act, a successful example of payment reform advocacy. These are some of the key non-psychiatric organizations with whom the APA can and does partner to promote collaboration and expand opportunities for payment reform.  The APA can build upon these existing relationships to support further implementation and broader dissemination of well-proven practices.

VISWANATHAN: With the help of ACLP and the APA Council on C-L Psychiatry, the APA can enhance the educational workforce on integrated and collaborative care, give educational presentations to various professional organizations, and have prerecorded sessions accessible via these organizations’ websites. We should also encourage education at the local level. For example, in the year 2019 I gave grand rounds to all 13 clinical departments in my medical center, in which I touted the value of integrated and collaborative care, with data. We should advocate collaboratively with other professional organizations, such as the American Medical Association, American College of Physicians, American Academy of Family Physicians, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, with our policy makers at the national and local levels to advance integrated care. We need to incorporate training in integrated care in our residencies.

2.

TRESTMAN: Simply put, there are neither enough psychiatrists or primary care physicians now nor in the foreseeable future to meet the needs of our patients. We must find ways to leverage our skills to meet psychiatric needs in both primary care and specialty care. Utilizing the skill and knowledge of C-L psychiatrists both within the APA and the ACLP is critical to continue to test, disseminate, implement, and sustain a variety of synchronous and asynchronous care delivery models. I view the ACLP as a key organization representing psychiatry in general medical settings, articulating the role of C-L psychiatrists in providing medical care in such settings, and expanding the reach and benefit of psychiatry beyond our traditional borders. Together, we can work to advocate and educate the various constituencies to help make these critical resources available broadly. 

VISWANATHAN: I am Board-Certified in both Internal Medicine and Psychiatry/C-L Psychiatry. Our APA leaders have been emphasizing that psychiatry belongs in the house of medicine. One thing that distinguishes psychiatrists from psychologists is our experience with non-psychiatric medical illnesses. ACLP should help APA advocate for medical (psychiatrist) leadership of team-based behavioral care in medical settings such as transplantation, oncology and nephrology. There is plenty of untreated, non-recognized behavioral and neuropsychiatric issues in our non-psychiatric medical patients, and medical issues in our psychiatric patients that need to be recognized and addressed. An important role for ACLP and CL psychiatrists is to help the APA, with its tremendous resources and reach, to advocate for integrated care and increase in the workforce in this area. Another area is to promote psychiatric research in the medical-surgical setting and advocate for better funding for this research. Currently the funding is mainly for research on patients with primary major psychiatric disorders with very little medical comorbidities. The neuropsychiatric and functional psychiatric sequelae of the Covid pandemic is a major area where ACLP can help the APA.

3.

TRESTMAN: Fellowship training provides a depth of training not provided in a general residency. Our field, along with most of medicine, continues to mature and as we learn more, develop subspecialties to achieve mastery over the evolving complexities of the field. Subspecialists are critical to the evolution of psychiatry, but there are clinical demands to be targeted given the profound shortages of general psychiatrists. It is my view that those choosing to pursue subspecialties have a responsibility to practice those skills and provide their unique training as a consultative resource to benefit as wide a population as possible.

VISWANATHAN: I am a C-L Psychiatry Fellowship director. Our current fellow was in practice for 8 years before starting her C-L fellowship, including working as a part-time (0.2 FTE) attending on our C-L Service. Her experience illustrates the value of subspecialty fellowship training. Even though she is a bright, knowledgeable, highly competent psychiatrist to begin with, both she and I see firsthand the advantage of fellowship training. She has repeatedly stated how much she is learning, and we can also see it in her handling of the consultations and liaison work. Psychiatry needs to train subspecialists, as a higher level of expertise in a particular area is needed in many situations. In addition to providing direct care, subspecialists can also act as consultants to other physicians including psychiatrists to extend their reach. Subspecialists help enrich the whole field of psychiatry, and ultimately benefit our patients.

4.

TRESTMAN: Many of our subspecialty fellowship slots, including C-L, currently go unfilled each year. Creative and innovative solutions to meeting the workforce demands are critical. The challenge is in many ways functional: can we achieve appropriate standards of training (that is: objective, observable competence) comparable to today’s approaches when we accelerate the training? What components of general and specialty training are potentially unnecessary, outdated, or redundant? The field has a shortage of generalists as well as subspecialists, so finding an appropriate balance requires thoughtful planning.

VISWANATHAN: Fast-tracking has pluses and minuses. Anything we do in life has gains and losses. The decision is made on priorities. Many residents have considerable financial debt and need to start families. The financial burden is heavier on the socio-economically disadvantaged. Some fellowship slots go unfilled because of this financial burden, even though there is need and desire. Fast-tracking will lighten this financial burden and enable more trainees to consider subspecialty fellowships. Many residents spend half of their fourth year in an elective. The subspecialty fellowships can take its place. A significant part of 4^th year residency is continued learning of psychotherapy. This can be accommodated by the fellowships offering psychotherapy training in their subspecialties. If a resident chooses a fellowship in their own institution, consideration may be given to continuing psychotherapy with their existing patients. We can run a pilot program for two years, assess its effects, then decide if to continue with it, and if so, what changes we need to make. For fellowships that require 4 years of psychiatry residency training because that level of clinical experience is desired, we need to increase the salary to partially offset the cost of what the physician would have otherwise earned.

TRESTMAN: One component is of course to develop a broad pipeline of diverse individuals who wish to pursue psychiatry as a field and assure adequate funding for expanded training slots. Beyond that, we need to assume the responsibility of leading. Leadership in this context includes the personal responsibility of guiding a team in care delivery settings to leverage quality care provision to more patients, as well as the organizational responsibility of national and regional leadership. Expanding the leadership training focus at the GME and CME levels is of growing importance. As physicians, we need to evaluate what work only we can do, and what work can safely and appropriately be done by clinicians with less training (such as nurse practitioners and physician assistants). We need to develop approaches that can leverage therapists, care managers, and other support staff to deliver the appropriate clinical and wrap-around service needs of our patients. And, as physicians, we need to be willing to provide the care too complex for others to address.

VISWANATHAN: We need to increase our overall workforce. There is abundant data showing the shortage of psychiatrists, and unmet mental health needs. The need for psychiatric services in medical-surgical patients and how they improve medical outcomes is increasingly appreciated. Residency training in psychiatry has become highly competitive, and hundreds of good applicants go unmatched. We have to advocate with our legislators to increase the number of GME training slots. In my APA-guided legislative advocacy work I have done so. An innovative solution that some centers have successfully done is partnering with private hospitals and the state government to provide non-Medicare funding for GME positions, in return for commitment to service at their institutions after graduation.

5.

TRESTMAN: The core issue is, as usual, the funding mechanism. While we have looked at cost offset and reduced length-of-stay as financial justification for the work of C-L psychiatrists, traditional fee-for-service models nevertheless carry structural impediments to broad dissemination in the real world. As we look at various models for capitated care, episodes of care, and other comprehensive funding approaches, we have the opportunity to propose meaningful integration of C-L psychiatry into this fee structure. In my role as past Chair of the American Hospital Association’s Behavioral Health Committee, and in my current role as chair of the APA’s Council on Healthcare Systems and Financing (CHSF), I have had the opportunity to review some of these models. For example, with The Joint Commission (TJC) requirements for mental health screening on inpatient med/surg admissions, and the known prevalence of psychiatric illness and suicidality in this population, the need for C/L integration is clear. Developing models and advocating for structured funding for C-L psychiatry in this context is a logical next step. Working together, the ACLP and the APA can use data to support an appropriate funding structure to optimize the overall care our patients receive.

VISWANATHAN: I have been part of the APA’s legislative advocacy efforts since the year 1992. We have successfully achieved parity of payment by health insurers for psychiatric services on par with other similar medical services. This is a notable achievement due to concerted and sustained efforts by several people. Unfortunately, in our current reimbursement scheme cognitive efforts are undervalued relative to procedures. Psychiatric consultation-liaison services are time-intensive and cognitively complex. ACLP can work with the APA in improving valuation of and payment for C-L services, and provide data in support. Our success in getting collaborative care paid by many health insurers is an example of such collaboration. We can also help institutions to use their own data to learn how C-L psychiatrists improve medical outcomes, which results in cost-savings such as reducing the number of 1:1 observations, length of stay and readmissions. We need the muscle power of the APA to advocate.

6.

TRESTMAN: The pandemic catapulted telepsychiatry from a convenient if limited option to a critical component of the system of care. It has clearly demonstrated value and benefit to so many of our patients. In my own health care system, Carilion Clinic, we deliver the bulk of our inpatient C/L services to our five outlying hospitals via telehealth. We need to advocate at multiple levels for continued and expanded support. We need to advocate for widely available broadband access to improve equity of care. Until then, we need to advocate for audio-only care delivery to those patients who would otherwise be deprived of care. As chair of the CHSF, I have spoken with the Office of the National Coordinator for Health Information, with the Centers for Medicare and Medicaid Services (CMS), and with various payor organizations about the need for continued and expanded funding. The APA has worked closely with the American Telehealth Association and will continue to do so. Ultimately, the best advocacy is going to be with outcomes data: proving for which patients in which circumstances telehealth (including audio only, remote monitoring, wearables, apps, etc.) works as effectively, or more effectively, than in-person care.

VISWANATHAN: I was an early advocate for telepsychiatry. In the year 2002, I passed an Assembly action paper that the APA promote telehealth to enhance access to care and ward off psychologists’ seeking prescription privileges. I also wrote about it in Psychiatric News. I was a pioneer in using telehealth emotional support sessions for our frontline physicians, trainees and nurses during the Covid pandemic, and published this work in our journal Psychosomatics. I have met with local and federal legislators advocating for telehealth. The Covid pandemic has catapulted the entire field of medicine into telehealth, especially the field of mental health. This has increased awareness among our legislators and policy makers as to how telehealth enhances access to care. APA and local state psychiatric organizations need to oppose some third-party payers putting obstacles to telehealth because they may view the ease of access as driving up their costs. Much of healthcare is driven by local policies, so when we say APA, we need to include the District Branches and state organizations also. I did such advocacy just two weeks ago with my New York State assemblywoman. We need to continue to advocate for the payment of audio only component on par with audiovisual telehealth, and for their parity with in-person visit payments. There has to be initial and intermittent in-person visits to optimize care. APA should educate members about best practices in telehealth.

7.

TRESTMAN: Several years ago, the APA began a coordinated and detailed effort to address racism and prejudice within our own organization. This has resulted in the creation of a formal Board-level Structural Racism Accountability Committee, an associated Task Force, and expanded support for internal education, Minority and Underrepresented (M/UR) caucuses and an M/UR Representative on the APA Board. These steps have advanced the conversation and made the APA focus on supporting and advancing M/UR psychiatrists within the organization. Focusing externally, the APA Council on Minority Mental Health and Health Disparities has developed a range of advocacy positions, education materials, and resource documents to support each of us in these ongoing efforts. Bringing needed psychiatric care into primary care settings also reduces some of the cultural barriers to receiving our services.  The APA Presidential Taskforce on the Social Determinants of Mental Health (2021-2022) was charged with the creation of sustainable policies and programs addressing these needs. As a small part of this work, I participated in creating a CME course on the Social Determinants of Mental Health that is still available online at the APA website. We have in earnest embraced this work; we are now positioned to build upon it to make it an intrinsic part of an equitable culture.

VISWANATHAN: The APA has recognized that there is not sufficient diversity and inclusion in its leadership including on its Board, and has instituted laudable efforts to address it. Once concerted efforts are made to address this issue, over a period of time, with enough diversity in leadership over the years, that will become the new norm. But in the beginning, we need conscious actions to diversify the leadership. The APA has a Division of Diversity and Health Equity and many other components to mentor minority and under-represented trainees, promote diversity and inclusion within our profession, and address disparities in healthcare.

At my medical center, we serve a patient population that has significant proportions of African Americans, Hispanic Americans, and Orthodox Jewish Americans. The community has a significant number of immigrants. It is predominantly socio-economically disadvantaged. Commercial insurers underpay the safety net hospitals and the physicians who practice in the community, compared to what they pay in neighboring affluent communities. We need to change that. If anything, healthcare in these settings need more financial support because it is much more challenging and requires more work, given factors such as housing, need for childcare support, lack of family support, difficulties with transportation and money for copay. APA needs to advocate more for equity in these settings, including enhancing the workforce. Case management and psycho-education are important components of this care.

I am proud of ACLP’s work in this area and the other areas discussed in other questions. If elected president-elect of the APA, ACLP is definitely one of the important organizations I will turn to for ideas, counsel and collaboration. I thank our readers for reading and considering my ideas.