Innovative practice models
As healthcare reform moves forward in each state, neuropsychologists and psychologists are developing innovative practice models in order to emerge as successful players. While much of the information on healthcare reform is abstract, hearing first hand about how practitioners are transforming their practice in response to healthcare reform gives us all very concrete examples of directions to take in our own practices. What changes are early adapters making? What tips can they offer us as we make changes?
We will post interviews with psychologists and neuropsychologists who are successfully adapting to this new healthcare environment, with the hopes that other clinicians will replicate and build on their success.
Michael Goldberg, Ph.D. Director, Child & Family Psychological Services/ Integrated Behavioral Associates.
Dr. Goldberg has transformed his large multi specialty group practice operating in a traditional fee for service paradigm into a model of psychological service delivery in the context of healthcare reform. Dr. Goldberg has been a long time advocate for access to neuropsychological services in his role as Past President of the Massachusetts Psychological Association, and current associate member of the Massachusetts Neuropsychological Society.
Dr. Goldberg, you are well known in the state of Massachusetts for your innovative practice model. Can you tell us about what your practice looked like, prior to healthcare reform?
Before healthcare reform the percentage of our practice related to primary care integration was much smaller. Healthcare reform catalyzed our goal of expanding our integration with primary and specialty healthcare entities.
What did you see as the dangers to traditional psychology practice, as a result of healthcare reform and the ACO structure/ global payment model?
"Traditional" psychology practice is difficult to define. However, it is clear that the ability to practice independent of larger systems of healthcare will become increasingly more difficult as the country moves away from the fee for service system of care toward global payment systems.
Can you tell us what your practice looks like now? What are the major changes you made in response to the changing healthcare climate?
Our practice was well equipped to weather the storm of changes blowing through now. We have always delivered comprehensive multi-modal and interdisciplinary services. The biggest changes we have made relate to developing formal agreements with primary care and specialty care entities to integrate services with the goals of increasing efficiencies and controlling costs while improving access to effective behavioral health services.
Can you tell us about the neuropsychologists in your practice. Is there a difference in the way neuropsychology services are delivered?
Neuropsychology continues to be practiced with the same core principles and goals. While there have been some changes already there will continue to be significant changes in how neuropsychology is practiced in the next 3-5 years. These changes can be summarized as follows:
- Being able to provide services for the full breadth of patients seen.
- Using technology and technicians to increase efficiency.
- Crafting reports based more on the needs healthcare providers.
- Completing reports in a timeframe that corresponds to the clinical needs of the patient.
- Moving away from a "diagnosis and adios" model of freestanding assessment to a model of assessment plus ongoing consultation.
As a group practice we are able to meet the overall needs of primary care practices while allowing individual neuropsychologists that ability to maintain expertise in particular areas of interests.
How do global or bundled payments effect neuropsychology billing in your practice?
The movement toward integrated care, which demands comprehensive services, has resulted in a very significant increase in the demand for all behavioral health services, including neuropsychology, in our practice. However, I am confident that as transition to the primary care entities taking on financial risk for healthcare continues, neuropsychology will be evaluated more in terms of its clinical utility as defined by physicians and its "return on investment" in helping to control healthcare costs while improving clinical outcomes.
When you speak with healthcare executives about behavioral health services, is neuropsychological assessment on their radar screen?
The good news is that frontline healthcare providers continue to demand neuropsychological services. However, health plan executives and healthcare group executives do not seem to value or demand neuropsychology services per se. They want us to assess, treat and manage the overall behavioral health needs of the patient. To the extent we use neuropsychology to do that effectively and efficiently neuropsychology will thrive.
What is your advice to practitioners as healthcare reform hits their states?
In addition to what I have already discussed, it’s important for practitioners to understand how global payment systems work and the needs and opportunities that the systems create for neuropsychologists. I would also recommend that practitioners become part of a system of healthcare.
Leslie Bourne, Ph.D. Director of Behavioral Medicine, Atrius Healthcare
Dr. Bourne runs the behavioral health program at Atrius Healthcare. In her interview, she shares strategies for speaking with healthcare executives about being included in ACO networks as well as strategies for integrating neuropsychology services in to primary care. Her interview will be posted shortly.
1. Leslie, can you tell us about your role in Reliant Medical Group?
Reliant is a large multi specialty, multi site medical practice. I am the Chief of Behavioral Medicine, and involved in a number of areas within the organization. Typically, referrals come to Behavioral Health through primary care and other physicians. We work with “health psychology” issues including weight loss, chronic pain, sleep issues, and diabetes management. We also see typical cases of depression and anxiety.
Our psychologists also go directly to primary care offices and co-lead group medical visits. These are innovative sessions with 6-12 patients, co led by a PCP and psychologist, addressing a common health concern. For example, it might be a follow up visit for patients with chronic pain conditions, or diabetes. The psychologist will facilitate the group process.
2. Are these group medical visits unique to Reliant?
No, these occur commonly in the Medical Home model. For example, Harvard Vangaurd is running sessions like these. With global payments, physicians have the latitude to create these types of innovative visits, without limitations involved with traditional billing.
Hmm. This sounds like something neuropsychologists might be able to do, co-leading group follow ups for memory problems, or mTBI….
3. Do you have neuropsychologists in your Behavioral Medicine Group?
Not at this time. Right now we have 4 psychologists and one psychiatrist.
4. How do the finances work for billing your services in the medical home model?
It’s complicated! There are a number of payment arrangements. Most of Reliant’s revenue comes from capitated contracts, when we bill there is an internal transfer of funds credited to our department. Fee for service revenue flows through as actual net collected fees. Reliant is one of 6 medical groups within Atrius Health Care, which is one of the 33 Pioneer Accountable Care Organizations with Medicare. With the Medicare Pioneer ACO system, there is risk-sharing. We have several new global payment contracts where the providers will be fully at risk for thousands of patients. [Leslie, I will link the bundled and global payments terms to definitions within our website].
Reliant will also be at risk for the behavioral health services for certain patient populations.
5. Are you all on salary?
Yes.
6. How does Reliant fund neuropsychological services if there are no neuropsychologists on staff?
If a patient is in a contract, and they need neuropsychological services, Reliant physicians will send them to see a neuropsychologist who is not part of the Reliant organization. Because of quality and cost issues, physicians are looking for neuropsychologists who offer quality, value and good communication. They want to see a high quality assessment, that is timely, with a well written report.
7. Do you have any advice for neuropsychologists who are out in the community. How can they increase the likelihood that they will be that neuropsychologist the large health organizations refer to?
The key thing is for community neuropsychologists to go and speak with the large medical groups. A good place to start would be with the chief of neurology, or the chief of primary care. When the administrators make financial decisions about where to send part of their global payments out of the organization, they will start by asking these chiefs, “Who do you know who does a good job as a neuropsychologist?”
The administrators involved in the decisions are typically our Chief Medical Officer, the Director of Utilization and the Medical Director of Quality should also ask to speak with them.
8. Do you have any tips for neuropsychologists when speaking to administrators within medical organizations? This is not part of our typical skill set!
Yes. First, show a willingness to help the administrators with how you might provide quality assessments for a good value. How might you work with larger populations? Demonstrate that you can be flexible with your assessment techniques for some screening, some full batteries.
Administrators and physicians within the larger medical homes are also very interested in you being a good communicator. Are you writing timely, targeted reports? Are you addressing the type of information they need to do their clinical jobs?
As a neuropsychologist, if you show some understanding of their dilemma, treating large populations of patients, with both high quality, and high value services, then they will see you as an ally.
Maggie Lanca, Ph.D., Director of Neuropsychology, Cambridge Health Alliance
Dr. Lanca is engaged in an innovative program of bringing neuropsychological assessments directly into the primary care medical home clinics at Cambridge Health Alliance.
1. You have an innovative approach to embedding neuropsychological services in primary care settings. Can you tell us about it?
Since Cambridge Health Alliance (CHA) has been transforming into an accountable care organization (ACO), it has become increasingly important to forge closer affiliations with our primary care providers. So we expanded our neuropsychology services to include cognitive screening at one of CHA primary care clinics, while maintaining our outpatient neuropsychology clinic for comprehensive and “typical” neuropsychological assessments. These one-hour long cognitive screens in primary care with very brief write-ups are focused on providing diagnostic screening of AD/HD and dementia versus pseudo-dementia. Currently, we are developing a third cognitive screening protocol for high utilizer complex patients to determine cognitive deficits that can impede medication adherence and treatment compliance.
2. How have physician colleagues at CHA responded to the changes?
The clinic’s physicians have welcomed our presence and referrals have been nonstop. There are even greater opportunities for growth. Many of CHA’s primary care clinics such as the one where we are based are functioning as medical homes so that primary care physicians and other physicians are accustomed to working on multi-disciplinary teams and have a highly developed system of coordination of care. Neuropsychological input to a patient’s cognitive functioning is vital to physicians who sometimes struggle to understand how to best treat a patient and know what expectations can be made of that patient to follow treatment. We have also had increased communication with the clinic’s clinical pharmacist who benefits from our cognitive screens of patients who are having difficulty with medication compliance. Physicians have also appreciated that, as neuropsychologists we are well versed in screening for both psychiatric conditions and cognitive conditions. Although we have not yet done screening just for mood disorders, we sometimes diagnose depression and other mood disorders from referrals for AD/HD and dementia. Mood disorder screening can be another way for neuropsychologists to function in primary care. We have forged a close working relationship with the team psychiatrist who also appreciates our cognitive screening as a means to streamline her referrals and to increase understanding of patients. Overall, our neuropsychology presence has resulted in a positive recalibration of other team physicians’ duties (i.e., primary care, clinical pharmacist, and psychiatrist) to enhance overall patient treatment and increase the efficiency of their work.
3. Can you tell us about the process of moving your services into primary care? Who did you approach? Was it a tough sell?
The overall process of moving to primary care was supportive and encouraging. I first approached the Chief of Psychology and then the Chief of the Psychiatry department, where our outpatient neuropsychology clinic is based. To contextualize the process, our psychiatry department had been apprised of the hospital’s transformation to an ACO for at least a year prior to my proposal for cognitive screening. We had numerous psychology faculty meetings to discuss the potential impact of this transformation to our work – much of it unknown. Several Psychiatry-Medicine Grand Rounds were dedicated to staff education ACO and Primary Care Medical Home (PCMH) models, and numerous psychiatry and psychology faculty meetings prepared us for inevitable shifts in our work. We were asked to accept the possibility of change in our usual ways of doing things, and encouraged to think innovatively about how to shift our practice to fit with an ACO and PCMH model of care. So when I approached our departmental chiefs, there was strong support for my proposal to do cognitive screening. I then approached the Medical Director of the primary care clinic who expressed interest and recognized the value to cognitive screening. The Medical Director and I then proceeded with a series of planning and strategic meetings for six months, before we embarked our neuropsychology work.
4. How does the billing work in your new embedded model? Are you dealing with global or bundled payments yet?
Because CHA has not completed the transformation process to an ACO model, we do not yet have global or bundled payments. We use our typical CPT codes.
5. You are also the Director of the Neuropsychology Postdoctoral Training Program. What advice do you have for training directors to help students make the transition to practice in these uncertain times?
Neuropsychology will undoubtedly go through its own transformation as the large majority of hospitals and medical clinics in the US are now poised to convert to ACOs. Primary care and preventative medicine will become more prominent in our health care system. My advice for training directors is to teach students to be versatile and adaptive. This translates to giving students a range of training experiences working with different patient populations and across various settings. Training students to write different kinds of reports – from cognitive screen brief-write ups to comprehensive neuropsychological evaluations broadens their skill set. Having students interface with patients at every level of an evaluation is also important. We teach our postdoctoral fellows how to provide feedback to patients, an important skill to develop as our neuropsychology professional referral base widens from its neurology and psychiatry roots to other specialties that are not well versed in neuropsychology. These professional colleagues depend on us to share test findings with patients. One very new skill for our postdoctoral fellows working in primary care, is to learn how to provide feedback to patients almost instantaneously (after consultation with the staff neuropsychologist). As neuropsychologists, we are accustomed to scoring and interpreting reports and cogitating on its findings. We provide feedback to patients when we are ready. Our medical colleagues are trained to “think on their feet” and respond to patients at the end of a visit. This can be an uncomfortable paradigm shift in our fellows’ neuropsychology training, but an important one that again, increases their versatility. Finally, if there are opportunities to give postdoctoral fellows some experience working with primary care physicians either as embedded clinicians in a primary care clinic or through outsourced referrals, I would highly recommend it. The greater the connection that neuropsychologists can make with primary care physician colleagues, the more viable our profession will be in the future. We need to be considered as a first-line referral source for cognitive testing by primary care physicians, not as secondary and tertiary referral sources.
Peter Duquette, Ph.D. Neuropsychologist at Cornerstone Healthcare, North Carolina
Dr. Duquette made a decision to join Cornerstone Healthcare as a staff neuropsychologist following his fellowship. The large, multi-specialty medical group is an early adopter in healthcare reform, and was chosen as a Medicare ACO Pioneer Pilot. Dr. Duquette shares his front seat view of healthcare reform from the perspective of a staff member in a large, private healthcare system.
Can you tell us about Cornerstone Healthcare?
Cornerstone was formed in the mid 1990s and is now a large group of over 300 physicians and specialists that serves a 40-50 mile geographic radius. There are a lot of academic medical centers in this region of North Carolina, and Cornerstone made a name for themselves offering quality care while reducing costs. In the last year and a half, Cornerstone has developed partnerships with commercial payers and is a Medicare ACO Pioneer Pilot organization.
What is your role with Cornerstone?
I am one of 4 neuropsychologists in the organization, and the only pediatric neuropsychologist.
How is the practice of neuropsychology different at Cornerstone than within a typical medical or group practice setting?
Cornerstone is in the process of “embedding” psychologists and neuropsychologists within certain clinics. Several of the neuropsychologists who focus on geriatrics are centrally involved in a Memory and Aging Care Clinic that collaborates with Neurology. There is also a clinical health psychologist who works part-time in the Heart Failure Clinic, in addition to a full time psychologist who is the director of psycho-social services within Oncology. There are also three psychologists who are working in primary care or pediatrics offices for at least part of their work weeks.
As the only pediatric neuropsychologist, I continue to get referrals from a variety of clinics, including pediatrics, local schools, and sports concussion.
How does billing work for neuropsychologists?
We all share a billing service. We all get base salaries, and there is an incentive program based on productivity and patient satisfaction. Some patients are in the process of being covered under global or bundled payments, but the vast majority are still fee for service. There is a population of high medical utilizers: patients who are hypertensive, obese, in their 50s and 60s and above. That clinic is looking toward a global payment situation. Neuropsychology has not yet had experience with the global or bundled payments yet.
What is the biggest change you have seen with health care reform in your work as a neuropsychologist?
The biggest structural changes are the neuropsychologists who are being embedded within clinics.
My report style has also changed a lot from the types of reports I was writing as a post doc. Cornerstone has been completely electronic with medical records for the past 7 years. When I finish an assessment, I send a 1-paragraph summary to the referring physician through the Electronic Medical Record. This happens within 24 hours. I will then dictate a report into Microsoft Word, and upload that file into the EMR. Schools typically get a more traditional report but I often send a brief summary ahead of time too. These brief communications are written in chunks and are later pieced together for the 6-8 page final report. Some of this was based on recent surveys conducted by AACN on what referral sources value most in our reports. For example, the pediatrician does not need highly detailed educational strategies. They are more interested in whether the child is a good medication candidate.