Letters to the Editor mood, any psychotic symptoms, or body image distortion. The sense of nausea continued until nighttime, during which it woke her up 5 to 6 times each night, and her quality of sleep was very poor. The psychiatric diagnosis was somatoform disorder, not otherwise specified, and the medical impression was CVS, which led to the daily prescription of 10 mg of escitalopram and 0.5 mg of lorazepam. Since there was no change in her symptoms, escitalopram was replaced with 7.5 mg of mirtazapine on the third day after transfer. The dose of mirtazapine was increased to 15 and 30 mg on the next day and the day after, respectively. On the first day of starting mirtazapine, her sleep quality improved and she experienced no nighttime vomiting. On posttransfer day 7, her symptoms of nausea and vomiting had improved significantly, and she left the hospital on her own request. She was discharged on posttransfer day 12 with a weight gain of 1.4 kg. Ms. C continued to visit the psychiatric clinic and take the medication for 4 months after discharge. However, her vomiting recurred after voluntarily skipping the mirtazapine for 2 days, but then improved immediately when she restarted this medication. At the last follow-up, she was satisfied with her treatment and managed to work quite well. Discussion Mirtazapine is a second-generation antidepressant with noradrenergic and specific serotonergic activities. Its specific blockade of postsynaptic 5-HT3 receptors—similar to that of antiemetics such as ondansetron— results in an antiemetic effect.5 Furthermore, mirtazapine may 312
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attenuate emetic episodes partly through their blockade of H1 histamine receptors. In addition, mirtazapine was reported to be effective in reducing nausea and vomiting as rapidly as within a few days, and hence this medicine could be considered a good treatment option in the treatment of CVS, which has the characteristic of rapid-onset symptoms.6,7 Based on our case, it would be reasonable to try mirtazapine for patients with CVS with or without depressive or anxiety symptoms. This report was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (Grant no. 20120003429). Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article. Seung Min Bae, M.D. Seung-Gul Kang, M.D. Yu Jin Lee, M.D. Seong-Jin Cho, Department of Psychiatry, Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea Chang Min Seo,n Department of Psychiatry, College of Medicine, Catholic University of Daegu, Daegu, South Korea n Send correspondence and reprint
requests to Seung-Gul Kang, M.D., Ph.D., e-mail: [email protected]
References 1. Li BU: Cyclic vomiting: the pattern and syndrome paradigm. J Pediatr Gastroenterol Nutr 1995; 21(suppl 1): S6–S10 2. Abell TL, Adams KA, Boles RG, et al: Cyclic vomiting syndrome in adults. Neurogastroenterol Motil 2008; 20: 269–284
3. Coksun M, Alyanak B: Psychiatiric comobidity and efficacy of mirtazapine treatment in young subjects with chronic or cyclic vomiting syndromes: a case series. J Neuroastroenterl Motil 2011; 17(3)305–311 4. Lindley KJ, Andrews PL: Pathogenesis and treatment of cyclic vomiting. J Pediatr Gastroenterol Nutr 2005; 41 (1):S38–S40 5. Delvaux M, Louvel D, Mamet JP, Campos-Oriola R, Frexinos J: Effect of alosetron on responses to colonic distension in patients with irritable bowel syndrome. Aliment Pharmacol Ther 1998; 12:849–855 6. Pae CU: Low-dose mirtazapine may be successful treatment option for severe nausea and vomiting. Prog Neuropsychopharmacol Biol Psychiatry 2006; 30:1143–1145 7. Guclu S, Gol M, Dogan E, Saygili U: Mirtazapine use in resistant hyperemesis gravidarum: report of three cases and review of the literature. Arch Gynecol Obstet 2005; 272:298–300
The Early-Career Consultation Psychiatrist: Mixing Business and Patient Care TO THE EDITOR: Finance and business models have long been understated in graduate medical training.1 Consequently, early-career psychiatrists (ECPs) must often acquaint themselves experientially with the business aspects of their profession, while balancing clinical work and administrative duties. Rarely are connections made for the ECP between clinical services provided and their financial repercussions, either personally or for the clinical division or department. An appreciation for the business of medicine permits the ECP to stay ahead of the curve in Psychosomatics 55:3, May/June 2014
Letters to the Editor an ever-changing environment of health care finance and reform. ECPs are typically introduced to the business of psychiatry while learning to bill for services using Evaluation and Management Codes.2 Fundamentally, the concept is simple: do a service (e.g., a consultation) and submit a bill for payment. For ECPs who are not in independent practice, this payment does not get reimbursed directly as salary. Instead, billing is reflected in the gross and net charges to the division or department, of which the ECP's salary is an expense. Billing, therefore, is an indirect measure of one's productivity and one's gauge of personal value to an organization. Not all clinical services are identical; more complex and timeconsuming care incurs greater charges that translate to higher productivity. The average ECP sees cases with a range of complexity that is reflected in variable coding for services (e.g., Evaluation and Management Codes 99221-99223 and 99231-99233). Contractual rates that are negotiated by each insurer and the service provider (i.e., the hospital or physician group employing the ECP) determine the amount billable for each Evaluation and Management Code. Because contract rates vary by insurer and are often delayed in collection, tabulating the annual sum of money collected by an ECP for performing clinical duties —and thereby measuring productivity—can be challenging. Consider, for example, 2 early-career physicians: one who sees patients with Insurance A and another who sees patients with Insurance B. Even if the number of patients seen and mix of clinical complexities are identical, the sum of money generated by each ECP may be very different. To ensure proper representation of one's Psychosomatics 55:3, May/June 2014
professional value, the ECP must properly document and choose appropriate Evaluation and Management Codes to reflect the actual work rendered. Undercoding (i.e., billing a lower service than actually provided) translates into lower collections for the ECP, whereas overcoding (i.e., billing a higher service than actually provided) translates into fraudulent claims and opens the ECP to litigation. Understanding these fundamental differences allows the ECP to negotiate with administrators and to advocate for team members using clinical revenue as a model. By using basic principles of business and finance, ECPs who undertake service directorship are poised to advance their service lines and to bolster morale among colleagues. For example, at institutions in which clinical complexity or coordination of care constitutes a significant aspect of the psychiatrist's role, the savvy ECP may consider an alternative method to calculate productivity, using relative value units that assign a clinical value to each service, independent of payment.3 Rather than a monetary target for the organization, the ECP can be contracted to perform a base number of relative value units per clinical year. Depending on the organization, overperforming or underperforming the relative value unit base may result in salary adjustment. To help guide the ECP who is new to the realm of coding and reimbursement, several professional organizations have developed resources for their members; these include the Academy of Psychosomatic Medicine, the American Psychiatric Association, and the American Medical Association. The consultation psychiatrist who takes on the role of hospital
administrator requires an even more nuanced understanding of profitand-loss sheets, health insurance contracts, reimbursement formulas, and staffing models. Kunkel et al.4 reviewed several metrics to evaluate staffing on a hospital consultation service, including numbers of consultations, descriptions of service providers (e.g., MD or non-MD), and calculations of full-time equivalents. Other potentially useful metrics include hospital discharges, patient volumes, payer mix, denial rates, and diagnoses. Tracking these measures can provide perspective on the economic and organizational value that a consultation service provides the institution. This can motivate consultation services to continue business as usual or spur trials of different service delivery models, such as case-finding5 or sitter-reduction programs.6 In addition, Lavakumar et al.7 described a series of questions that can be used to evaluate the strengths and limitations of a consultation service. Measuring quality in this fashion can be particularly helpful when negotiating with hospital administration or payers for financial support on behalf of a clinical service line. ECPs face many challenges at the start of their careers, including development of clinical, administrative, and leadership skills. With limited experience, ECPs must develop a network of collaborators with expertise in finance, contracts, hospital administration, and practice management. Whether in a tertiary academic medical center, community-based hospital, or private practice, the sustainability of a practice relies on honing skills in administration, management, and business. Like clinical expertise, these remain learnable skills that develop www.psychosomaticsjournal.org
313
Letters to the Editor over time with the proper foundation, available resources, and motivation. Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article Patrick R. Aquino, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA Priya Gopalan, Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, PA Pierre N. Azzam, Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, MA References 1. Roberts JL, Ostapchuk M, Miller KH, Ziegler CH: What residents know about health care reform and what we should teach them. J Grad Med Educ 2011; 3:155–161 2. American Medical Association. CPTs Changes 2013: An Insider's View. Chicago: American Medical Association; 2013 3. Office of Healthcare Systems. Relative Value Units (RVU) for CPTs Codes Most Frequently Used by Psychiatrists. Arlington, VA: American Psychiatric Association; 2013 (Accessed, June 2013). 〈http://www.psychiatry.org/File %20Library/Practice/Managing%20a %20Practice/CPT/2013-RVUs-CodesMost-Freq-Used-by-Psychiatrists.pdf〉 4. Kunkel EJ, Del Busto E, Kathol R, et al: Physician staffing for the practice of psychosomatic medicine in general hospitals: a pilot study. Psychosomatics 2010; 51:520–527 5. Bronheim HE, Fulop G, Kunkel EJ, et al: The Academy of Psychosomatic Medicine practice guidelines for psychiatric consultation in the general
314
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medical setting. Psychosomatics 1998; 39:S8–S30 6. Jin C, Novik S, Saravay S: Consultationliaison psychiatry training and supervision results in fewer recommendations for constant observation. Gen Hosp Psychiatry 2000; 22:359–364 7. Lavakumar M, Gastelum ED, Hussain F, et al: How do you know your consult service is doing a good job? Generating performance measures for C-L service effectiveness Psychosomatics 2013; 54: 567–574
Measures of Satisfaction With ConsultationLiaison Services TO THE EDITOR: We congratulate Kitts, Gallagher, Ibeziako, Bujorneanu, Garcia, and DeMaso on their article on Parent and Young Adult Satisfaction with Psychiatry Consultation Services in a Children's Hospital.1 Their study demonstrates not only that it is feasible to deliver consultation services to children and their families that result in a high level of satisfaction but also that it is possible to assess satisfaction with a high level of acceptance of the survey instrument by the patient and family raters, and that such a survey can provide information both on overall indices of satisfaction and on specific performance parameters that can be targeted for improvement as necessary. We see the appearance of this article, along with our own article,
addressing consultee satisfaction with consultation services, which appeared in the same issue of the journal,2 as welcome evidence of growing recognition of the importance of assessment of our services0 clinical work and overall function and of the development of the means and the willingness to do such assessments. We are currently performing a multicenter validation of our previous study on parameters of consultee satisfaction and look forward to replication and extension of work on patient satisfaction survey instruments to include adult patients. Even taken together, consultee and patient satisfaction will not comprise a perfect index of the quality and effectiveness of consultation-liaison services, but they will be a very good start. Peter A. Shapiro, M.D. Department of Psychiatry, Columbia University Medical Center, New York, NY Mallika Lavakumar, M.D. Department of Psychiatry, MetroHealth Medical Center, Cleveland, OH
References 1. Kitts RL, Gallagher K, Ibeziako P, Bujorneanu S, Garcia G, DeMaso DR: Parent and young adult satisfaction with psychiatry consultation services in a Children0 s Hospital. Psychosomatics 2013; 54:575–584 2. Lavakumar M, Gastelum ED, Hussain F, et al: How Do You Know Your Consult Service is Doing a Good Job? Generating Performance Measures for C-L Service Effectiveness. Psychosomatics 2013; 54:567–574
Psychosomatics 55:3, May/June 2014
www.psychosomaticsjournal.org
attenuate emetic episodes partly through their blockade of H1 histamine receptors. In addition, mirtazapine was reported to be effective in reducing nausea and vomiting as rapidly as within a few days, and hence this medicine could be considered a good treatment option in the treatment of CVS, which has the characteristic of rapid-onset symptoms.6,7 Based on our case, it would be reasonable to try mirtazapine for patients with CVS with or without depressive or anxiety symptoms. This report was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (Grant no. 20120003429). Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article. Seung Min Bae, M.D. Seung-Gul Kang, M.D. Yu Jin Lee, M.D. Seong-Jin Cho, Department of Psychiatry, Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea Chang Min Seo,n Department of Psychiatry, College of Medicine, Catholic University of Daegu, Daegu, South Korea n Send correspondence and reprint
requests to Seung-Gul Kang, M.D., Ph.D., e-mail: [email protected]
References 1. Li BU: Cyclic vomiting: the pattern and syndrome paradigm. J Pediatr Gastroenterol Nutr 1995; 21(suppl 1): S6–S10 2. Abell TL, Adams KA, Boles RG, et al: Cyclic vomiting syndrome in adults. Neurogastroenterol Motil 2008; 20: 269–284
3. Coksun M, Alyanak B: Psychiatiric comobidity and efficacy of mirtazapine treatment in young subjects with chronic or cyclic vomiting syndromes: a case series. J Neuroastroenterl Motil 2011; 17(3)305–311 4. Lindley KJ, Andrews PL: Pathogenesis and treatment of cyclic vomiting. J Pediatr Gastroenterol Nutr 2005; 41 (1):S38–S40 5. Delvaux M, Louvel D, Mamet JP, Campos-Oriola R, Frexinos J: Effect of alosetron on responses to colonic distension in patients with irritable bowel syndrome. Aliment Pharmacol Ther 1998; 12:849–855 6. Pae CU: Low-dose mirtazapine may be successful treatment option for severe nausea and vomiting. Prog Neuropsychopharmacol Biol Psychiatry 2006; 30:1143–1145 7. Guclu S, Gol M, Dogan E, Saygili U: Mirtazapine use in resistant hyperemesis gravidarum: report of three cases and review of the literature. Arch Gynecol Obstet 2005; 272:298–300
The Early-Career Consultation Psychiatrist: Mixing Business and Patient Care TO THE EDITOR: Finance and business models have long been understated in graduate medical training.1 Consequently, early-career psychiatrists (ECPs) must often acquaint themselves experientially with the business aspects of their profession, while balancing clinical work and administrative duties. Rarely are connections made for the ECP between clinical services provided and their financial repercussions, either personally or for the clinical division or department. An appreciation for the business of medicine permits the ECP to stay ahead of the curve in Psychosomatics 55:3, May/June 2014
Letters to the Editor an ever-changing environment of health care finance and reform. ECPs are typically introduced to the business of psychiatry while learning to bill for services using Evaluation and Management Codes.2 Fundamentally, the concept is simple: do a service (e.g., a consultation) and submit a bill for payment. For ECPs who are not in independent practice, this payment does not get reimbursed directly as salary. Instead, billing is reflected in the gross and net charges to the division or department, of which the ECP's salary is an expense. Billing, therefore, is an indirect measure of one's productivity and one's gauge of personal value to an organization. Not all clinical services are identical; more complex and timeconsuming care incurs greater charges that translate to higher productivity. The average ECP sees cases with a range of complexity that is reflected in variable coding for services (e.g., Evaluation and Management Codes 99221-99223 and 99231-99233). Contractual rates that are negotiated by each insurer and the service provider (i.e., the hospital or physician group employing the ECP) determine the amount billable for each Evaluation and Management Code. Because contract rates vary by insurer and are often delayed in collection, tabulating the annual sum of money collected by an ECP for performing clinical duties —and thereby measuring productivity—can be challenging. Consider, for example, 2 early-career physicians: one who sees patients with Insurance A and another who sees patients with Insurance B. Even if the number of patients seen and mix of clinical complexities are identical, the sum of money generated by each ECP may be very different. To ensure proper representation of one's Psychosomatics 55:3, May/June 2014
professional value, the ECP must properly document and choose appropriate Evaluation and Management Codes to reflect the actual work rendered. Undercoding (i.e., billing a lower service than actually provided) translates into lower collections for the ECP, whereas overcoding (i.e., billing a higher service than actually provided) translates into fraudulent claims and opens the ECP to litigation. Understanding these fundamental differences allows the ECP to negotiate with administrators and to advocate for team members using clinical revenue as a model. By using basic principles of business and finance, ECPs who undertake service directorship are poised to advance their service lines and to bolster morale among colleagues. For example, at institutions in which clinical complexity or coordination of care constitutes a significant aspect of the psychiatrist's role, the savvy ECP may consider an alternative method to calculate productivity, using relative value units that assign a clinical value to each service, independent of payment.3 Rather than a monetary target for the organization, the ECP can be contracted to perform a base number of relative value units per clinical year. Depending on the organization, overperforming or underperforming the relative value unit base may result in salary adjustment. To help guide the ECP who is new to the realm of coding and reimbursement, several professional organizations have developed resources for their members; these include the Academy of Psychosomatic Medicine, the American Psychiatric Association, and the American Medical Association. The consultation psychiatrist who takes on the role of hospital
administrator requires an even more nuanced understanding of profitand-loss sheets, health insurance contracts, reimbursement formulas, and staffing models. Kunkel et al.4 reviewed several metrics to evaluate staffing on a hospital consultation service, including numbers of consultations, descriptions of service providers (e.g., MD or non-MD), and calculations of full-time equivalents. Other potentially useful metrics include hospital discharges, patient volumes, payer mix, denial rates, and diagnoses. Tracking these measures can provide perspective on the economic and organizational value that a consultation service provides the institution. This can motivate consultation services to continue business as usual or spur trials of different service delivery models, such as case-finding5 or sitter-reduction programs.6 In addition, Lavakumar et al.7 described a series of questions that can be used to evaluate the strengths and limitations of a consultation service. Measuring quality in this fashion can be particularly helpful when negotiating with hospital administration or payers for financial support on behalf of a clinical service line. ECPs face many challenges at the start of their careers, including development of clinical, administrative, and leadership skills. With limited experience, ECPs must develop a network of collaborators with expertise in finance, contracts, hospital administration, and practice management. Whether in a tertiary academic medical center, community-based hospital, or private practice, the sustainability of a practice relies on honing skills in administration, management, and business. Like clinical expertise, these remain learnable skills that develop www.psychosomaticsjournal.org
313
Letters to the Editor over time with the proper foundation, available resources, and motivation. Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article Patrick R. Aquino, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA Priya Gopalan, Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, PA Pierre N. Azzam, Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, MA References 1. Roberts JL, Ostapchuk M, Miller KH, Ziegler CH: What residents know about health care reform and what we should teach them. J Grad Med Educ 2011; 3:155–161 2. American Medical Association. CPTs Changes 2013: An Insider's View. Chicago: American Medical Association; 2013 3. Office of Healthcare Systems. Relative Value Units (RVU) for CPTs Codes Most Frequently Used by Psychiatrists. Arlington, VA: American Psychiatric Association; 2013 (Accessed, June 2013). 〈http://www.psychiatry.org/File %20Library/Practice/Managing%20a %20Practice/CPT/2013-RVUs-CodesMost-Freq-Used-by-Psychiatrists.pdf〉 4. Kunkel EJ, Del Busto E, Kathol R, et al: Physician staffing for the practice of psychosomatic medicine in general hospitals: a pilot study. Psychosomatics 2010; 51:520–527 5. Bronheim HE, Fulop G, Kunkel EJ, et al: The Academy of Psychosomatic Medicine practice guidelines for psychiatric consultation in the general
314
www.psychosomaticsjournal.org
medical setting. Psychosomatics 1998; 39:S8–S30 6. Jin C, Novik S, Saravay S: Consultationliaison psychiatry training and supervision results in fewer recommendations for constant observation. Gen Hosp Psychiatry 2000; 22:359–364 7. Lavakumar M, Gastelum ED, Hussain F, et al: How do you know your consult service is doing a good job? Generating performance measures for C-L service effectiveness Psychosomatics 2013; 54: 567–574
Measures of Satisfaction With ConsultationLiaison Services TO THE EDITOR: We congratulate Kitts, Gallagher, Ibeziako, Bujorneanu, Garcia, and DeMaso on their article on Parent and Young Adult Satisfaction with Psychiatry Consultation Services in a Children's Hospital.1 Their study demonstrates not only that it is feasible to deliver consultation services to children and their families that result in a high level of satisfaction but also that it is possible to assess satisfaction with a high level of acceptance of the survey instrument by the patient and family raters, and that such a survey can provide information both on overall indices of satisfaction and on specific performance parameters that can be targeted for improvement as necessary. We see the appearance of this article, along with our own article,
addressing consultee satisfaction with consultation services, which appeared in the same issue of the journal,2 as welcome evidence of growing recognition of the importance of assessment of our services0 clinical work and overall function and of the development of the means and the willingness to do such assessments. We are currently performing a multicenter validation of our previous study on parameters of consultee satisfaction and look forward to replication and extension of work on patient satisfaction survey instruments to include adult patients. Even taken together, consultee and patient satisfaction will not comprise a perfect index of the quality and effectiveness of consultation-liaison services, but they will be a very good start. Peter A. Shapiro, M.D. Department of Psychiatry, Columbia University Medical Center, New York, NY Mallika Lavakumar, M.D. Department of Psychiatry, MetroHealth Medical Center, Cleveland, OH
References 1. Kitts RL, Gallagher K, Ibeziako P, Bujorneanu S, Garcia G, DeMaso DR: Parent and young adult satisfaction with psychiatry consultation services in a Children0 s Hospital. Psychosomatics 2013; 54:575–584 2. Lavakumar M, Gastelum ED, Hussain F, et al: How Do You Know Your Consult Service is Doing a Good Job? Generating Performance Measures for C-L Service Effectiveness. Psychosomatics 2013; 54:567–574
Psychosomatics 55:3, May/June 2014
