California Psychiatric Association Documents
Utilization of Psychiatry and Psychiatric Specialists in Managed Care Systems

Revised and updated by CPA Managed Care Task Force October 1997

Part I. Adult Population

Optimal cost-effective mental health care would dictate that adults presenting with psychiatric symptoms would be initially evaluated by a psychiatrist for the following reasons:

• Symptoms that appear to be caused by a psychiatric disorder could be a result of underlying medical illness. (See Appendix I ).
• Serious psychiatric symptoms can be caused by drugs prescribed for treatment of medical conditions, over the counter medications, illicit drugs
  and combinations of the same. (See Appendix II ).
• There must be assurance that psychotropic medication be prescribed as quickly as possible whenever it is clearly indicated.

In any of the above situations misdiagnosis or delay in treatment prolongs the suffering of the patient and is more costly for the payer of the care provided over time. Consistent with evolving health trends, however, adult consumers who may have psychiatric illness receive their psychiatric care in either an "integrated" or a "carved-out" health care plan. (See Appendix III ). In the former they will most likely be seen initially by a primary care physician or nurse practitioner and in the latter by a non-medical health practitioner (psychologist, social worker or marriage and family counselor). The point at which a patient is referred to a specialist then becomes a matter of clinical judgment on the part of the primary care provider. The following guidelines represent broad standards to which the Primary Care Provider can refer and are based on the current scientific data available, as well as many years of experience accumulated by California Psychiatric Physicians and provide a fair representation of the psychiatric community standard of care.

It is the responsibility of the primary care provider to refer to the specialists if under the same circumstances a reasonably careful and skillful general practitioner would do so. If the patient should be referred to a specialist and is not referred, the primary care provider is required by law to treat the patient with the same standard of knowledge and skill as that ordinarily possessed by a reputable specialist. (see Appendix IV).

In the integrated model the primary care physician is clearly in the position to assure that the psychiatric symptoms are not due to an underlying medical condition or to prescribed or illicit drugs. Sometimes the primary physician can also initiate treatment utilizing psychotropic medication and/or psychosocial intervention in a timely manner. In the carve-out model non medical clinicians with expertise in psychotherapy or counseling may be utilized at less expense in the short term, however, early medical evaluation and treatment is sacrificed and the expense is often greater in the long run. In either case, however, there are situations where patients clearly require more specialized care and referral to a psychiatrist is indicated. These include, but are not limited to, the following:

 A. Psychiatric Referral At The Time of Assessment

1) In those situations where a patient is a danger to him/herself or to others, immediate psychiatric consultation is indicated. Expert evaluation is required to determine the most appropriate level of care in this critical situation and there is great risk of catastrophic outcome if it is not available or obtained. A psychiatrist has the expertise to determine if such a patient requires psychiatric hospitalization or treatment can be safely carried out in a less intensive setting, i.e. a partial hospitalization program or on an outpatient basis.

2) In those cases where a patient is gravely disabled as a consequence of their mental disorder, psychiatric consultation is indicated unless the patient has a very consistent and reliable support system and the primary care provider feels he/she has the expertise and time to treat a serious mental illness on an outpatient basis.

3) Situations where the primary psychiatric diagnosis is unclear and more comprehensive evaluation is required. The latter may include brief hospitalization thereby providing an opportunity for twenty-four hour observation of the patient's behavior and/or the opportunity to obtain more sophisticated diagnostic testing that could not otherwise be obtained on an outpatient basis because of the patient's debilitated condition.

4) In those situations where forensic issues are, or may be, involved with the patient's psychiatric illness. This is particularly true of situations involving workers compensation or criminal prosecution. Those cases in which a patient is already involved in ongoing litigation, and their mental state is at issue, may also be very difficult and time consuming for primary providers to manage.

5) In situations where there has been a pattern of prior treatment with consistently poor outcomes. This may be reflective of either misdiagnosis or a process of ineffective and/or incomplete treatment.

6) Situations where the patient has serious and persistent mental illness (such as schizophrenia or other disabling major mental illness) which requires, or will require, a comprehensive biopsychosocial rehabilitation plan as implemented by a multi- disciplinary team. Once stabilized on psychotropic drugs the medication needs can be monitored by a primary care physician, as long as there is timely ongoing collaboration with the multi-disciplinary team.

7) In situations where the patient is experiencing comorbid illness (i.e., dually diagnosed patients), psychiatric consultation should be sought. This may take the form of a primary psychiatric disorder and substance abuse, a developmental disability, dementia, a concurrent medical illness, or a severe personality disorder.

8) In those situations where the primary care physician or non-medical mental health practitioner feels unable to initially assess a patient or recognizes either a conflict of interest or countertransference issues that may interfere with an objective evaluation.

9) In those situations where the primary care physician or non-medical mental health practitioner recognizes the need for a more advanced psychotherapeutic intervention than they themselves are able to provide.

10) In those situations where a patient has been utilizing medical care resources disproportionate to the severity of their medical illness (i.e., somatization disorder, chronic pain syndromes) or where question arises as to whether there is any medical illness at all (i.e., factitious disorder or hypochondriasis).

11) In the carve-out model, in those situations where the patient inquires as to whether psychotropic medication would be useful in their situation or where the non medical therapist feels psychotropic medication is indicated and the patient is receptive to an evaluation by a psychiatrist.

12) In the carve-out model, in those situations where the patient has significant medical illness or is on multiple prescribed medications either of which might potentially be playing a role in their manifest psychiatric symptoms.

13) In the carve-out model, in those situations where the patient has complex medical disease along with a major psychiatric illness and the medical background of the psychiatrist facilitates dialogue with the patient regarding the integration of the medical illness and the psychiatric condition and enhances communication and coordination with the patient's primary care physician and/or other medical specialists involved in his/her care.

B. Where Comprehensive Psychiatric Evaluation Has Not Occurred, And Treatment Has Been Established By A Primary Care Physician or Non-Medical Mental Health Care Practitioner, Psychiatric Consultation Should Be Undertaken When:

1) there is deterioration in the patient's condition despite the treatment approach being utilized. Referral should be made immediately if the patient has become a danger to self or others or gravely disabled.

2) there is no improvement after six to eight psychotherapy or counseling sessions or if either the therapist or the patient feels medication should be considered and the patient is receptive to a medication evaluation.

3) a complicating co-morbid, forensic, countertransference or non-compliance issue appears.

4) in the integrated model, a patient has been given an optimal trial of two psychotropic medications of different classes appropriate to an accurately made diagnosis and without amelioration of the presenting symptoms.

C. Preparation for Referral

In those situations where referral is indicated, the patient should be informed that a referral is being made to a psychiatric specialist prior to the examination by the latter. An explanation as to why the referral is being made, the time frame within which it will occur, and the setting in which it will be undertaken should also be provided. The explanation given should be delivered in such a way that the patient doesn't feel stigmatized, belittled or made to feel that their pain or physical problem is "just in the head. " A very brief sketch including the qualifications of the specialist to whom the patient is being referred, is also sometimes helpful.

In those cases where a patient refuses referral, a telephone consultation with the psychiatrist to whom the patient was to be referred may facilitate convincing the patient to agree to the referral or may provide alternate treatment approaches thus precluding the need for referral. Of course, the psychiatric consultant should insist that a referral is necessary if that is, in fact, the consultant's opinion. To fail to do so may expose the consultant to legal claims if there is no referral and the patient experiences an adverse outcome. In other instances the telephone consultation may provide the primary care provider with information as how to assure the patient receives appropriate care when the patient is a danger to self, others, or gravely disabled and legal intervention is required.

The request for referral should clearly specify what the primary care physician or non-medical mental health care practitioner wishes the psychiatrist to do. The patient must understand that the consulting psychiatrist will provide to the referring provider information pertaining to a diagnosis and to an appropriate treatment plan. It should be made clear that this information need not include specific or intimate details that the patient divulges to the psychiatrist.

The psychiatrist should be made aware of any medical conditions, lab data, or current medications that could influence the psychiatric diagnostic workup or treatment approaches. In those situations where the patient has been evaluated and/or treated by a non-medical mental health practitioner, the results of current or past attempts at counseling or psychotherapy, psychological test results, and social service or forensic reports should be forwarded to the psychiatrist.

D. Adult Psychiatric Evaluation

Most routine adult psychiatric evaluations can be accomplished in a two hour evaluation session when the above noted referral data are made available. At times, however, meetings with significant others are critical to the evaluation process and require more time. More complex evaluations will also require proportionately more time.

When sufficient numbers of appropriately qualified psychiatrists are not available within the plan to perform psychiatric evaluations, a patient should be referred to a psychiatrist outside the plan.

In some cases the psychiatrist may require additional consultations, including but not limited to, neurological evaluation, psychological testing, or vocational evaluation. This is most efficiently carried out by direct referral to the required consultant, particularly where time is of the essence. In those circumstances where the managed care plan does not offer the required additional consultant, there should be opportunity for the patient to be referred outside the plan. Additionally,, in those situations where a medication is recommended that is not a part of the plan formulary, there should be an efficient procedure for approval of its use if there are no clinically appropriate substitutes available.

The results of an elective psychiatric evaluation should be made available to the referring physician or non-medical health care practitioner as soon as possible but in no case any later than fourteen working days. In emergent situations the result of the consultation should be verbally conveyed at the conclusion of the evaluation with a written report to follow. The psychiatrist should be as explicit and concise as possible in making recommendations and should do so in a way that is understandable, practical, and cost effective. The psychiatrist must clearly state whether she/he is assuming ongoing treatment responsibility for the patient or whether the patient is being referred back to the primary care physician or non- medical mental health practitioner. In the case of the latter, the psychiatrist will not infrequently assume responsibility for initiating and monitoring psychotropic medication while referring the patient back to the non-medical provider for ongoing counseling or psychotherapy. In these cases, sufficient time must be provided by the managed care plan for close collaboration between the psychiatrist and the therapist to assure optimal treatment results. 

E. Psychiatric Treatment

Psychiatric treatment approaches usually incorporate time limited marital. family. and group or individual psychotherapy. The latter may, or may not, incorporate the use of psychotropic medication. In acute and more complex situations, however, provision must be made for psychiatric hospitalization, partial hospitalization, and residential treatment.

Medication management may require long term monitoring and ongoing supportive psychotherapy. Issues of informed consent and medication education for patient and family or significant others are important. Therefore, flexibility in length of visits and visit intervals is essential for optimal monitoring.

Managed care plans should make provision for extended outpatient individual psychotherapy in those cases in which psychopathology is particularly severe or resistant to change. Allowance for this exception to shorter term treatment in difficult cases will, in the long run, avoid costly emergency room visits, unnecessary medical visits, and superfluous psychiatric or medical hospitalizations. Appropriate justification for this exception should be required from the specialist in a format that is brief, concise and respectful of the patients confidentiality

Managed care plans should provide for a "point of service option" for those consumers who desire to participate in long term psychotherapy but who do not meet the criteria above for an exception covered within the plan. Patients that wish to pursue psychiatric care entirely outside the plan must be able to contract privately with a psychiatrist of their choice.

A number of patients require concomitant psychotherapy and psychotropic medication for optimal treatment outcomes. Many managed care plans have established severe financial disincentives that effectively prevent or prohibit psychiatrists from providing individual psychotherapy to such patients. Splitting the treatment process between a non medical therapist and a psychiatrist who provides only medication and management often leads to significant management problems and a prolonged overall treatment process. Integrated treatment should be allowed to take place without penalty whenever requested on a clinically appropriate basis by either the treating psychiatrist or the patient.

F. Appeals

Denials or modification of a recommended treatment approach by a plan should be made only by a psychiatrist who has reviewed the recommended treatment in order to assure optimal psychiatric care to the patient and to avoid legal liability on the part of the plan. If the treating psychiatrist and the patient continue to disagree with the denial and/or modification, the case should be reviewed by a neutral third party with appropriate adult psychiatry credentials outside the plan.

Part II: Child and Adolescent Population

A. Triage and Gatekeeper Functions

Optimally all children and adolescents should have an initial assessment by a child and adolescent psychiatrist in order to provide multi-system assessment, accurate diagnosis, and appropriate treatment planning. Early involvement of a child and adolescent psychiatrist is also important for timely intervention with adjunctive medication management for major mental illness or other disorders particularly responsive to medication management such as ADHD. In addition, initial assessment by a child and adolescent psychiatrist allows early identification of possible neurological, neuroendocrine, or metabolic disorders, leading to appropriate referral or further diagnostic evaluation and treatment. Recognizing that most managed care systems will not assign psychiatrists to this important function, there should be clearly defined thresholds and indicators for referral to a child and adolescent psychiatric specialist.

Recommended thresholds for referral should include: 1) Any treatment protocols in which there is lack of progress within a period of three months; 2) Significant deterioration and/or lack of response to the prescribed treatment plan; 3) Development of a new symptom indicating a change in diagnosis or evidence of a significant comorbidity.

Other indicators for referral to a child and adolescent psychiatrist for consultation include: 1) Complex diagnostic issues involving cognitive, psychological, and emotional components which may be related to organic etiology; 2) Major mental illness suspected (schizophrenia, schizoaffective disorder, bipolar affective disorder, major depression, persistent disabling anxiety disorder, significant or dangerous level of explosive disorder, etc.); 3) Significant mixed specific developmental disorder including social and emotional components (integrative developmental disorder); 4) Co- morbid substance abuse and severe emotional disturbance in a child or adolescent; 5) Any instance in which issues of safety to self or others are involved, requiring consideration of specialized environmental and/or psychopharmacologic interventions.

B. Psychiatric Evaluation

The child and adolescent consultant should have full access to prior medical evaluations, psychological testing, and other mental health assessments, laboratory data, response to previous courses of treatment, school assessments, and social service, or other agency reports as indicated. Sufficient flexibility in evaluation time and modality should be provided to allow a full multi-system assessment as indicated by a clinical presentation. Such an evaluation may include, for example, collateral sessions with parents, significant school personnel, contacts with social workers, probation officers, and current and past psychotherapists. In addition, multiple sessions are often required to obtain valid clinical data from children and adolescents in the presence of resistance, developmental delays, or developmental difficulties in verbal communication, requiring nonverbal interactive techniques to obtain necessary data.

C. Medication Management

All medication management must be preceded by a comprehensive evaluation by the treating child psychiatrist. With medication trials, there must be sufficient flexibility in time and number of sessions to provide education and informed consent to the patient and family, to adequately assess the clinical effects and potential side effects of the medication trial in a timely way, to communicate adequately with the psychotherapist in split therapy, and to allow sufficient time to carry out a brief mental status examination and review of the course of therapy being carried out by the psychotherapist if not being done by the child psychiatrist.

Managed care organizations should approve medications considered to be "standard of practice" in the child and adolescent psychiatric community, as reflected in the child and adolescent clinical psychopharmacology literature.

D. Appeals

A denial of a course of treatment recommended by a child and adolescent psychiatrist should be appealable to a child and adolescent psychiatrist reviewer within the managed care plan. In the event of a dispute or lack of resolution of this appeal, there should be external review by a neutral third party with appropriate child and adolescent psychiatry credentials.

E. Psychotherapy with Child and Adolescent Psychiatrists

Any patient considered for psychotherapy with adjunctive medication management, who does not already have a therapeutic alliance with an existing therapist, should be treated by a child and adolescent trained psychiatrist. Use of a single therapist in these instances will reduce communication difficulties, splitting and delay in intervention or adjustment of medications, compared to a two-therapist model. In addition, a child and adolescent psychiatrist with known specialized expertise should be considered as therapist for patients who require such specialized training (for example, eating disorders, substance abuse disorder, severe personality disorders with potential for brief psychotic regressions or effective symptomatology, tic disorders, and other neurodevelopmental disorders, etc.).

F. Consultations

Managed care programs should approve appropriate consultations with other medical specialties, psychiatrists, psychologists, etc., for the purpose of further elucidating diagnosis, clarifying treatment resistant issues or to provide appropriate treatment for co-morbid non-psychiatric medical conditions. In the event that plan-specific consultations are not available, the provider should be able to go out of the plan for needed consultation. Patients that wish to pursue psychiatric care entirely outside the plan must be able to contract privately with a psychiatrist of their choice.

APPENDIX I: Some Medical Problems That Present With Psychiatric Symptoms

APPENDIX II: Psychiatric Highlights - Psychosis or Side Effects

APPENDIX III: Integrated Health Care Plan - "Carve-out" Psychiatric Plan

APPENDIX IV: Standard Jury Instruction stating the legal obligations of health care providers.

THIS HANDBOOK IS INTENDED TO HIGHLIGHT SOME COMMON ISSUES FACED BY PRIMARY CARE PHYSICIANS AND NON-MEDICAL MENTAL HEALTH PRACTITIONERS FOR SUCH ILLNESSES. THESE ARE GUIDELINES ONLY AND THEIR APPLICATION TO ANY PARTICULAR PATIENT MAY NOT BE APPROPRIATE.

IT SHOULD NOT BE USED AS A SUBSTITUTE FOR REFERRAL TO AND CONSULTATION WITH QUALIFIED PSYCHIATRIC SPECIALISTS.

This handbook was prepared by the California Psychiatric Association. If you would like copies or reprint permission you may contact: