vol. 18 no. 1 t h e winter 2005 aapvine -...

GrAAPvineFrom the president's deskby Pat Sanders Romano

Inside this issue

Vol. 18 No. 1Winter 2005T h e

Continued on page 3

President's desk 1

Monkey business 2-3Member info changes 2

Comings and goings 2 Board notes 2

Feature Meet Ron Menaker 5

Conference Highlights 6-15 Academic sandbox 7 PhD prescribing 8 Telemedicine 9 AAP photo album 11 Building effective teams 12 PACT programs 13 Take two minutes 15

Research 16-19 Clinical compensation 16 Elimination of mail notification 17 Time-sensitive research 18 Clinical and translational science 19

Billing/Clinical 20-23 National provider identifier 20 Use of macros 20 New testing CPT codes 21 CMS name/ID edit 21 CMS MD voluntary reporting 22

ExtrasCollege corner 4Coming attractions 21Back page 24

Comments overheard at the fallconference:* I decided to come to the Conferencebecause I thought it was important tobe with everyone * A hotel onLouisiana Street, was this planned? *I am amazed at the level of yourfriendships and caring for one another,especially as demonstrated through thegiving to Jim. As an outsider that wasa pretty remarkable scene for me towitness * I wanted to cry * Excellent

program * I learned three new things at this conference * Let’s skipthe conference and just go on adventures * This feels like a familyreunion * Relaxation and 'Buns of Steel' at the same time * See yain Chicago!

Going beyond…The theme of this fall’s educational conference was “Psychiatry:

Beyond Clinical Practice” -- a theme that carried through both the formaland informal experiences we have had this fall. Others in this issue of TheGrAAPvine will discuss the formal experiences of the conference. I wouldlike to focus on the informal ‘going beyond…’ as AAP members, and asconference participants.

In my mind, summer ended early this year, specifically on August 29th

-- and fall started in the Gulf Coast. It’s been a fall of adversity, temperedby affiliation and affection.

My first thoughts early in the morning of August 29th were of JimLandry (Tulane U) and his family. We had spoken late the week beforeand I knew he was planning to move to his farm, but I was still concerned.Frankly, my second thoughts were about the fall conference: Could we stillhave it in New Orleans? Would we be ‘dissing’ Jim if we moved it? Howwill we ever be able to pull off getting a conference together in twomonths? Who could I turn to—since Jim has always been my ‘rock’?

…And then, the members of AAP joined together. We heard fromJim, and responded with words of comfort, support and tangible offers ofassistance with housing, rebuilding and refurnishing for him and his family.

The GrAAPvine Vol. 18 No. 12

Monkey Business

Comingsand goings

Feel free to call newmembers and personallywelcome them to our

organization. One of the things thatmakes AAP special is its friendlymembers! The hospitality offered bya personal contact will surely beappreciated.

AAP wishes to extend awarm welcome to the followingnew members:

Edie BambergerUniversity of Illinois at Chicago(312) [email protected]

Patricia BlackmerUniversity of Michigan(734) [email protected]

Ruth IrwinUniversity of California - Los Angeles(310) [email protected]

Joseph Ricci, PhDMedical College of Georgia(706) 721-9604jricci@mcg@edu

Randolph SiwabessyUniversity of California-San Francisco(415) [email protected]

Marietta Taylor, FACMPEBassett Healthcare(Affiliated with NY Presbyterian)(607) [email protected]

Member information changes

Please make the following changes in your rolodexes, palm pilots oraddress books:

Address change:Debbie PearlmanDepartment of PsychiatryYale University300 George Street Suite 901New Haven, CT 06520

Phone number changes:Marti Sale(859) 257-9617

Terry Gevedon(859) 323-5499

Board notes

The Board ofDirectors heldtheir semiannual

meeting on the Fridaybefore the FallConference inIndianapolis. All elevenof us spent some timeupdating each other onwhat was happening currently intheir departments and personally.Since we share the same problems/issues, this introduction focuses theBoard on the AAP mission and onthe issues affecting us in ourprofessional and personal lives.

We took a close look at ourStrategic Plan and our Bylaws andhave formed working group torecommend necessary revisions.AAP is fiscally stable, and therehas been an excellent transition tothe new treasurer, JaniceMcAdam. President-Elect JimLandry, Member- at-Large forEducation Marti Sale and theircommittee have begun planning thespring conference in Chicago; itwas also decided to hold the fall2006 meeting in Tucson. KevinJohnston will be convening theNominating Committee. Memberswith an interest in serving on theBoard should contact Kevin.

Membership is robust, with84 active members and 25 newmembers in 2005, thanks to

Membership DirectorSteve Blanchard andMember-at-Large forMembership JoannMenard. Member-at-Large for StrategicCollaborations PaulMcArthur has beenexploring affiliations

with other organizations, bothformal and ad hoc. The Board iseager to work in the direction ofupgrading our website and will beexploring ways to do so. Ournewest “venture," addingBenchmarking to the Boardresponsibilities, is in its infancy.Member-at-Large forBenchmarking Debbie Pearlmanand her committee will bedeveloping a survey of themembership to profile ourinstitutions and to determine our“hot topics.”

The Board is so fortunate tohave Elaine McIntosh assecretary, as her minutes provide aframework for the meetings, andshe tirelessly scribes during the fivehours we meet.

And of course, we aregrateful to Jan Price who not onlyserves as our communications link,but is our historian.

Pat Sanders Romano

The GrAAPvine Vol. 18 No. 1 3

Monkey Business

We noted that another member,Dwayne Clayton was at LSU andwe reached out to him to provide ascholarship to support hisattendance at the conference.When Rita threatened, we kept intouch with Doris Chimera andPatricia Birkmeyer (both of UTexas Medical Branch -Galveston), who evacuated fromGalveston. We made personalcontributions to relief agencies andas an organization made a $1,000donation to the Red CrossHurricane Relief. We shared theexperiences of Jim, his family andhis colleagues and thought abouthim living in a trailer. We wantedto do something special from “us”to him -- after a great deal ofthought and idea (hot sauce fromall parts of the country?) --gathering our school shirts justseemed to be right.

In the meantime, there was aconference to be had. The Boardagreed strongly that the “MeetingMust Go On.” A number ofpeople offered their home cities ashosts for the conference; Kevinand Chris Johnston (both ofIndiana U) made the mostcompelling pitch for Indianapolis—and so we were on our way, withabout six weeks to go. Jim had puttogether a framework for the

educational program, and themembers who had agreed topresent in New Orleans "hung inthere" and presented inIndianapolis. I am so grateful toDoris Chimera, PatriciaBirkmeyer, Marti Sale UKentucky), Lee Fleisher(formerly of Vanderbilt U), SteveBlanchard (U Iowa), and JaneBieler (U Oklahoma), a first timeattendee, for their hard work andfor their commitment to ensuring anexcellent program. Kevin foundtwo excellent and informativeoutside speakers, and was evenable to maintain the same topic,“Prescribing by Psychologists” thathad been on the original program.Thanks, Kevin for recruiting Dr.Dennis Jones form IndianaUniversity and Dr. John Courtneyfrom the Child DevelopmentCenter in South Bend.

Jan Price (U Michigan), whocame up with our surprise and"schlepped" two large cartons ofshirts to the conference, wasinvaluable in setting the spirit for themeeting. Finally, the conferenceand all of the attendantarrangements would not have beenpossible without the incredibleefforts by Chris Johnston and herassistant Margie Hughes. They dideverything: arranged the hotel, gotthe favorable room rates, set the

meeting facilities and meals,scouted out two amazing dinnerlocations—and maintained a senseof humor throughout. And thetwenty-five members who attendedand who were so kindhearted andso engaging and engaged, each ofyou contributed to the weekend’ssuccess. I certainly felt, and heardfrom others that this was the bestconference ever, a great mix ofsolid education, compassion andfun.

Getting above adversityWhat did we do, and how did

we do it? We, individually and asan association, were resilient. Wewere able to weather stress,bounce back from trauma andmove on. We used what wasnegative and turned it into positive.We showed strength and ability tochange our path when our directionwas blocked; we focused on thethings we could control. We builton each other’s strengths, we feltconfident in letting go and allowingothers to help. We allowedourselves to have fun. We were awhole greater than the parts. Weare pretty terrific.

And, as I said at theconference, I am so proud to be anAAP.

Continued from page 1

President's message (continued)

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The college corner

Katrina, Wilma and Newt

by David Peterson, FACMPE

Bird Flu. Katrina. Wilma.Newt. Defeat of personaladversity. Physician

compensation. Patient satisfactionand diversity. These unrelatedtopics and more were woventogether at the annual conferenceof the Medical Group ManagementAssociation held in conjunctionwith the 49th Convocation of theAmerican College of MedicalPractice Executives (ACMPE)in Nashville.

Certainly with problems suchas the Asian bird flu and hurricanesKatrina and Wilma, it was keynotespeaker Newt Gingrich’s view thatthey represent failures – orpotential failures in the case of birdflu – of the government to providean effective solution to theproblems. Whether one agreeswith Newt’s view or not (I’ll defercomment on Katrina to ourcolleague Jim Landry CMPEwho experienced Katrina “up closeand personal” at Tulane), Newt’soverall message was thatgovernment is not the answer andthat the free marketplace willempower citizens to makeinformed healthcare decisions,notably through technologicaladvances.

Other keynote speakers toldpersonal tales of overcomingadversity – a former Miss Americawho was hearing impaired and aformer Olympic gold medalgymnast who returned to the sportafter what appeared to be career-ending injuries.

And, without a doubt, therewere breakout sessions focusing onphysician compensation,productivity, maximizing patientrevenues, patient and staff diversityand satisfaction, to name a fewthemes.

One might ask how this allrelates to medical group practicemanagement?

At the risk of stating theobvious, the medical practiceexecutive needs to understand theenvironment in which he or she isworking, whether that environmentis global, national, regional or local.Knowledge of the environmentassists the executive in makinginformed decisions, helps oneanticipate trends or problems oropportunities and helps him or herto work with culturally andethnically diverse staff and patientpopulations.

To be sure, the medicalpractice executive needs to beknowledgeable about the tasks at

hand,namelybilling,collection, compliance, financialand human resource managementalong with the other dutiesincorporated into the administrativedomain, but understanding thebigger picture and folding suchknowledge into everyday decisionmaking and analysis assists themedical practice executive inbecoming a more effective leader.

Membership in the ACMPEencourages professionaldevelopment, offers benchmarksfor professional success andencourages an understanding of thebigger picture. The topicspresented at the MGMA/ACMPEannual conference are an exampleof this big picture and it is thiscommon theme that connects theseeming diverse and disconnectedtopics that were offered inNashville.For more information on joining theACMPE or the board certification andfellowship process, contact theACMPE directly at (303) 397-7869 orcontact David Peterson, FACMPE at(414) 456-8990, email [email protected] or at theDepartment of Psychiatry andBehavioral Medicine, Medical Collegeof Wisconsin, 8701 Watertown PlankRoad, Milwaukee, Wisconsin 53226.

May your holidays be filledwith love

and the new year bring youhappiness and good health.


Meet . . .Ronald Menaker, FACMPE

He's got the beatby Christina Pope, MGMA seniorwriter

The Rolling Stones hasCharlie Watts. U2 hasLarry Mullen Jr. And the

Mayo Clinic has Ron Menaker.Menaker has been drumming

as long as any of the other (sincehe was 11), though hisperformances tend to rockbasements and community hallsrather than Madison SquareGarden.

He's on his third band as anadult. Yet unnamed ("trying toname a band is one of the mostpainful exercises . . ."), the bandwas organized in Rochester,Minnesota, this spring afterMenaker started work at the MayoClinic. His first group was ThePointless Brothers in Marshfield,Wisconsin, where he joined arheumatologist and a Parkinson'sdisease expert looking for adrummer (to start a band, notdiagnose). His first publicperformance with The PointlessBrothers took place at a 1987Halloween party. "It was just somuch fun for me; it was such arelease."

Menaker's second band wasAlter Ego in Green Bay,Wisconsin, where he moved for a

medical practice position. Aninspirational highlight was the daythe band performed for the 2003unveiling of the newly renovatedLambeau Field, home stadium ofthe NFL's Packers football team.

The most memorable gig,however, came closer to homewhen Menaker's daughter askedhim and his band to perform for her2000 high school graduation party."That was particularly fun. Whoknow I was so cool?"

All four of his children, ages21-36, play music "at varying levelsand capacity." His wife, Linda,knits and collects dolls, though"we're in rhythm, so to speak,"Menaker says, all puns intended.

Faithful to his one majorhobby, Menaker does not hunt orfish - "heresy" in Minnesota andWisconsin. "I also golf, but Ishouldn't," he says.

In Menaker's book, there isonly one type of music: classicrock. He favors the Eagles,Beatles, Eric Clapton and DoobieBrothers. However, he says, likeworking in medical group practice,he knows he needs to listen,understand, compromise and trynew music. Like what?

"We're trying some RodStewart. The rest, I have no ideawhat the songs are. I'm just reallyfocused on the rhythm," Menakersays. "I spend lots of energy payingattention to the guitarists and thesinger. The drummer is the pulse ofthe band. The drummer is the mostimportant member of any band," hesays, wryly joking. Or maybe not.

"People have told me thatdrummers are egomaniacs orschizophrenics," Menaker says."Really, we're just Type Bs."

Hmmm, now about that bandname . . .

Reprinted with permission fromthe Medical Group ManagementAssociation, 104 Inverness TerraceEast, Englewood, Colorado 80112-5306; 303.799.1111. www.mgma.com.Copyright 2005

Ronald Menaker is theadministrator of the department ofpsychiatry and psychology of the MayoClinic, Rochester, MN. He is also thevice chair of the American College ofMedical Practice Executives(ACMPE).


Conference Highlights

A huge thank you goes out to Kevin and Christine Johnston (and their staff, Margie Hughes) forpicking up the pieces of our conference when plans had to be quickly changed as it became obvious thatNew Orleans could not be the site of our Fall meeting. It seems that the effects of Hurricane Katrinaextended all the way to Indianapolis! While we didn't have the French Quarter to stroll in, Indy was amarvelous host city to twenty-five attendees who (as we always do) met to learn, network, and meet oldfriends and new. This was an especially moving conference, as Jim Landry was presented with all of thewonderful gifts members sent. And, all of the attendees wore special t-shirts made just for the occasion.


This year’s NormanMacLeod Lecture wasdelivered by Dennis R.

Jones, MSW, MBA,Administrator, Indiana UniversityPsychiatric Associates, President& CEO, Indiana UniversityPsychiatric Management andHealth/Behavioral HealthConsulting.

Mr. Jones presentation,entitled “Playing in the SameAcademic Sandbox,” began with adescription of the diverse players inthe academic arena at IndianaUniversity. He discussed howthese relationships originated andhow they are evolving into thefuture. These institutions include:· Indiana University School of

Medicine· Department of Psychiatry· Clarian Health Partners (3 major

university hospitals)· Health and Hospital Corporation

(230 bed county hospital)· State of Indiana (FSSA – the

umbrella agency for mentalhealth, DMH – state mentalhealth authority and LarueCarter Hospital – 160 bed statemental health facility)

· Eli Lilly – major drugmanufacturer and researcher

· Indiana University PsychiatricManagement – Managed mentalhealth organization created and

The Norman A. MacLeod LectureThe Norman A. MacLeod LectureThe Norman A. MacLeod LectureThe Norman A. MacLeod LectureThe Norman A. MacLeod LecturePlaying in the same academic sandboxby Christine Johnston

owned by the Department ofPsychiatry.

After setting the stage, Mr.Jones then discussed the positiveoutcomes from such collaborativerelationships. Some examplesinclude multiple teaching venuesand research sites, enhancedrevenues, improved patient careand continuity of services, andbeing seen as an active partner inpublic sector venues. Along withthe positives, he pointed outtension points. Issues arise fromfaculty recruitment and the constantnegotiating of funding needs. Aswell, these varied off-campus sitesfunction with different operatingsystems, cultures and competingmissions. Management ofexpectations, multiple employersand the necessity for administrativemanagers continue to challenge.

As the IU Department ofPsychiatry has positioned itself tobe a player in this diverse sandbox,new opportunities continue to

present that have the possibility toenhance mental health care needsfor the state. One such initiative isa proposed new mental healthcampus that would consolidateLarue Carter, Clarian inpatientunits and the Institute forPsychiatric Research. This singlecampus concept proposes a newhospital model to includeemergency, acute and intermediatecare. The state’s bonding authoritywould build the new facility, theacute hospital network wouldmanage under contract with thestate and IU Department ofPsychiatry would staff the hospital.The research institute, coupled withenhanced partnerships through EliLilly, would also be an integral partof the facility. There is potential forconnectivity to both clinical andresearch endeavors in theneurosciences.

In summary, Mr. Jonesdescribed how years ofrelationships with outside playerscan enhance the servicedeliverability for departments ofpsychiatry. These are ongoingrelationships, which whencultivated and constantly refined,can provide exciting opportunitiesfor academic institutions to be keypartners in providing neededservices outside of the universitycommunity.(Christine Johnston is the practiceplan administrator for the IndianaUniversity department of psychiatry).

Dennis R. Jones, MSW MBA


Prescriptive authority for psychologists: Demand andtraining requirementsby James Rodenbiker

John Courtney, Psy.D. andRoger B Hensley, M.D.presented an informative and

thought provoking session onprescriptive authority bynonphysicians. They provided asummary of the pros and cons ofpsychologists being granted

profession. As a result, the totalnumber of psychiatrists has grownvery little, while the other threelargest medical specialties, internalmedicine, family medicine, andpediatrics have grown significantly.In addition, the specialty ofpsychiatry has become overlyreliant on international medicalgraduates (IMGs) to fill residencyand practice openings. ShouldCongress restrict the training ofIMGs, it would be even moredifficult to maintain the currentpsychiatry workforce.

A second issue that seems tobe resulting in a shortage ofpsychiatrists is that they aredistributed unequally across thecountry (large urban areas have anadequate supply, while rural areasare very much undersupplied).Moreover, psychiatrists areworking fewer hours and arespending less time in direct patientcare activities. To add to thisproblem, child psychiatrists areeven fewer in number, withshortages in both urban and ruralareas. Currently there are only7000 child psychiatrists nationally,with projections indicating that atleast 33,000 child psychiatrists areneeded to address the currentdemand for services.

Given the growing need forpsychiatric services, an agingpsychiatry workforce, a workforcethat is working fewer hours, anuneven distribution of psychiatriststhroughout the country, and areliance on IMGs to bolster thesupply of psychiatrists, can thecurrent rate of growth ofpsychiatrists keep up with theprojected demand for services? Ifnot, what nonphysician disciplines

are best suited and trained to begranted prescriptive authority formental health patients?

Are psychologists the bestoption to fill the need fornonphysician prescriptiveauthority? Currently psychiatryprescriptions are being writtenprimarily by family medicine(85%), with the remainder being

Continued on page 9

John Courtney, Psy. D.

prescriptive authority. Currently,psychologists with appropriatetraining have prescriptive authoritywithin federal facilities, the states ofLouisiana, New Mexico and theterritory of Guam. The primarymessage of this presentation was“Is there a need for anotherprescribing mental healthprovider?” and if so “Whatprofessional discipline is bestqualified and what training torequired to fill this need?”

Is there a demand for otherdisciplines to be give prescriptiveauthority? Psychiatry is currentlythe fourth largest medical specialty.However, over the past decade,fewer physicians are choosing apsychiatry practice due somewhatto the economic pressures thatmanaged care has imposed on the

Roger Hensley, M.D.

written by pediatricians, nursepractitioners, and psychiatrists.The nonphysicians with prescriptiveauthority receive 99 hours or lessof training in pharmacology, (onlypart of which includespsychopharmacology) and anaverage on 6.8 weeks of training inpsychiatric diagnoses.Psychologists, on the other hand,have mutual goals with psychiatrywhich include properly diagnosingmental disorders and providingaccurate and safe interventions. Inaddition, for those interested inreceiving prescription authority theAmerican PsychologicalAssociation (APA) recommendspostdoctoral training inpsychopharmacology. This training


requires 300 hours of didacticinstruction, and as importantly, aclinical practicum to include 1) aminimum of one hundred patientsseen for medication with a diversepatient mix relevant to thepsychologist’s expected currentand future practice, 2) in inpatientand outpatient settings, 3) inclusionof appropriate didactic instruction,and 4) a minimum of two hours perweek of individual supervision byan MD or DO experienced inpsychopharmacology. Moreover,the APA developed apsychopharmacology examinationfor psychologists to be completedafter the postdoctoral training withan anticipated additional sixhundred hours to prepare andstudy for this exam. Based on thisadditional training, psychologistsassert that, of nonphysicians, theyperhaps have the most knowledgeand best understanding of patientmental health issues and

prescription needs, hence are oneof the best choices fornonphysician prescriptive authority.Despite the points made thatpsychologists are very wellqualified to be granted prescriptiveauthority, there continues to beresistance from psychiatrists.Perhaps this is due to psychiatry’sfear that psychologists willencroach on what has traditionallybeen a skill specific to psychiatrists,in addition to the long held beliefthat psychologists do not have thetraining to become skilled atmedication management.

In summary, the psychologydiscipline presents a strongargument to be given the option toattain prescribing authority. ThePhD level of psychologist alreadyhas significant training in thediagnosis and treatment of mentaldisorders and is already anindependent health care provider.The postdoctoralpsychopharmacology training is

rigorous and in collaboration withsupervising physicians. Thephysicians who choose to becomesupervising physicians forpsychologists have been convincedthat prescriptive authority forpsychologists could be a legitimateoption. Moreover, their history ofcollaboration with psychiatry couldallow for the evolution ofprescribing psychologists, which inthe long run could alleviate some ofthe backlog of patients needingservices of a psychiatrist.However, continued collaborationand discussion with psychiatry willbe necessary if psychologists hopeto convince mainstreampsychiatrists that prescriptiveauthority for psychologists willalleviate the backlog of patientsand not create competition forpatients.(James Rodenbiker is theadministrator of the CreightonUniversity department of psychiatry).


Telemedicine: Lessons learned and future trendsby JoAnne Menard

Telemedicine has advancedinto mainstream psychiatry,as evidenced by the

informative and well-integratedpanel presentation by DorisChimera ( U Texas - Galveston),Patricia Birkmeyer (U Texas -Galveston), and Marti Sale (UKentucky).

While over the last severalyears, previous conferenceattendees have been able to followthe development of telepsychiatrythrough presentations by pioneeringcolleagues, it was clear from thispresentation that telepsychiatry has“arrived,” and in the future it willbecome commonplace.

Doris traced the historicaldevelopment of usingtelecommunications in thehealthcare industry, whichsurprisingly goes back to early1900’s experiments using radio.Since the mid-1990’s, telemedicineprograms have become commonthroughout the world in nearlyevery specialty and area ofhealthcare.

According to Doris, recentgrowth in telemedicine has beenfacilitated by several factors: lowercost, more widely availablecommunications; lower cost, higherperformance computers; greaterpublic confidence in the use ofcomputer technology; greateracceptance of the technology bymedical professionals; and

emerging global standards incommunications, videoconferencing, and medicaldisciplines.

However, in spite ofcontinuing developments intelemedicine, telecommunicationsmethods initially weren’tconsidered applicable topsychiatry. But as the needincreased for mental health care inrural areas, telepsychiatry met thedemand.

The department of psychiatryat University of Texas MedicalBranch – Galveston has been usingtelepsychiatry for four years.Although the uses are endless,Doris reported that there are still

Continued on page 10


roadblocks in some areas, such asthe cost of equipment andinfrastructure, education of patient

When Patricia’s departmentstarted contracting fortelepsychiatry services, there wasno administrative checklist, but shestrongly recommended using one.Detail should be written intoservice contracts up front.

Provider choice is important:someone who has awareness andappreciation of cultural issues,good communication skills,comfortable camera presence, andis technologically comfortable andwilling to follow the practice

In the beginning,approximately $1 million of federalfunds were used for equipment andstartup costs at UK. The Statenow funds the technology in 37sites. Operations are now financedprimarily through the University,with annual expenses running about$350,000.

Marti stated that a key aspectof the network is that it doesn’tchange the way medicine ispracticed; rather, it integrates newtools into its delivery system.

UTMB also has been usingtelecommunication technology forten years, and, according toPatricia, today their medicalservices comprise the largesttelemedicine operation in theworld, with over 300 locations andover 60,000 patient encountersannually.

Patricia Birkmeyer

Marti Sale

Doris Chimera


and provider, and generalacceptance of this mode oftreatment to overcome culturalresistance, patient privacy issuesand, most common, concernsabout impersonal service.

As the process expands andmatures, issues that emerge arelicensure requirements, practiceacross state lines, contractingregulations, provider credentialing,and ethical standards of care. Turfissues are “huge,” according toDoris, involving market forces andterritoriality across state lines.Resulting impacts may be nationallicensure legislation and federal,state and commercialreimbursement.

Patricia continued byaddressing specific reimbursementand regulatory issues in the use oftelemedicine. She stated thatpayers are slowly acceptingtelemedicine as a valid resourceand are reimbursing for services.Medicare requires the service areato be a Rural-Health ProfessionalShortage Area, and requires aspecial modifier when billing fortelemedicine. Medicaidrequirements vary by state and “arechanging daily.” About one-thirdof the states still have no Medicaidinsurance reimbursement.

requirements of the contractagency. Once providers andpatients use telemedicine, Patriciasaid the majority become “likeMikey – they like it!”

Relating the development ofthe Telecare program at theUniversity of Kentucky, Marti toldhow telepsychiatry started tenyears ago with one child beingtreated at home. The child asked tohave the monitor moved to hisbedroom, where he sat on the bedfor therapy sessions. It was a verysuccessful therapy experience.

UK Psychiatry now has beenusing the Telecare system for 10years to see patients, to trainresidents in didactics, for GrandRounds, for court testimony, etc.Not only physician fees, butadministrative costs are written intothe contracts. Telemedicinecontracts are approximately 5% ofthe psychiatry department’s clinicalrevenue.

In the four years that UTMBhas been using telepsychiatry,Patricia states it has found it ideal intreating poor, underserved, ruraland border populations with uniqueneeds. Their site also currentlyparticipates and sees furthergrowth in serving oil rigs,Antarctica, Homeland Defenseprojects and natural disaster needs.

The presentation concludedwith the following quote:

“The doctor is not here, butwill see you now.”(JoAnne Menard is administrator ofHarborview Medical Center Division,University of Washington department ofpsychiatry).


AAP

photoalbum

Jim Landry modelling a new shirt New buddies Jane Biehler andJanice McAdam

The fruits of your very generous giving

Pat Sanders Romano presenting ChrisJohnston the AAP Board of Directors Award

Good friends Narri Shahrokhand Liz Smith

Chris Johnston displaying her very AAP-ishthank you gift!


Building effective teamsA group dynamics model

by Elaine McIntosh

Lee Fleisher presented aninteractive discussion aboutbuilding teams,

understanding group process, teammember satisfaction, and usingmeeting effectiveness to optimizethe success of team goals. Lee hasdeveloped expertise in leadingeffective groups through his morethan fifteen years as a member ofAAP serving as AAP Presidentfrom 1994-1995 and his manyyears as a leader in the Departmentof Psychiatry at VanderbiltUniversity School of Medicine.

Lee began his presentationwith a focus on individuals. Thepremise of this section of the talkwas based on the philosophy heldby Bill Hewlett, cofounder ofHewlett Packard. He believedthat “men and women want to do agood job, a creative job, and ifthey are provided the properenvironment, they will do so.”

Two key factors of focusingon individual success aremotivation and recognition.However, management’sassumptions of what will motivateemployees do not always coincidewith what employees really want.Managers tend to think employeeswant good wages, job security,and promotion/growth opportunityas the top three desires. Employeesurveys indicate that their topdesires are full appreciation forwork done, feeling “in” on things,and getting supervisors sympathetichelp on problems.

The benefits associated withemployee recognition are bettermorale, increased productivity,higher level of business

• Increased visibility/opportunity/responsibility

Lee concluded this portion ofhis presentation with five simpleinsights:• You get what you reward• What motivates people,

motivates people• The most motivating rewards

take little or no money• Everyone wants to be

appreciated• All behavior is controlled by its

consequences.The presentation then shifted

focus from the individual to theteam. Lee defined a team as “agroup of individuals who havecomplementary skills and arecommitted to a shared, meaningfulpurpose and specific goals.” Hestated that the characteristics ofeffective teams are a sharedpurpose or mission, a set ofspecific and measurable goals, acollaborative work approach, well-defined roles and responsibilities,mutual accountability for the team’sresults, possession of skills andtools required to do the job, andcommitment to learning andimprovement. From a manager’spoint of view, team goals should bespecific, measurable, attainable,results oriented, time bound. It isalso helpful to identify theresponsibility of each team membertoward achieving the defined goal.

The third and final segment ofthe presentation focused ongroups. Teams are designed tohave a defined goal to be

Lee Fleisher

competitiveness, and a rise inrevenue/profits. Additionally,stress, absenteeism, and turnoverand related costs are reduced byemployee recognition. A nationalsurvey on why workers leave jobsrevealed that 34% of respondentsleft their jobs due to “limitedrecognition.” The top techniquesto recognize individuals are bypersonal thanks, written thanks,promotion for performance, publicpraise, and morale buildingmeetings. Praise should be timedclose to the work being praised,and should be sincere, specific,personal and positive.

Additionally, Lee listed lowcost ways to energize employees:• Interesting work• Information/communication/

feedback• Involvement• Independence/autonomy/

flexibility



completed in a limited time frame.The criteria defining groups areidentifiable membership; membershaving a common interest, goal orpurpose; and members thinking ofthemselves as a group. Whenthese three conditions are in place,certain predictable, orderly andobservable patterns and processesoccur. Lee emphasized that anunderstanding of these patterns andprocesses is needed by theleadership of groups. Oneimportant dimension of groups isdecision making. This is moreaccepted and effective if the

Continued from page 12 decision is made by consensusrather than majority rule. Task andmaintenance related behaviors arealso important to effective groups.Task oriented behaviors areinitiating, seeking information oropinions, giving information oropinions, clarifying and elaborating,summarizing, and consensustesting. Maintenance orientedbehaviors include controlling thechannels of communication,encouraging, compromising,standard setting or testing, andharmonizing.

Lee concluded hispresentation with a list of reference

and recommendations for furtherinformation. A few resources foradditional information on this topicare listed below:• 1001 Ways to Reward

Employees, Ken Blanchard andBob Nelson

• The Team-Building Workshop:A Trainer’s Guide, VivettePayne

• Group Dynamics, DorwinCartwright and Alvin Zander

• The Guru Guide, JosephBoyett and Jimmie Boyett

(Elaine McIntosh is the administrator of theUniversity of Nebraska department ofpsychiatry).

Disease management initiatives for the severely andpersistently mentally illby Janice McAdam, MPA

This panel discussion offeredtwo perspectives onAssertive Community

Jane Biehler, is a relatively newprogram. The other, AssertiveCommunity Treatment (ACT) atUniversity of Iowa, presented bySteve Blanchard, is anestablished program. The programsare similar in many ways while stillbeing unique to their populationand services.

ACT programs began in thelate 1960’s by a group of MendotaSate Hospital researchers. Theyobserved that the serious andpersistently mentally illdecomposed quickly andfrequently without the support ofthe hospital inpatient milieu. Usinga disciplinary team model thatworked well for other consumers,the program entitled “Training inCommunity Living” became knowas “hospitals without walls.” Thename of the program was laterchanged to “Program of AssertiveCommunity Treatment (PACT)”

and was effective in helpingconsumers stay out of the hospital.In the 1970’s the PACT programsspread across Wisconsin, wherecurrently there are 62 PACT


Jane Biehler

Treatment programs. TheIntegrated MultidisciplinaryProgram of Assertive CommunityTreatment at the University ofOklahoma College of Medicine(OU IMPACT), presented by

Steve Blanchard

teams. From the late 70’s, thegrowth of PACT spread across theeastern half of the United States. In1998, NAMI promoted the PACT



Across America Initiative, movinggrowth to the western states.

In January 2004, the PACTprogram was developed at theUniversity of OklahomaDepartment of Psychiatry as aninterdisciplinary team consisting ofmental health professionals thataims to meet the clinical needs andto provide intensive treatment topersons with severe and persistentmental illnesses. OU IMPACTprovides care around the clockincluding medication management,vocational training, substanceabuse treatment, rehabilitationservices and crisis management.The goal is to help individuals inrecovery from mental illness leadhealthier, happier, more productivelives.

The OU IMPACT fifteenmember team consists of apsychiatrist as the programdirector, a team leader, assistantteam leader, two RNs, socialworker, counselor, two casemanagers, two peer specialist,program assistant, and memberservice representative. The twopeer specialists are individuals whoare in recovery of severe andpersistent mental illness and wellenough to be employed. Theprogram assistant functions as aclinic manager and the memberservice representative is equivalentto a clinic receptionist.

The target population for OUIMPACT are homeless individualsdiagnosed with illnesses such asschizophrenia, schizoaffectivedisorder, recurrent majordepression, and bipolar disorder.Currently there are 55 enrolleesand the program can handle up to75. The admission criteria are AxisI diagnosis of one of the illnessesmentioned above, four or morehospitalizations in the past 2 years(including crisis unit visits) or a stay

longer than one month in the pastyear, plus three of the following:failure to utilize standard treatmentoptions, legal problems as aconsequence of mental instability,imminent or current homelessness,comorbid substance use disorder,and inability to functionindependently.

Funding from OU IMPACTstarted as total funding from theOklahoma Department of MentalHealth and Substance AbuseServices (DMHSAS). Thefollowing year, Medicaid fundedapproximately 5% with theremaining 95% to DMHSAS. Inthis current year the funding is split50-50 between Medicaid andDMHSAS. Medicaidreimbursement for the program isnontraditional as a per diem rate of$120 per day with a maximum 12contact days per month.

The University of Iowa’sACT is an older program, startedin 1996. Start up support wasprovided by Iowa Plan, which is abehavioral health care carve out forTitle XIX. Contracts with Magellanand Wellmark (BC/BS) have beenestablished and they currently haveabout 9 enrollees in theseprograms. Instead of a per diemrate, ACT payments are on amonthly case rate.

Staffing of the UI programs isless than Tulsa’s PACT programwith only 8.1 FTE. The positionsinclude a full-time clinical director(ARNP), halftime medical director,RNs, OT, two clinical outreachcounselors, and a rehabilitationcounselor. Like OU IMPACT, theACT program has a currentenrollment of 55.

With a change in system, alook at how to measure outcomeswas important to ACT. Did theyeffect change and how effectivewas the care? The first phasemeasured hospital utilization, Brief

Psychiatric Rating Scale (BPRS),Multnomah Community Function,and Patient Satisfaction.Hospitalization was reduced.Dramatic changes were realized atthe beginning of the program andthen stabilized in both the BPRSand the Multnomah Communityscores. Patient satisfaction isassessed every two years byindependent phone or face-to-faceinterviews. The average score is2.76 on a 3.0 rating scale.

The second phase is currentlyunder development and moves theemphasis toward measuring clientresults and ability to live in thecommunity with less emphasis oninstitutional measurements. Themeasurements for phase two arehospital utilization, employment,substance abuse, legal involvement,homelessness, and patientsatisfaction. Hospitalization is adownward trend. Employment hasa lot to do with identity andtherefore it is important forparticipants to be involved in sometype of work. Both days ofincarceration and contacts with thejustice system are low.Homelessness has been eliminateddue to developing housingconnections and helping individualsoff the streets.

No matter what location, thePACT program provides a moresatisfying approach to treatment forthe severely and persistentlymentally ill patients and theirfamilies, an additional source oftraining for residents, and offsetmedical benefits. Medicine is beingprovided that patients normallywould not be able to afford or notbother to fill. And from JaneBiehler’s summary, “There isrenewed hope for those afflictedwith severe mental illness.”(Janice McAdam is the administrator of theUniversity of Kansas department ofpsychiatry).


by Hank Williams

Joanne Menard (UWashington) - I have heardcomments here about bothfavorable and unfavorableMedicaid reimbursement. Canpeople comment on how you aredoing with Medicaid?

Margaret Moran (MedicalCollege of Ohio): There are twoways we are paid. Traditionalreimbursement is terrible. We arecertified and have a servicecontract, so we are a serviceprovider with the state departmentof mental health and our countymental health board, where ourreimbursement is cost-based, andthey are our best payer. MartiSale (U Kentucky): Ours is similar.Direct billing is terrible, but we arepart of a community health center,and we get reimbursed more thanour fee most of the time. TheCommunity mental health centercuts a check to UK directly. Ourmoney from them is over a milliondollars a year. Janice McAdam(U Kansas): The state decided toreimburse at $90 per visit formedicine checks, but we arehearing that will go away.

Steve Blanchard (U Iowa) -Where are folks in the evolutionof electronic medical records(EMRs)? We are in a selectionprocess.

Brenda Paulsen (UArizona): We are going from paperto EMR using AllScripts. It’sprovider based. The problem is

Take two minuteswe just started running a hospitaland we have converted clinics toprovider based clinics. We haveheard cost may be $35K perprovider for licensing, but ourestimate was about $10K perprovider. Doris Chimera (UTexas, Galveston): Three years agowe installed Duke University’sEMR. We had many issues, butnow it has worked out well,primarily for outpatient clinics. Thedecision was made last year topurchase Epic, but there is not aPsych module, it has to be built.We will transition in the next 1-2years. Lee Fleisher: Vanderbiltbuilt its own system, there were alot of interface concerns, and a lotof interest on the research side fortechnology transfer. So weconcluded if you invest properly,you can develop your own system.We created WizOrder—it’smaking millions, and the goal is tomake money. It’s better also whenyou want to “tweak the system”yourself, rather than going back toa vendor. Narri Shahrokh, (UCalifornia, Davis): We are abouthalfway into the Epic EMR (about18 months), another 2 years beforegoing on board live.

Paul McArthur (URochester) - We have just gottenback the first reimbursementreports back from Medicare PPSsystem. Medicare has now gonefrom being our best to worstpayer. Have other schools feltthe impact of PPS in one way or

another, eitherprogrammatically or fiscally?

Patricia Birkmeyer (UTexas, Galveston): We project wewill lose a quarter million dollars ayear over 4 years. BrendaPaulsen: We are looking at aseven-figure loss, we don’t knowwhat changes will do. Jim Landry(Tulane U): There is a difference inpublic and private. Tulane is forprofit, they predict ourreimbursement will increase $750Kper year, but we don’t have accessto data. Steve Blanchard: Ourcost is $6.84, but under PPS ourestimated reimbursement is $6.93.We’re not changing anything justyet, but it hits everyone differently.

Jan Price (U Michigan) - Ihave a question aboutconsultation liaison services. Wehave an issue with patients whoneed a transfer to a psychiatrybed, but their insurance requiresprior authorization. Who doesyour authorizations? How aboutweekend transfers? Med surgdocs want them off their floorsas soon as possible, but if wecan’t get the insuranceauthorization, we are not excitedabout moving them.

Steve Blanchard: It’s still aproblem, but we’ve been able tocatch those through our registrationoffice. Lee Fleisher: Vanderbiltdealt with this as a contract issue,not needed for initial consult.Doris Chimera: We have a case



Guidelines for inclusion of clinical practice compensationin institutional base salary charged to NIH grants andcontractsNotice: NOT-OD-05-061National Institutes of Health

This Notice providesguidance and policy to addressrequests for revision of establishedNIH requirements for the inclusionof Clinical Practice Compensation(CPC) in Institutional Base Salary(IBS) to provide enhanced clarityand flexibility in implementationwhile maintaining appropriatestewardship and accountability forthe utilization of NIH funds.

IBS is defined in the NIHGrants Policy Statement (12/03)<http://grants.nih.gov/grants/policy/nihgps_2003/NIHGPS_Part2.htm> as: Theannual compensation paid by anorganization for an employee’sappointment, whether thatindividual’s time is spent onresearch, teaching, patient care, orother activities. Base salaryexcludes any income that anindividual is permitted to earnoutside of duties for the applicant/grantee organization. Base salarymay not be increased as a result ofreplacing organizational salaryfunds with NIH grant funds.

CPC is the compensationprovided for the clinical serviceactivities of an individual.Institutions manage CPC in a widearray of arrangements and thepurpose of this guidance is neitherto proscribe nor encourage aspecific approach to the provisionof this compensation or its inclusionin IBS.

Whether CPC should beincluded in IBS is most often aquestion related to facultyappointments at a University. Inthese settings the inclusion of CPCin IBS must be established

consistent with the provisions ofOMB Circular A-21 (CostPrinciples for Colleges andUniversities) <http://www.whitehouse.gov/omb/circulars/a021/a21_2004.html>.These requirements are addressedunder ‘Compensation for personalservices’ Section J.10, which inpart states; “Compensation forpersonal services covers allamounts paid currently or accruedby the institution for services ofemployees rendered during theperiod of performance undersponsored agreements” and thatpayroll distribution “will (i) beincorporated into the officialrecords of the institution, (ii)reasonably reflect the activity forwhich the employee iscompensated by the institution, and(iii) encompass both sponsoredand all other activities on anintegrated basis…”

Based on these principles andthe input of the extramuralcommunity, the NIH in consultationwith other HHS and other Federalofficials has revised therequirements to be used asguidance in the determination ofwhen it is appropriate to includeCPC in the IBS. All these criteriamust be met for CPC to beincluded in the IBS used to chargesalary and personnel costs to NIHgrants.

The previous criteria areprovided in the NIH Grants PolicyStatement <http://grants.nih.gov/grants/policy/nihgps_2003/NIHGPS_Part6.htm>:

“For investigators withuniversity and clinical practice planappointments, compensation fromboth sources may be consideredthe base salary if the following

criteria are met:· Clinical practice

compensation must be guaranteedby the university

· Clinical practice effort mustbe shown on the universityappointment form and must be paidthrough the university

· Clinical practice effort mustbe included and accounted for onthe university’s effort report.”

These criteria have beenrevised to more clearly recognizewhen it is appropriate to includeCPC in situations when the CPC ispaid by a separately organizedsource. The revised criteria are asfollows:

For investigators receivingcompensation from the institution(grantee/contractor) and separatelyorganized clinical practice plans,compensation from such sourcesmay be included in the institutionalbase salary (IBS) budgeted andcharged to NIH sponsoredagreements if all of the followingcriteria are met:· Clinical practice compensation

must be set by the institution.· Clinical practice activity must be

shown on the institution’s payrollor salary appointment forms andrecords approved by theinstitution.

· Clinical practice compensationmust be paid through or at thedirection of the institution.

· Clinical practice activity must beincluded and accounted for inthe institution’s effort reportingand/or payroll distributionsystem.

· The institution must assure thatall financial reports andsupporting documents


Research


associated with the combinedIBS and resulting charges toNIH grants are retained andmade available to Federalofficials or their duly authorizedrepresentatives consistent withthe requirements of 45 CFRPart 74.53 (A-110 Subpart C53).

Set by the institution meansthat the grantee/contractorinstitution must be in a position todocument and certify that thespecified amount of clinical practicecompensation is being paid inessentially the same manner as

other specified amounts of thecommitted IBS (compensation) ofthe investigator. Further, thisrequires that the IBS not varybased on the specific clinicalservices provided by theinvestigator within the periods forwhich total IBS is certified by thegrantee institution.

The NIH recognizes thatreimbursement for investigatoreffort on grants must be providedconsistent with the actualinstitutional costs of these servicesin accord with applicable FederalCost Principles and otherlimitations for such reimbursement,such as the legislative cap on salary

Continued from page 16 reimbursement. The revised criteriasupport conformance withapplicable cost principles andconsistency in the treatment ofcompensation across the institutionregardless of the source of supportfor compensated activities.

InquiriesFor additional information

concerning this change contact:Office of Policy for Extramural

ResearchAdministration Office of Extramural

ResearchNational Institutes of Health Phone:

301-435-0938FAX: [email protected]

Research

NIH announces plans to eliminate mailing of papernotificationsNotice: NOT-OD-05-075National Institutes of Health

The NIH continues towardsits goal of a paperless grantsprocess through the elimination ofthe following notifications which arecurrently sent in hard copy:Summary Statements and PeerReview Outcome Letters. Instead,investigators are instructed to usethe eRA Commons, a Webinterface where NIH and theapplicant organizations are able toconduct extramural researchadministration businesselectronically.

The NIH encouragesinstitutions and their investigators toregister in the Commons as soon aspossible. In addition to complyingwith a Congressional mandate tomove from paper-based toelectronic systems, these newprocedures will also improveconsistency and timeliness ofcommunication between NIH,investigators, and institutions duringthe grant application process.

Over the next two grant

review cycles, the NIH willdiscontinue mailing the followingtwo kinds of documents:

Summary StatementsBeginning October 1, 2005, NIHwill no longer send hard copies ofthe Summary Statements toPrincipal Investigators (PIs) andIndividual Fellows Applicants.Summary Statements areaccessible electronically to PIs andFellows in the eRA Commonswithin approximately 8 weeks ofthe Scientific Review Group (SRG)meeting.

Review Outcome “Mailers”Beginning February 1, 2006,

the NIH will no longer send hardcopies of the notification letter (alsoknown as a “mailer”) to PIs andFellows regarding the reviewoutcome of an application by theSRG. When the SRG rosters andmeeting dates become available,they may be accessed throughhttp://www.csr.nih.gov/Committees/rosterindex.asp(Center for Scientific Review

[CSR] reviews) or http://era.nih.gov/roster/ (Institute/Centerreviews). Scores will be posted inthe eRA Commons approximately5 working days after the SRGmeeting.

At this time, the NIH willcontinue to send assignment andchange of assignment mailers.

In order to avoid delays inthe e-notification process, it isvital that all GranteeOrganizations, Principallnvestigators, and IndividualFellows register in the eRACommons and periodicallycheck e-mail addresses foraccuracy.

Inquiries on this NIH GuideNotice may be directed to:Division of Grants PolicyOffice of Policy for Extramural

Research AdministrationNational Institutes of Health6705 Rockledge Drive, Suite 350Bethesda, MD 20892 Telephone:

(301) 435-0938FAX: (301) [email protected]


Mechanism for time-sensitive research opportunitiesProgram Announcement: PAR-05-150National Institutes of HealthInstitute of Mental HealthNational Institute on Drug Abuse

This Program Announcement(PA) is intended to support publicmental health and/or substanceabuse services research in rapidlyevolving areas (e.g., changes inservice systems, health carefinancing, policy, etc.) whereopportunities for empirical studyare, by their very nature, onlyavailable through expedited awardof support. There are threedistinguishing features of an eligiblestudy: 1) the study’s scientific valueand feasibility are clear, 2) rapidreview and funding are required inorder for the scientific question tobe answered and for the researchdesign to be carried out, 3) theknowledge gained from the studycannot be obtained through theregular NIH cycle of review andaward. It should be clear that theresearch question offers anuncommon and scientificallysignificant services researchopportunity that could only becomeavailable if the project is initiatedwith minimum delay.

In particular, this PAencourages innovative scientificpartnerships between researchersand community or public partners(e.g., public mental health/substance abuse or health caresystems, long-term care providers,criminal justice settings, health careproviders, payers, health

authorities, etc.) who cannot delaypolicy or program changes in orderto obtain baseline research datarelated to such changes. Researchcollaborations intended to answerunique and innovative questionsconcerning changes in a health caresystem or policy are of mostinterest. The PA provides amechanism for accelerated reviewand award to support opportunitiesfor this type of research.

Examples of appropriatestudies include, but are not limitedto, the following:· Examining the impact of rapid

changes in policy/legislation thataffect delivery of mental healthand/or substance abuse servicesand treatment.

· Evaluating the impact of systemsinterventions, new qualityimprovement of evidence basedpractice programs implementedas an immediate response toadministrative or policydirectives.

· Determining the impact of newpayment mechanisms includingthe cost-effectiveness ofalternative treatments, servicesor structures for provision ofservices.

· Identifying, describing ortracking individual, family,provider, organizational orsystems-level outcomes resultingfrom changes in services orbenefits.

· Determining the impact of newdissemination or implementationstrategies.

IMPORTANT NOTE: Alleligible applications responding tothis PA will be subject to anaccelerated review and awardprocess. It is intended that eligibleapplications selected for fundingwill be awarded within 4-6 monthsafter the application receipt date.However, administrativerequirements and other unforeseencircumstances may delay issuancedates beyond that timeline.Investigators pursuing support formental health research in theimmediate aftermath of a disasterare referred to Rapid AssessmentPost-Impact of Disaster, PAR-02-133 at http://grants.nih.gov/grants/guide/pa-files/PAR-02-133.html.

Key DatesLetters of Intent Receipt Date(s):4 weeks prior to plannedsubmission dateApplication Receipt Date(s): The9th of each monthPeer Review Date(s): Within 6weeks of submissionCouncil Review Date(s): Within 6weeks of reviewEarliest Anticipated Start Date:Within 6 months after receiptAdditional Information To BeAvailable Date (URL ActivationDate): N/AExpiration Date: August 10, 2008

Additional informationThe entire Program Announcementcan be found at http://grants.nih.gov/grants/guide/pa-files/PAR-05-150.html.

Research


NIH launches major program to transform clinical andtranslational science

National Institutes of Health(NIH) Director Elias A.Zerhouni, M.D., recently

announced a new programdesigned to spur the transformationof clinical and translational researchin the United States, so that newtreatments can be developed moreefficiently and delivered morequickly to patients.

“We are truly at a crossroadsin medicine,” Zerhouni said. “Thescientific advances of the past fewyears, such as the completion ofthe Human Genome Project,dictate that we act now toencourage fundamental changes inhow we do clinical research, andhow we train the new generationsof clinician scientists for the medicalchallenges of this century.”

The Institutional Clinical andTranslational Science Awards(CTSAs) program, unveiled todayin The New England Journal ofMedicine (NEJM), is designed toenergize the discipline of clinicaland translational science at theacademic health centers around thecountry.

“This program will giveresearch institutions more freedomto foster productive collaborationamong experts in different fields,lower barriers between disciplines,and encourage creative, newapproaches that will help us solvecomplex medical mysteries,” saidZerhouni. “Ultimately, patients willbe better served because newprevention strategies andtreatments will be developed,tested, and brought into medicalpractice more rapidly.”

The grants will encourageinstitutions to propose newapproaches to clinical andtranslational research, including

new organizational models andtraining programs at graduate andpostgraduate levels. In addition,they will foster original research indeveloping clinical researchmethodologies, such as clinicalresearch informatics, laboratorymethods, other technologyresources and community-basedresearch capabilities. Potentialbenefits to patients include: newmedical monitoring devices thatthey can use in their own homes;improved methods for predictingthe toxicity of new drugs in specificindividuals; and a seamless andsafe experience for those whoparticipate in clinical trials.

NIH plans to award four toseven CTSAs in FY 2006 for atotal of $30 million, with anadditional $11.5 million allocatedto support 50 planning grants forthose institutions that are not readyto make a full application. NIHexpects to increase the number ofawards annually so that by 2012,60 CTSAs will receive a total ofapproximately $500 million peryear. The CTSA program is anNIH Roadmap for MedicalResearch initiative and will beadministered by the NationalCenter for Research Resources(NCRR), a component of the NIH.Funding for the new initiative willcome in part from the Roadmapbudget and existing clinical andtranslational programs. This will beaccomplished entirely throughredirecting existing resources,including Roadmap funds. “We aretaking great care to preserve theinvestigator-initiated researchsupport pool in these times ofconstrained budgets,” Zerhounisaid.

For the purposes of this

initiative, NIH is defining clinicalresearch as studies and trials thatinvolve human subjects.Translational research is to includetwo segments of the researchcontinuum. The first is the processof applying discoveries made in thelaboratory, testing them in animals,and developing trials and studiesfor humans. The second concernsresearch aimed at enhancing theadoption of best treatmentpractices into the medicalcommunity.

The CTSA program willencourage the development of thediscipline of clinical andtranslational science by providingthe resources for the creation of aredefined academic home. Theprogram will allow for localflexibility so that each institution candetermine whether to establish acenter, department, or institute, orother interdisciplinary structure,depending upon local and regionalcircumstances.

“We hope to increase thenumber of translational and clinicalinvestigators by providinginterdisciplinary training in adedicated intellectual environmentthat offers clear career pathways,combined with opportunities todevelop new approaches to clinicalresearch,” said Barbara M. Alving,M.D., NCRR Acting Director.“We hope this CTSA programprovides the much-needed catalystto increase the efficiency and speedof clinical and translationalresearch.”

The Request for Applications(RFA) calls for submissions byMarch 27, 2006. Initial awards areexpected to be made by Fall 2006.The RFA is available atwww.ncrr.nih.gov.

Research


The American Academy ofMedical Colleges has beenworking with the Physician

Regulatory Issues Team at CMS

Use of macros for teaching physician documentationto allow teaching physicians to usemacros in their part of the medicalrecord and speed up the process,according to the PRIT Web site atwww.cms.hhs.gov/physicians/prit.

CMS is making final revisions to a“clarifying statement” about the useof macros. This will probably beincorporated into the manualbecause of the importance of thissubject to teaching physicians.

National provider identifier (NPI): Not just another numberby Janice McAdam, MPA

The Centers for Medicareand Medicaid Services(CMS) announced on May

6, 2005 the availability of a newidentifier for use in the standardelectronic health care transactions.The National Provider Identifier(NPI) will be the single provideridentifier for use by each healthplan with which you do business.Health Insurance Portability andAccountability Act of 1996(HIPAA) requires theimplementation of an identifier forall health plans, health careclearinghouses, and health careproviders that conduct electronictransactions for which theSecretary of the Department ofHealth and Human Services hasadopted a standard (i.e., standardtransaction).

NPI is one of the steps CMSis taking to improve electronictransactions for health care. Todate, HIPAA has implemented thefollowing standards: electronichealth care transactions and codesets, privacy, security, and thenational employer identifier. Nowbegins the implementation of NPI.On January 23, 2004, theSecretary published a Final Rulethat adopted the NPI. HIPAAcovered entities must use NPIs toidentify health care providers instandard transactions, such as

claims, eligibility inquiries andresponses, claim status inquiriesand responses, referrals, andremittance advices by May 23,2007. Small health plans have untilMay 23, 2008 to start using NPIs.Health care providers may use onlytheir NPIs to identify themselvesafter these compliance dates.

Implementation of the NPIwill eliminate the need for healthcare providers to use differentidentification numbers to identifythem when conducting standardtransactions with various healthplans. The old provider numberwill no longer be used. Where theNPI is called for only the NPI willbe used. Health plans includeMedicare, Medicaid, and privatehealth insurance issuers, and allhealth care clearinghouses.

There are only three ways toapply for your NPI:1. Web-based application process

at https://nppes.cms.hhs.gov.2. Prepare a paper application and

send it to the entity that will beassigning the NPI on behalf ofthe Secretary, known as theEnumerator. A copy of theapplication, including theEnumerator’s mailing address,will be available on https://nppes.cms.hhs.gov, or call theEnumerator for a copy, 1-800-465-3203 or TTY 1-800-692-2326.

3. With your permission, anorganization may submit your

application in an electronic file.This could be a professionalassociation or a health careprovider who is your employer.This process will be available inthis fall.

The application form containsa Privacy Act Statement, whichexplains the dissemination of theinformation contained on theapplication. When gatheringinformation for your applicationmake sure it is correct, such asyour social security number andFederal employer identificationnumber. Safeguard the use of yourNPI number once you receive it.

You need only apply once foran NPI. However, you mayreceive numerous reminders orrequests for NPI application.Every health plan uses the sameNPI for you. Although health careplans are not required to use NPIsprior to May 23, 2007 some maystart notifying you that they areaccepting NPIs prior to thatdeadline.

Additional information aboutthe NPI is available atwww.cms.hhs.gov/hipaa/hipaa2.CMS will provide updates on theNPI will be available on theNPPES web site at http://nppes.cms.hhs.gov, or you maycall the Enumerator at 1-800-465-3203 or TTY 1-800-692-2326.(Janice MacAdam is the administratorof the Kansas University MedicalSchool department of psychiatry).

Billing/Clinical


Billing/Clinical

Medicare eliminates name/ID edit — for now

Pressure from thousands ofproviders has led theCenters for Medicare &

Medicaid Services to reverse anedit that was causing massivedenials.

Since CMS instituted an editrequiring providers to match

Medicare beneficiaries’ names andMedicare ID numbers exactly,some providers have had as manyas 30 percent of their claimsdenied. But now CMS officials saythe edit is being deleted for now.

Officials say they decided theedit was “too restrictive,” perhaps

because of the excessive number ofdenials. CMS hasn’t announcedthe change publicly, except torevoke a Medlearn Matters articleabout the requirement (SE0516).But you can’t kiss the edit good-bye forever — the agency isreworking it, and plans to reinstatea revised version at some point inthe future.

New CPT codes for psychological testing effectiveJanuary 1, 2006

The current CPT codes forpsychological andneuropsychological testing

will be replaced effective January1, 2006 in order to reflect whodoes the testing: a psychologist,technician or computer.Additionally, the code for theneurobehavioral status exam codewill change from 96115 to 96116.

There will be no grace periodduring which bills can be submitted

with the old codes. Claimssubmitted after December 31,2005 with the old codes will be notbe accepted.

Billing under the new codeswill be based on who administersthe test and how long it takes.Testing by a psychologist is billedin hourly units, based on thenumber of hours spent in theadministration, interpretation andreporting. Testing conducted by a

technician is based on the numberof hours spent in the face-to-faceadministration of the test. Testingby computer is billed at a flat rateregardless of time. In the case ofboth technician and computertesting, the test portion is billedusing the appropriate technician orcomputer code and thepsychologist will bill for time spentinterpreting and reporting resultsusing the PhD code.

96100Psychological Testing

96102Testing bytechnician

93103Testing bycomputer

96101Testing by PhD

96117Neuropsychological Testing

96119Neuropsych testing

by technician


by computer


by PhD

Administrators in Academic Psychiatry Spring ConferenceMay 6, 2006Chicago, ILwww.adminpsych.org

Academic Practice Assembly Annual ConferenceMay 7-9, 2006Chicago, ILwww.mgma.com

NIH Regional Seminars in Program Funding and GrantsAdministrationMarch 30-31, 2006 May 30-June 1, 2006Boston, MA Riverside, CAgrants.nih.gov/grants/seminars.htm

Comingattractions


Billing/Clinical

CMS physician voluntary reporting program

As part of its overall qualityimprovement efforts, CMSis launching the Physician

Voluntary Reporting Program(PVRP). This new program buildson Medicare’s comprehensiveefforts to substantially improve thehealth and function of ourbeneficiaries by preventing chronicdisease complications, avoidingpreventable hospitalizations, andimproving the quality of caredelivered. Under the voluntaryreporting program, physicians whochoose to participate will helpcapture data about the quality ofcare provided to Medicarebeneficiaries, in order to identifythe most effective ways to use thequality measures in routine practiceand to support physicians in theirefforts to improve quality of care.Voluntary reporting of quality datathrough the PVRP will begin inJanuary 2006.

Given the recognized need forevidence-based quality measuresto help improve the quality ofhealth care services, and the timerequired to implement processes toobtain and use such measureseffectively, a voluntary programcan help Medicare and physiciansbecome better positioned to usherin a system that promotes higherquality and rewards better healthcare delivery.

As noted by CMSAdministrator Mark B. McClellan,M.D., Ph.D. in his testimonybefore the House Ways andMeans Subcommittee on Health onSeptember 29, 2005, CMSbelieves that an importantcomponent of delivering highquality care is the ability to measureand evaluate quality. Accordingly,

CMS is committed to thedevelopment of reporting andpayment systems that will supportand reward quality.

CMS has developed severalquality initiatives that provideinformation on the quality of careacross different settings, includinghospitals, skilled nursing facilities,home health agencies, and dialysisfacilities for end stage renaldisease. The quality initiatives aimto empower providers andconsumers with information thatwould support the overall deliveryand coordination of care, andultimately to support new paymentsystems that provide more financialresources to provide better care,rather than simply paying based onthe volume of services.

The PVRP would initiate theprocess by which physicians whochoose to participate would beginreporting quality data and be ableto receive feedback on theirperformance, as well as to provideinput on how quality reporting canbe improved and made even lessburdensome.

These steps are an importantstep in enabling CMS to providebetter support for physicians’efforts to deliver high-quality care.

CMS has developed theunderlying infrastructure so thatvoluntary reporting of qualitymeasures can begin by January2006, using the existingadministrative system for physicianclaims.

While the usual source of theclinical data for quality measures isretrospective chart abstraction,data collection through this processcan be burdensome. Consequently,the voluntary reporting program

will focus on ways to obtain validquality measures as efficiently aspossible.

Physicians can beginproviding voluntary information forconstructing evidence-basedquality measures for the Medicarepopulation through a defined set ofHCPCS codes (called “G-codes”),which are reported on thepreexisting physician claim form.These new codes will supplementthe usual claims data with clinicaldata that can be used to measurethe quality of services rendered tobeneficiaries.

The G-codes are an interimstep until electronic submission ofclinical data through EHRs replacesthis process. Medicare expects towork with some physician groupsthat have already adopted EHRs toassist with this transition.

Medicare’s contractedQuality Improvement Organizations(QIOs) are helping physiciansmove toward a more dynamic andevolving public reporting and pay-for-performance qualityimprovement environment. Inspecific, QIOs are providingassistance to help physicians createsystems so that the measures canbe more easily reported.

Measuring and evaluatingquality requires the development ofclinically valid quality measures.

Effective measures forperformance measurement, qualityimprovement, disease prevention,and public reporting should bevalid, reliable, evidence-based, andrelevant for consumers, cliniciansand purchasers. In addition, suchmeasures must be developedthrough open and transparent



processes and implemented in arealistic manner with minimalburden on physicians so as not todiscourage appropriate care.

The PVRP will begin to phasein quality performance measuresthat are consistent with theserequirements. These 36 evidence-based clinically valid measureshave been part of the guidelinesendorsed by physicians and themedical specialty societies and arethe result of extensive input andfeedback from physicians andother quality care experts.Physicians recognize theimportance of these measures forthe management of their patients’care, providing CMS with a strong

starting point for the voluntaryprogram.

Additional quality measuresare under development now andcould be phased-in for reportinglater in 2006.

The 36 quality measures arearranged in sets of measures, withmultiple G-codes in each set. Thephysician will report theappropriate G-code that representsthe clinical services furnished withregard to a specific measure set.

Each measure set has adefined numerator (the appropriateG-code) and a denominator(specifically defined according tothe appropriate services orcondition), which will be used tocalculate performance.

The objective of the PVRP is

to help physicians obtaininformation they can use toimprove quality and avoidunnecessary costs. Thus, CMS willprovide feedback to physicians ontheir level of performance basedupon the data submitted throughthis voluntary effort. This feedbackmay begin as early as summer2006.

The quality measures relevantto psychiatry for voluntaryreporting through the PVRP are:Antidepressant medication duringacute phase for patient diagnosedwith new episode of majordepression; and Antidepressantmedication duration for patientdiagnosed with new episode ofmajor depression.(CMS Fact Sheet October 28, 2005).


manager on call, she is notified, andcontacts are made. BrendaPaulsen: For us it’s a contractissue. We require 24/7 access tothem, and it’s their choice whetherthey act on it, but it’s in theircontract now.

Elaine McIntosh (UNebraska) - We are beginning towrite faculty compensationincentive plans. Do you havethem and will you share?

Kentucky, Arizona, and Yaleoffered to share, and a suggestionwas made to put the question outon the listserv. Kevin Johnston

(Indiana U): IU’s compensationplan was mission based, but is nowundergoing a major revision, asnew NIH regulations caught us offguard and we must reinstate somefaculty with back salaries. Bemindful of this when working onyour plans.

Patricia Birkmeyer (UTexas, Galveston) -In a relatedquestion, we are just beginningthe CARTS system mission basedmanagement - it’s very specific.Has anyone been through it?

Narri Shahrokh: My chairand I wrote an article about it in“Academic Psychiatry.” (Ed. note:

See Mission-Based Reporting inAcademic Psychiatry in AcadPsych 28:129-135, June 2004 oronline at http://ap.psychiatryonline.org/cgi/reprint/28/2/129).

Steve Blanchard - Just acomment - There are January2006 Joint Commissionreconciliation requirementssurrounding clinics and inpatientand their medication histories.Patients show up, the idea is youcan look at their comprehensivemedication histories.(Hank Williams is the finance administratorfor the University of Washington departmentof psychiatry).

Take two minutesContinued from page 15


Editorial staffEditor:

Janis PriceAssociate Editors:

Radmila BogdanichDavid Peterson

The GrAAPvine is published quarterly anddistributed to the members of Administrators inAcademic Psychiatry as part of the membershipin AAP.

Publication deadlinesPublication deadlines are on the 5th ofFebruary, May, August and November. Newsitems and articles are welcome and should besent to:

Janis PriceSection AdministratorDepartment of PsychiatryUniversity of Michigan Health SystemUH9C 9151Ann Arbor, MI 48109-0120(734) 936-4860(734) 936-9983 [email protected]

Copyright: Administrators in Academic Psychiatry 2005

Visit the AAP website at: http://www.adminpsych.org

President Pat Sanders-Romano [email protected] (718) 430-3080

President-Elect Jim Landry [email protected] (504) 584-1975

TreasurerJanice McAdam

[email protected] (316) 293-2669

Secretary Elaine McIntosh [email protected] (402) 595-1480

Membership Director Steve Blanchard [email protected] (319) 356-1348

Immediate Past President Kevin Johnston [email protected] (317) 274-2375

Members at Large Paul McArthur

(Strategic Collaboration) [email protected] (585) 275-6732

Joanne Menard (Membership) [email protected] (206) 341-4202

Debbie Pearlman (Benchmarking)[email protected](203) 785-2119

Marti Sale (Education) [email protected] (859) 257-9617

2005-2006 Board of Directors

The back page

During a visit to the psychiatric hospital, a visitor asked the Director, “What is thecriterion that defines a patient to be institutionalized?”

“Well,” said the Director, “we fill up a bathtub, we offer ateaspoon, a teacup, and a bucket to the patient and ask thepatient to empty the bathtub.”

1. Would you use the spoon?2. Would you use the teacup?3. Would you use the bucket?

“Oh, I understand,” said the visitor. “A normal person would choose the bucket because it'slarger than the spoon or the teacup.”

“Noooooo,” answered the Director. “A normal person would pull the plug.”

(You are not required to tell anyone how YOU did on this test.)

(Thanks to Rich Erwin!)

Psychiatry hospital admission test

vol. 18 no. 1 t h e winter 2005 aapvine -...

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