Time for New Evaluations and Follow-Ups

[SomeDoc]

I'm looking for some input regarding time for visits in community mental health. How many minutes are reasonable for new patient evaluations? What about follow-ups? My current schedule is 20 mins for follow-ups and 40 for new patient evaluations; it seems reasonable. The Medical Director (non psych MD) is pushing for 15 min follow-ups and 30 min new evals. It's just not sustainable IMO. When I was a resident, the CMHC had 30 mins for follow-up's, that seems like a luxury these days. Apparently, according to the director, providers at the CMHC in the area are seeing 30 patients a day. I can only imagine the quality of care these patients are getting if this is accurate.

I can't find any definitive data on pubmed or from official sources about how much time is adequate or recommended.

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[wolfvgang22]

I think 15 min follow ups and 45 min new evals are the minimum acceptable. A lot depends in the severity of illness in your patient population and ancillary staff support. All the same, even with the "worried well" I will stick to the minimum times I mentioned for my own health and sanity. I'm not the equivalent of a psychiatric prescription dispensary machine that can see 30 patients a day. If it were sustainable primary care would be doing it and not referring these patients to me.

 

[nexus73]

Do you get paid more for seeing more patients?

 

[Shikima]

Do you get paid more for seeing more patients?

It's an assembly line, whether or not you're employed or a contractor, it all works out the same. The differences is how your business/contracts are set-up based on productivity.

 

[TexasPhysician]

I wouldn't trust a word the director says. 30 min new evals is impossible without significant liability issues. It is substandard in my opinion.

Hypothetically, someone churning that volume in private practice is worth north of $600,000. Unless they are paying $500K+, you are getting taken advantage of.

 

[carlosc1dbz]

I'm looking for some input regarding time for visits in community mental health. How many minutes are reasonable for new patient evaluations? What about follow-ups? My current schedule is 20 mins for follow-ups and 40 for new patient evaluations; it seems reasonable. The Medical Director (non psych MD) is pushing for 15 min follow-ups and 30 min new evals. It's just not sustainable IMO. When I was a resident, the CMHC had 30 mins for follow-up's, that seems like a luxury these days. Apparently, according to the director, providers at the CMHC in the area are seeing 30 patients a day. I can only imagine the quality of care these patients are getting if this is accurate.

I can't find any definitive data on pubmed or from official sources about how much time is adequate or recommended.

First off, think about the patient population in a community mental health clinic, usually medically complicated and multiple psychiatric problems. Many times you are seeing community patients with severe mental illness and are not only talking to them, but also their family because that is who brings them in to the clinic. Many times in the community clinics, patients are not seen by the same provider or there seems to be less continuity of care, you have to write a note not only that you will understand why you did what you did, but also, so that the next doctor knows exactly how the patient presented to you and your thought process on the treatment plan. Good luck with 15 minutes follow ups.

In regards to a 30 minute New Patient Evaluation, I am not even going to speak to that....lol

This brings up another issue, is it the best decision to have a non MD (social workers and psychologist) run a community mental health clinic? I have seen this happen too often and the disconnect between what MDs need to do and what psychology thinks happens on a visit is just too different. I sometimes have to remind psychologist, social workers or "Clinic Directors" that there are things called labs, that I not only have to look for, but also review....

 

[SomeDoc]

Do you get paid more for seeing more patients?

It's something I'll have to negotiate if I start seeing more patients than what was agreed in our contract. Currently my numbers are slightly below the average (11.4) for the # of CMH patients seen in a day

 

[SomeDoc]

I wouldn't trust a word the director says. 30 min new evals is impossible without significant liability issues. It is substandard in my opinion.

Hypothetically, someone churning that volume in private practice is worth north of $600,000. Unless they are paying $500K+, you are getting taken advantage of.

I agree that 30 minutes for new patients are substandard. The upside is that the no show rate is high so I think admin is trying to figure out how to increase volume. I was able to negotiate a cap on how many new evals can be seen in a day (5), and its a matter of seeing if this will be sustainable in the long term.

 

[wolfvgang22]

I capped my new evals in clinic at 2 per day. Some days I do 3, but not usually.

Of course, I do some consults in the hospital and ER, and those are basically new evals unless I know the patient. Clinic new evals often take longer because the patient/family are more talkative.

A lot of times new evals are way easier than follow ups with patients who are not too engaged or motivated, especially if the new patient is treatment naive (and haven't already put on Adderall, Xanax, Klonopin, Clozapine, and Seroquel for Adjustment Disorder by the local private hack who sees 50 patients a day.)

 

[dl2dp2]

The Medical Director (non psych MD) is pushing for 15 min follow-ups and 30 min new evals.

One thing you should discuss w/ clinical director is the psychotherapy add on codes. They are a bit of a game changer IMHO and are probably responsible for dramatic salary increases in the last few years in certain private settings. If you do 99213/4+90833 you can basically get reimbursed as 2x 99213 if your panels are good and still have 30 min for 1 follow-up. Same with using the E&M codes for eval.

Interestingly, I have found that it's not uncommon at a NUMBER of CHMCs directors are so dinosauric they aren't aware of the existence of add on codes.

 

[splik]

Interestingly, I have found that it's not uncommon at a NUMBER of CHMCs directors are so dinosauric they aren't aware of the existence of add on codes.

This is true. But it is also true that in many areas (much of california for instance), county run CMHC psychiatrists cannot bill psychotherapy add on codes.

 

[nexus73]

This is true. But it is also true that in many areas (much of california for instance), county run CMHC psychiatrists cannot bill psychotherapy add on codes.

Why?

 

[splik]

because medical will not pay for it. That is certainly the case in all of the counties I work in; we can't bill for add on codes

 

[nexus73]

because medical will not pay for it. That is certainly the case in all of the counties I work in; we can't bill for add on codes

MediCAL won't pay? That's crazy.

 

[dl2dp2]

because medical will not pay for it. That is certainly the case in all of the counties I work in; we can't bill for add on codes

That's interesting and would be a frank violation of CMS advisory--90833 cannot be billed at all *except* as an addon with 99213. Of course you may or may not be at a position for MediCal advocacy work but at the clinic director level, especially for a full clinic of MediCal patients who are fairly sick, there's a case to be made to directly appeal to the state agency responsible for this. Sometimes the clinic director tells you this not because it can't be billed, but because they haven't done the leg work to get it certified through the chain of command.

What I have also found in interacting with a few clinic directors is that often Medicaid practices, supposedly uniformly applied, are highly variable. I.e. often individual organizational leads appeal directly to state agencies if they have "relationships". Given a lot of budget are a mixture of block grants and code based reimbursement (fee for service), there's a HUGE amount of "fudge" there, especially ancillary services such as labs being billed out at different rates, local "one time" supplementations and other games. It would be kind of interesting if it's not so horribly relationship driven. State agencies assume you are in the black unless you complain endlessly until you get a block grant, then it's a protracted and endless negotiation of chicken---give me more grants or I shut down the clinic and release 300-500 patients with SMIs.

In my state one of the things immediately after parity happened was that commercial insurance refused to reimburse psych 99213s at the same rate as med 99213, citing a lower overhead. The local psych society actually went to multiple Congressional members to put pressure on major insurances to become compliant with parity. There might be similar violations if add on codes can be only reimbursed dependent on provider. This is also where partnerships with large systems can be helpful. For example, I would argue that most Medicaid clinics should be part of a county system and receive oversight and protection from local jurisdictions. Of course we all know there are lots of private Medicaid clinics, and often they reap huge profits inappropriately by doing these things such as exploiting providers.

 

[SteinUmStein]

I'm curious, when medical directors such as the above (non-MD's) push for a 30 minute eval, what are they expecting to have accomplished? What would they expect an evaluation to include? It may be worth asking them what components of an evaluation they would like included in that 30 minute time (since you will not be doing an actual full assessment with treatment recommendations in 30 minutes to the standard of care). Would they want you to see the pt for two 30 minutes sessions one week apart or a few days apart? I might inform them that I won't be able to make treatment recommendations after 30 minutes with a new patient, but I could do a safety assessment and start to gather historical information, and set up another 30 minute appointment to finish the evaluation and make a set of recommendations.

A side question, how do you all approach 15 minute "med follow-ups"? I haven't had much success in consistently containing follow-ups to a short period of time (have tried finishing visits in 15-20 mins with mixed success, depending on pt complexity), particularly when I include some form of therapy intervention or psychoeducation. Do you simply say "our time is almost up" and ask to continue at the next visit? When they bring up lots of detailed psychosocial information, do you ask them to save that information for their therapist?

 

[dl2dp2]

I'm curious, when medical directors such as the above (non-MD's) push for a 30 minute eval, what are they expecting to have accomplished? What would they expect an evaluation to include? It may be worth asking them what components of an evaluation they would like included in that 30 minute time (since you will not be doing an actual full assessment with treatment recommendations in 30 minutes to the standard of care). Would they want you to see the pt for two 30 minutes sessions one week apart or a few days apart? I might inform them that I won't be able to make treatment recommendations after 30 minutes with a new patient, but I could do a safety assessment and start to gather historical information, and set up another 30 minute appointment to finish the evaluation and make a set of recommendations.

A side question, how do you all approach 15 minute "med follow-ups"? I haven't had much success in consistently containing follow-ups to a short period of time (have tried finishing visits in 15-20 mins with mixed success, depending on pt complexity), particularly when I include some form of therapy intervention or psychoeducation. Do you simply say "our time is almost up" and ask to continue at the next visit? When they bring up lots of detailed psychosocial information, do you ask them to save that information for their therapist?

I know your pain. I don't have good answers to either of these questions. I hated it when I worked at a CHMC managed by a non-MD for the above reasons. I ended up getting ****ty performance evals for the brief period of time.

Furthermore, you often need more than 60min for a thorough eval, plus family time, etc. for these fairly sick patients to come up with a thoughtful treatment plan. Doing med checks on people with multiple problems is really challenging in 15 min. And if you space the visits too closely they may not show up. A lot of these patients basically come in only when they run out of meds (if even then). When I reviewed the charts, a lot of their diagnoses were incorrect (presumably because there weren't enough time to be thorough), or that the meds were incorrectly dosed or wrong med was picked (again, not enough time to check?) And then when I tried to fix it I was up against multiple administrative barriers as "the trouble maker", and it came back to bite me in the ass because my notes were not in the exact specifications that they wanted.

Cash solo practice ;-) cleaner with better care. #LibertarianAmerica (I kid I kid). Frankly I think if you are an MD and you want to work at a CHMC, you should OWN and RUN the CHMC. Interesting effects occur...I know someone who works for some MD who runs a CHMC, and he told me then what happens is that the staff MDs are super biz savvy, get profit shares, and end up exploiting the allied providers (and, trainee/early careers that they hire), and then rake a **** ton. This vs. when clinics are run by non-MDs, which usually means the clinic is a nonprofit and walking on the side non-solvancy constantly (see above). Pick your poison...

 

[michaelrack]

I'm curious, when medical directors such as the above (non-MD's) push for a 30 minute eval, what are they expecting to have accomplished? ?

They are expecting a billable H and P and some type of medication prescribed.