Hidden Costs in Paediatric Psychiatry Consultation Liaison Services.

AIM: Children with acute mental health (MH) concerns increasingly present to Emergency Departments, and in the absence of an accessible MH bed, are admitted. This study estimated the hidden associated costs. METHODS: All Emergency MH admissions over a 12-month period (2016) were identified (N=105). Costs associated with length of stay (LOS) and one-to-one nursing were calculated. RESULTS: The average Length of Stay for acute MH presentations was 6 days, there were 615 bed day associated with this cohort, totalling costs of €1,216,470, with an average cost/patient of €12,684. Sixty-eight patients (65%) required an average of 5 days of one-to-one nursing, totalling 335 days. Estimating that 40% of this was provided by agency staff, the hospital cost was €115,374. Taken together, the costs associated with primary Emergency Mental Health presentations is €1,331,844. Costs associated with patients who were previously known to MH services were €843,417. DISCUSSION: Despite an increasing number of dedicated MH beds, demand outweighs availability, and immediate access remains problematic, the default often being a paediatric admission. Adequate funding and appropriate use of these scare and costly resources must be part of national MH policy planning, especially with ongoing planning for the National Children's Hospital.

[Child psychiatry: limited research, evidence for cost-effectiveness of treatment]. / Kinderpsychiatrie: beperkt onderzoek, aanwijzingen voor substantiële baten.

BACKGROUND: Research into cost-effectiveness of treatment of child psychiatric disorders is extremely limited. There are two main reasons for this: it's a new field and the type of research required is intrinsically complicated.
AIM: To review selected articles that reveal the prevalence of child psychiatric disorders, demonstrate the complexity of cost-efficiency research in child psychiatry and point to the possible benefits of appropriate treatment.
METHOD: We provide an overview of a selected number of articles dealing with the prevalence of child psychiatric disorders and the costs involved, we stress the diffulty of assessing whether current treatment is cost-effective and we describe the possible benefits of treatment.
RESULTS: However, the limited number of articles that we located do indicate that the treatment of children with psychiatric disorders is cost-effective. Not only does it benefit the child, it also eases the burden on the parents and on society as a whole. Findings need to be interpreted in the light of the limited scope and shortcomings of the research done so far.
CONCLUSION: Although current research seems to be cost-effective, we stress the need for further investigations, particularly in the form of longer-term studies.

[Nonnative guidelines for allocating human resources in child and adolescent psychiatry using average values under convergence conditions instead of price determination - analysis of the data of university hospitals in Germany concerning the costs of calculating day and minute values according to Psych-PV and PEPP-System]. / Normative Vorgaben zum Personaleinsatz in der Kinder- und Jugendpsychiatrie statt Preisfindung anhand von Mittelwerten unter Konvergenzbedingungen.

OBJECTIVE: Despite substantial opposition in the practical field, based on an amendment to the Hospital Financing Act (KHG). the so-called PEPP-System was introduced in child and adolescent psychiatry as a new calculation model. The 2-year moratorium, combined with the rescheduling of the repeal of the psychiatry personnel regulation (Psych-PV) and a convergence phase, provided the German Federal Ministry of Health with additional time to enter a structured dialogue with professional associations. Especially the perspective concerning the regulatory framework is presently unclear. METHOD: In light of this debate, this article provides calculations to illustrate the transformation of the previous personnel regulation into the PEPP-System by means of the data of §21 KHEntgG stemming from the 22 university hospitals of child and adolescent psychiatry and psychotherapy in Germany. In 2013 there was a total of 7,712 cases and 263,694 calculation days. In order to identify a necessary basic reimbursement value th1\t would guarantee a constant quality of patient care, the authors utilize outcomes, cost structures, calculation days, and minute values for individual professional groups according to both systems (Psych-PV and PEPP) based on data from 2013 and the InEK' s analysis of the calculation datasets. CONCLUSIONS: The authors propose a normative agreement on the basic reimbursement value between 270 and 285 EUR. This takes into account the concentration phenomenon and the expansion of services that has occurred since the introduction of the Psych-PV system. Such a normative agreement on structural quality could provide a verifiable framework for the allocation of human resources corresponding to the previous regulations of Psych-PV.

[Hometreatment- an effective alternative to inpatient treatment in child and adolescent psychiatry?]. / Hometreatment -Eine effektive Alternative zu konventionellen Behandlungsformen? .

In many countries hometreatment (HT) offers a cost-effective alternative to hospitalization for children and adolescents with mental health problems requiring intensive mental healthcare. However, the database on HT varies as HT may refer to different models and settings of intensive outpatient treatment. In Germany HT is not used routinely in mental healthcare in child and adolescent psychiatry, therefore the data on HT in Germany, especially in child and adolescent psychiatry, are scarce although funding for studies investigating the effectiveness of HT is available. This review represents a comprehensive search in electronic databases (1980-2014) of literature on HT. It provides as well an overview of the underlying concepts of and the present evidence for HT. In addition, the evidence base on HT for specific child and adolescent mental health disorders is reviewed. Future prospects for the development of HT in Germany facing the upcoming change in health service commissioning (PEPP = «pauschalierendes Entgeltsystem in Psychiatric und Psychosomatik>>) are discussed, as HT in child and adolescent psychiatry, when accurately indicated, can be a valid alternative to inpatient treatment.

[The new hospital reimbursement system: a chance and a challenge to child and adolescent psychiatry or «much ado about nothing¼?]. / Das neue Entgeltsystem.

New legislation in the financing of psychiatric hospitals in Germany stipulates the introduction of a new reimbursement system for psychiatric child and adolescent psychiatric and psychosomatic hospitals in Germany by 2013. In several steps norms are to be empirically defined and services to be documented, and the current per diem system of hospital charges has to be replaced by a more specific system reflecting differences in the level of distinct patient groups. This discussion paper gives an overview of the legal framework as well as the risks and chances of the new system. An increased effort in documentation will be one of the clear consequences of the new system («much ado¼ ...). Psychiatric inpatient treatment will be much more transparent in detail, though it is not yet clear whether there will be a real improvement for patients (... «about nothing¼). The new system also offers the chance to introduce modern treatment concepts like home treatment. Such chances for innovation should be implemented to the benefit of patients.

Cost savings of telemedicine utilization for child psychiatry in a rural Kansas community.

The costs of pediatric telemedicine services remain underreported and understudied; however, there is evidence that telepediatric services can be cost competitive with traditional ones. For 15 years, the University of Kansas Center for Telemedicine and Telehealth has been providing telemental health outreach from the University of Kansas Medical Center (KUMC). One service site is located in Crawford County, Kansas, which provides telepsychiatry services to children and adolescents. The purpose of this study was to examine the costs of operating the Crawford County site relative to accessing services at KUMC, the likely alternative service location. The cost of travel time to parents who accompanied a dependent to either location also was estimated. Patients and parents were examined over a 6-month period in 2006. One hundred thirty-two patients received 257 telemedicine psychiatric consultations during this period. Cost estimates for using the pediatric telemedicine service were assessed for all patients; however, travel and related costs were collected from a sample of 26 patient-parent dyads. The estimated costs of services were obtained using standard cost-accounting procedures. An average cost per consultation in Crawford County was $168.61. The cost savings in travel time and other expenses to parents and patients were substantial between use of the county site and KUMC. Subtracting average savings in travel costs to patients and parents produced an average cost of a telepsychiatry consult in Crawford County of only $30.99. This study was conducted over 6 months with a small number of observations; it should be replicated over a longer study period, with more patients, and with more data that might capture marginal costs of services.

Revenue: understanding insurance reimbursement and CPT coding in child and adolescent psychiatry.

Since the early 1990s, Current Procedure Terminology (CPT) has been the gold standard for billing for medical services. After reviewing the historical context of CPT coding, this article presents the coding methodology, discussion of specialty codes (psychiatric and other specialty codes of potential use to child and adolescent psychiatrists), and the evaluation and management (E/M) codes. Various coding options for common clinical encounters are also presented.

Is child psychiatric service different when provided by attendings versus clinicians-in-training?

OBJECTIVE: This study examines the clinical management characteristics of outpatient child and adolescent psychiatric care provided by attendings and clinicians-in-training in an academic institution. The authors hypothesized that no significant differences would exist between initial evaluations conducted by attendings and those conducted by clinicians-in-training. METHODS: The amount of information obtained during an initial evaluation and the number and type of services recommended postevaluation were assessed for 429 patients treated in the child and adolescent psychiatry clinics at Stanford University by attending psychiatrists and clinicians-in-training. RESULTS: No significant differences were found for the evaluations conducted by attendings and clinicians-in-training for the amount of data collected during an evaluation of the number or type of recommendations made postevaluation. CONCLUSION: These findings lend themselves to the conclusion that attendings and clinicians-in-training offer comparable services in the assessment of new patients. Study limitations and future areas of study are discussed.

A doubtful guest: managed care and mental health.

This article examines the ways in which mental health services have been affected by managed care and describes how to address some of the ethical conflicts that have always existed, but have been transformed immeasurably. It outlines the ethical dilemmas between the competing values of mental health providers and managed care, as well as the practical ethical considerations related to confidentiality, billing, and coding. It suggests that there can be no real improvement for mental health providers in the ethical minefield of managed care until they stop focusing on how distressed they are about it and start dealing with the larger, systemic issues in psychiatry and American health care. The article concludes by noting that the only way to effect meaningful change in the health care system is to combine knowledge with advocacy and to proactively define the standards needed to make the necessary choices.

Inpatient treatment in child and adolescent psychiatry--a prospective study of health gain and costs.

BACKGROUND: Inpatient treatment is a complex intervention for the most serious mental health disorders in child and adolescent psychiatry. This is the first large-scale study into its effectiveness and costs. Previous studies have been criticised for methodological weaknesses. METHODS: A prospective cohort study, including economic evaluation, conducted in 8 UK units (total n = 150) with one year follow-up after discharge. Patients acted as their own controls. Outcome measurement was the clinician-rated Childhood Global Assessment Scale (CGAS); researcher-rated health needs assessment; parent- and teacher-rated symptomatology. RESULTS: We found a significant (p < .001) and clinically meaningful 12-point improvement in CGAS following mean 16.6 week admission (effect size .92); this improvement was sustained at 1 year follow-up. Comparatively, during the mean 16.4 week pre-admission period there was a 3.7-point improvement (effect size .27). Health needs assessment showed similar gain (p < .001, effect size 1.25), as did teacher- and parent-rated symptoms. Improvement was found across all diagnoses. Longer stays, positive therapeutic alliance and better premorbid family functioning independently predicted better outcome. Mean cost of admission was pound 24,100; pre-admission and post-discharge support costs were similar. CONCLUSIONS: Inpatient treatment is associated with substantive sustained health gain across a range of diagnoses. Lack of intensive outpatient-treatment alternatives limits any unqualified inference about causal effects, but the rigour of measurement here gives the strongest indication to date of the positive impact of admission for complex mental health problems in young people.