Frequently Asked Questions about the Medical-Psychiatric Coordinating Physician Method (MPCP)
- Yet another professional on the treatment team? Doesn’t that increase complexity, and lead to more fragmentation and disorganization?
- Why is an MPCP team leader required to be an MD?
- What are the differences between the appropriateness and use of the MPCP method in a private practice environment versus an institutional setting, e.g., an outpatient clinic?
- How does the MPCP model fit into current systems of care delivery?
- When using the MPCP method, is the whole truly greater than the sum of its parts? Is a coordinated treatment incorporating the MPCP more powerful, and likely to be more economical, than the sum of the individual treatments required by the patient?
- How cost effective is the MPCP method? Can the cost of using an MD as team leader be justified?
- When should an MPCP or MPCP clinic be selected as opposed to a primary care physician (PCP)? And, when should an MPCP be chosen over a non-medical team coordinator?
- Why should the MPCP be a psychiatrist or dually-trained physician? Why can’t a PCP fill this role?
- What are the criteria for selecting patients for MPCP care?
- How is MPCP work carried out?
- Who is best suited for MPCP work? What unique training is required for an MPCP?
- What convinces us that the MPCP is a superior method of care? To what do we compare it?
- How can MPCP care be paid for in institutions or private practice?
- How can MPCP training and implementation be set up in academic centers?
A. The MPCP’s job is in fact to reduce complexity by designating a single person to organize and manage the treatment. When an MPCP takes over a case, the situation is usually already quite complex and disorganized. The MPCP takes charge of the entire case, sets goals, makes sure these are being met, and monitors utilization of resources.
Facility with, and attention to, coordination of care and resource utilization is a key part of the MPCP’s responsibility. The result of using an MPCP is invariably to pull together and organize the treatment.
A. (1) The training of physicians centers around identifying and managing critical factors in complex clinical situations. No other health care professional is trained to deal with and take responsibility for situations with this level of complexity and urgency.
(2) Clinically complex cases almost always have an associated medical, or at least a biological, aspect. Medical training explicitly prepares the MPCP to deal with and understand both.
(3) The team leader in complex cases needs to be able to communicate with other medical professionals on the treatment team, and with consultants at their own level of sophistication. Cogency and respect count heavily in executing this role.
While using a physician as team leader may add initial expense, overall costs for MPCP physician-led work with difficult to manage, clinically complex patients are apt to be less over time than for a process led by a non-physician. Physicians are equipped to make rapid and accurate decisions about treatment situations involving clinically complex medical and psychiatric issues.
A. Institutional settings have their own, often clearly delineated, structures, rules, communication capabilities, and allocation of resources. (See the next question for more elaboration.) The MPCP’s work in these settings can usually be restricted to a delineated group of complex patients.
In the independent practice environment, the MPCP’s charge may be broader and more diffuse than in an institutional (clinic) or managed care setting. The emphasis in independent practice situations is still on the complexity of the case and the involvement of multiple professionals, as it is within more structured settings. In both situations, the MPCP has the same broad supervisory role and responsibility for outcome. However, consider the example of an MPCP in independent practice, with training in child and adolescent psychiatry, taking on the case of an adolescent with chronic school failure and deviant behavior. In this situation, the MPCP might work with the patient, family, and school, as well as learning specialists. The MPCP’s general medical and psychiatric training would also allow that person to work with associated medical professionals and participate in decisions about medication. However, medical-psychiatric co-morbidity would be much less evident than in cases typically encountered within structured settings. This is an example of the type of case which an institutionally-based MPCP is not likely to engage in.
MPCPs practicing in the private sector are likely to have a more general practice than those operating in institutional or managed care settings and these physicians are likely to be called upon to provide a broader spectrum of functions.
A. The MPCP model is ideal for incorporation into closed systems like HMOs and university-based clinics where multiple disciplines are housed within the same organization but are not necessarily integrated or coordinated with one another. In these situations, MPCP care would have to be configured to fit within that system e.g., the make-up of its staff, and availability of appropriate resources.
The exact configuration for the MPCP component that could be incorporated into an existing structure would have to be determined by such considerations as the characteristics of the population served, and the criteria used for identifying clinically complex patients. Criteria for making this selection might, for example, also include number of visits and calls by a problematic patient over a six-month period, frequency of emergency room visits, and diagnostic considerations, including a patient’s acuity and chronicity.
Q. When using the MPCP method, is the whole truly greater than the sum of its parts? Is a coordinated treatment incorporating the MPCP more powerful, and likely to be more economical, than the sum of the individual treatments required by the patient?
A. The MPCP in effect “treats the system,” making it progressively more cohesive and focused. “The system” refers to all the people who are directly and indirectly associated with the treatment: professionals and care delivery systems contributing to the patient’s treatment, and others such as family and relatives who influence treatment. With the MPCP attending to the details of treatment and following it closely, patients feel both cared about and well-served, both personally and medically. The experience of MPCP care is opposite to the usual patient experience of outpatient, “silo” based care, where multiple providers operate out of individual offices and communicate inefficiently.
A. There is much less redundancy in services and resources with MPCP-coordinated care. As a physician, the MPCP has the training and technical understanding to make judicious choices about treatment and the use of medical resources. These considerations especially apply to complicated, difficult to manage cases involving complex or chronic patients.
A. We believe that a physician with MPCP training is the best choice for difficult to manage, clinically complex cases, especially those with medical-psychiatric co-morbidity and/or requiring the involvement of several professionals. As compared to a PCP, the consistency that an MPCP can offer, as well as the familiarity with understanding and managing psychiatric and psychosocial issues, makes this kind of professional especially suited for work with these cases.
Factors distinguishing MPCPs from non-physician clinicians include their experience and comfort in dealing with clinical urgency, familiarity with difficult medical challenges and clinically relevant biology, and the authority they bring to collaborative work with and between other medical professionals.
However, the fact that MPCPs are physicians is only part of their value. The remainder comes from their unique training and orientation as MPCPs, and their skills in working with complex systems and management intensive patients.
A. We hope that primary care physicians find our model useful and assume that some, perhaps eventually many, will decide to take on or at least take an interest in assuming the MPCP role. We believe that MPCP leadership, at least to begin with, is most likely to be embraced by psychiatrists, especially those with an interest in the intersection of systemic medicine and psychiatry, and a strong interest in the psychosocial needs of their patients as well as their medical requirements. Ultimately, the MPCP model is intended to be quite inclusive in its application, as its implementation requires multi-disciplinary teams of professionals organized to serve the needs of a particular case.
Primary care physicians generally view their charge as providing comprehensive care for their patients. Theoretically, psychiatric and psychosocial issues that affect medical needs fall within their scope of responsibility. In addition to providing direct care for their patients they often take responsibility for the progress of each case, and seek and coordinate the required consultants and specialists. The latter activities, especially, overlap the responsibilities of an MPCP.
However, few PCPs have the time or interest in probing deeply into the broader, less discretely medical, areas of their patients’ needs. The same applies to the time and effort required to coordinate and manage the multiple professionals required for treatment of their more difficult patients. These limitations and preferences may be especially challenged by the group of patients we label the most management intensive “complex” patients. Patients from this latter group often require frequent outpatient visits, need multiple specialist contacts, and may require more than the usual frequency of emergency room visits and hospitalizations.
The complex patients at issue are truly ubiquitous in medical and psychiatric practice. “Complex” refers to patients with coexisting medical, psychiatric, and psychosocial problems. These are patients who typically are not treated in a fully integrated way when the case is conceived as essentially medical (e.g., “diabetes”) or psychiatric (e.g.,” depression”). These patients tend to overuse the mental health system and its resources when their care isn’t carefully organized and monitored. They flood the health care system, whether in clinics or practitioners’ offices. In our view, care for the most difficult of these patients is best rendered by a treatment team headed by a physician who is capable of understanding and addressing systemic medical, psychiatric, and psychosocial issues. (A PCP would still be associated with each-MPCP managed case.)
Physicians with dual training (psychiatry and internal medicine or family medicine) would seem especially well prepared to take on and be interested in the broader responsibilities of the MPCP. This is especially likely to be true if these physicians choose to acquire skills working with complex, interconnected systems consisting of other physicians, non-physician medical professionals, care delivery systems, and families. While a psychiatrist, in particular a dually trained or psychosomatically trained psychiatrist, would be an ideal choice for the MPCP role, other physicians, most particularly primary care physicians with supplementary training, could serve in this function as well. Preparation for the involved coordination and management roles is generally minimal within standard medical training and even in training for dual medicine-psychiatry physicians. It is these skills that are emphasized in the added, specialized training to become an MPCP.
A. This choice depends on whether the patient or patients at issue qualify as “clinically complex” or difficult to manage within the setting in which the provider is based, and the standards for adequate care determined by the provider or in that setting. Factors that may be involved in making this choice include diagnosis, the number and identity of providers or otherwise involved people, the type and extent of medical-psychiatric co-morbidity, previous failed attempts at treatment, the chronicity of the patient’s condition, and over-utilization of resources by the patient. Any combination of these factors could qualify a case as appropriate for MPCP care.
A. The answer is complicated and case-specific. In general:
(1) There is an evaluation that includes gathering information from all treating professionals and the patient’s family and records.
(2) A system is set up for communication and collaboration involving all contributing parties; this system is altered as needed over time.
(3) A treatment plan is created that can be modified over time in collaboration with all team members.
(4) Progress is monitored on an ongoing basis.
A. Those best suited to do MPCP work are physicians who have an interest in the intersection of systemic medicine and psychiatry, prefer in-depth and extended work with patients, enjoy working with the psychosocial issues associated with their cases, and have training and facility for working with multi-person and multi-disciplinary treatment situations. MPCP work is unique in its attention to input from each of the multiple systems — medical, family, and social — within which the patient operates.
MPCP training should ideally extend beyond the training requirements of general psychiatry, internal medicine, or family medicine residency, or psychosomatic medicine fellowship. Included should be instruction in human development and psychopathology, as well as the psychology of families and groups. Here are some of the topics that can be included in MPCP training.
Proposed Topics for MPCP Training
- Orientation to the MPCP method of patient care and care delivery: its structure, indications, and supporting theories.
- The place of the MPCP method in outpatient systems and hospitals.
- Health care delivery systems: history, models, economics and their relevance for the MPCP model of care.
- The MPCP’s role in appraising, working up, and strategizing complex cases.
- The treatment team: its creation and management; the coordinating role of the MPCP.
- The psychology and management of the family in the treatment of complex cases.
- The ongoing MPCP management of complex cases, including the selecting, ordering, and prioritizing clinical interventions.
- Principles of optimizing treatment using “truing” measures as applied by: (1) individual physician team members, and (2) the MPCP at the level of team coordination. (“Truing” refers to techniques through which providers can confirm that the case is going according to plan and, if not, to reorient their work accordingly.)
- Practical issues in the relationship of an MPCP-coordinated team with case-related organizations, including agencies, schools, hospitals.
- Conducting case conferences.
- Review of systemic illnesses with significant psychiatric co-morbidity.
- Management of psychotropic medications in medically-ill patients.
- Drug interactions.
- Psychotherapy models and their modification for systemically ill patients.
- Understanding and working with the psychology and sociology of interconnected personal, social, and medical systems.
- Collaboration between medical professionals: how it succeeds or fails.
- Treatment modalities in psychiatry and psychology that are pertinent to the work of an MPCP.
- Relevant cultural issues and biostatistics.
A. Our pilot study involves more than 50 cases, each treated for at least a year and a half. Our observations suggest that MPCP treatment tends to be less costly and more effective than conventional treatment for complex, management-intensive cases, especially when these costs and results are compared to traditional outpatient care.
A. Methods will have to be worked out on a situation by situation basis. The new AMA current procedural terminology (CPT) “complexity” coding presumably makes billing for complex clinical situation more straightforward and less problematic.
A. One suggestion is to incorporate MPCP training in existing programs as asix month to one year, half-day per week complex case clinic experience for PG5 residents, especially those engaged in dual internal medicine/family practice and psychiatry training. Another is to create a one-year complex case fellowship to be filled by a dual training resident or psychosomatic medicine fellow. The fellowship could be funded by one or several academic departments. In either case, faculty and other advanced fellows could supervise.