Roger Kathol, President and CEO of Cartesian Solutions Inc., an international medical consulting company with a special focus on integration of medical and psychiatric services, and winner of the 2020/21 Frits Huyse Award.
Interview by Silvia Ferrari, MD, PhD
Professor Kathol, how do you feel winning about this award?
Prof. Kathol: It is a great honor to have received this prestigious award from EAPM. I have been going to the EAPM and collaborated with a number of its members throughout Europe for many years. It was a surprise to have received such recognition.
During your long and fruitful career, you particularly contributed to the clinical topic of integrated care, which is a core element in the field of consultation-liaison psychiatry as well as a major responsibility for psychiatry towards the rest of medicine. How did this topic become so central and interesting for you? How did this start, can you remember?
It was, frankly, while I was in medical school (Kansas University) but doing a rotation at Maudsley Hospital in London that I decided to complete two residencies, i.e., internal medicine and psychiatry, and to devote my career to helping patients with combined medical and psychiatric illness. Back in the 1970s and, in most ways, even today, those with combined medical and psychiatric illness are essentially orphans in our international medical systems. This is certainly true in the US, but it is also true in many, if not most countries throughout the world. Patients with comorbid medical and psychiatric problems have to bounce from the medical to behavioral care systems and back again to have their interacting medical and behavioral health (BH) challenges addressed.
The EAPM and ACLP, my home CL organization, while devoted to patients with psychiatric problems in the medical setting, remain hampered by the health systems in which they provide CL services. First, their members are “guests” in “medical” settings where they practice since standalone BH payors typically only reimburse for services delivered in BH settings. In many systems, BH notes are also located in separate servers from medical notes, despite the fact that it is the same person that has, likely interacting, medical and BH challenges. Finally, few medical and BH services are combined (collaborative) so that all medical and BH practitioners work together and provide integrated care for the best results in common patients.
My career, in many ways, has been dedicated to overcoming these health system challenges that we all face.
That was the starting point, and then, most recently, you are still contributing to the topic of integrated care by means of your intense collaboration with the INTERMED foundation-consortium and the EAPM Special Interest Group on Integrated Care. How would you describe this experience? How long has it been going on?
Prof. Kathol: I initiated work with the INTERMED group in the 1990s, however, was frustrated that the INTERMED was not being more widely used, other than in a number of small research settings, largely in Europe. As a result, in the early 2000s, I decided to connect an Americanized version of the INTERMED, what we call the Complexity Assessment Grid (CAG), to a full integrated (medical and BH) case management program. The intent was to create a way to correct identified problems in the 20 adult complexity grid boxes with concrete “helper” activities.
In 2010, we published our first textbook on the topic and started training case managers, i.e., medical and BH nurses and social workers, psychologists, even physical and occupational therapists, etc., to assist patients with what we call health complexity to overcome identified clinical and non-clinical issues and to stabilize their lives. As we were doing this, we decided that there should also be a similar process available for children/youth. Thus, as we put together the first edition of the ICM Manual, we added a similar, yet adapted, 25-item pediatric version of the CAG (the PICM version) and connected it to a similar assistance and support process that was used in adults.
Since 2010, we have trained nearly 1,200 case managers and deployed components of the value-based integrated case management (VB-ICM) process in nearly 20 organizations, largely in the US. In 2016, we also published a Physician’s Guide on how to work with VB-ICM managers since few physicians even knew what these talented health care managers did. Finally, in 2018, a largely new group of authors published the second edition of the original ICM Manual with many updates to work practices, including systematic documentation of outcome findings. As far as we know, it is one of the only case management approach that has outcome measurement built into its structure.
For years, we have been encouraging those at the EAPM, where the INTERMED was originally formulated, to consider adapting the process we have expanded related to the INTERMED for use in patients in each of their countries. To date, uptake on this offer has been limited, but it remains open.
We are living a critical phase, worldwide, as far as the organization of health care (mental and physical) is concerned, due to many obstacles and limitations, i.e. lack of resources and contrasting interests. What do you think may be the “magical ingredients” for facing and overcoming this phase?
Prof. Kathol: There is now irrefutable evidence that separation of medical and BH care leads to billions of dollars in excess cost for US patients with concurrent illness annually (Melek et al, 2018). I would be surprised if this is different in other countries. While there is no “magic ingredient” to correct this, there is one necessary change that needs to take place virtually everywhere, i.e., that all health services are paid from a single “medical” health budget, which includes BH services.
There is a tendency for BH specialists to think that the illnesses that they deal with are somehow “special” or “different” than with other health issues. This, of course, is untrue. There are health sensitivities in virtually all medical specialties, e.g., orthopaedic (battered child), infectious disease (venereal diseases), obstetrics (pregnancy out of wedlock/due to rape), etc. Psychiatry does not have a corner on the market in this respect. As a result, psychiatric illnesses should just be a standard part of health by paying for these services through the same benefit dollars as every other medical specialty.
While this change will not correct the medical and BH disconnect of clinicians that currently exists in nearly every health system worldwide, it will open the door for trying new medical and BH coordinated care approaches improve communication between medical and BH practitioners, and lessen the barriers to integrated care delivery since all practitioners will be paid by dollars in the same financial pool. It is only when BH payment become just a component of standard medical payment that improved care for patients with BH morbidity and co-morbidity will occur. These, of course, have to be built after the payment issue is resolved.
Could you comment on your next projects that you are excited about?
Prof. Kathol: For the past 25 years, I have owned and run an integrated care consulting service for hospitals and clinics, insurance companies, government agencies, and businesses. This has been a challenge in a world living with the delusion that BH conditions are different than other health conditions. Payors were different, medical and BH practitioners did not talk with each other, health records were separated, and, importantly, most patients with BH conditions got no care since they refused to go to the BH setting to get services.
Now that I am nearing my retirement, we are at a different place than when I started Cartesian Solutions, S Corp, (CS S Corp) my initial integrated care consulting company. It is for this reason that seven other talented US physicians have chosen to become the owners of a new CS, limited liability company (LLC). We started advertising in January 2020 and have already found that there is increased interest in moving forward with integrated approaches to medical and BH care that were only pipe dreams when I first started.
Thus, my next (and perhaps final) project will be to help this group of talented individuals develop consulting expertise and take over the inevitable transition from segregated to integrated medical and BH services delivery in the 2020s. There are now at least 12 areas of integrated practice that have evidence of efficacy. The problem is that most health care organizations do not know how to put together integrated programs that add predictable value. That is what this young and talented group of integrated care physicians will be doing moving forward.
At this point, I can say that if there are interested health professionals in Europe who would be interested in doing the same thing, i.e., fostering the development of integrated models of care in their countries, give me your names and I will see if my co-owners are interested in working with you in developing a franchise. Integrated care is a challenge for us all. We have to work together to solve it.
Can you share with us the memory of one or two “topical” moments in your professional life, that you now realize were pivotal in addressing your career and “style” as C-L psychiatrist?
Prof. Kathol: Perhaps, the most memorable situation in my professional career was when I worked for an insurance company after they had been sued by their US state of business for several deaths and hundreds of patient injuries related to their refusal to pay for many BH practices. It was while I worked for them that I was able to connect care delivery with health care payment practices.
While you all will tell me that these differ substantially from country to country, which is in part true, it is the fact that BH services are paid from separate funds that segregated medical and BH services persist. There can be no resolution when payment is separate. While a single payor is only the first step in the process to integration, it is necessary for widespread integration to occur. It was while I worked at the insurance company that I learned this lesson and why I am so insistent that all health systems move in this direction—worldwide.
Could you please share your vision for the future of Consultation-Liaison Psychiatry and Psychosomatic Medicine?
Prof. Kathol: CL Psychiatry and Psychosomatic Medicine have a very bright future, particularly if they can complete a transition into the larger medical delivery system. Seventy percent of BH patients refuse to access BH services in the BH setting, even when prodded. It is for these patients and the primary psychiatric patients with comorbid medical illnesses that these two components of healthcare will have accountability to support or deliver effective care.
As a part of the transition, this will bring a slow but steady growth in the relationship between medical and BH practitioners. In fact, many of the services that we think of primarily BH can and will be effectively delivered by trained and/or supported medical practitioners. Of course, the more severely ill BH patients will still require BH specialty services by trained BH providers, perhaps in standalone settings like other medical specialties, however, there will be many with lesser medical skills that can take over care of those with less complicated BH conditions or with more severe conditions that have stabilized. This will only be possible when the medical setting is as much a home to BH patients and professionals as the BH setting.