Duration and Direct Cost of Behavioral Health Concerns in Pediatric Primary Care

Behavioral, emotional, and psychosocial issues of children and adolescents are often brought to the attention of primary care physicians by parents (Smith, Rost, \& Kashner, 1995). In fact, behavioral health concerns are the primary reason for visits to physicians in 15% to 21% of cases (Kelleher, Childs, Wasserman, McInerny, Nutting, \& Gardner, 1997; Lavigne, Gibbons, Arend, Rosenbaum, Binns, \& Christoffel, 1999; Williams, Klinepeter, Palmes, Pulley, \& Foy, 2004). During 50% to 80% of child health care visits, parents or physicians raise concerns of behavioral or psychosocial issues (Cassidy \& Jellinek 1998; Fries, Koop, Beadle, Cooper, England, Greaves, et al., 1993; Sharp, Pantell, Murphy, \& Lewis, 1992).

Several concerns have been raised when patients seek mental health services from primary care physicians, including an increase in the number of medical visits, an increase in the time spent with the physician, lost revenue if a patient takes more time than scheduled, a lower reimbursement rate for mental health issues, limited training in mental health treatment, a decrease in the number of patients seen, an increase in the risk of physician burnout, unsatisfied patients, an increase in impairment in patient health and functioning, and an increase in the use of acute and emergency care (Connor, McLaughlin, Jeffers-Terry, O'Brien, Stille, Young, \& Antonelli, 2006; deGruy, 1997; Leaf, Owens, Levelthal, Forsyth, Vaden-Kiernan, Epstein, et al., 2004; Strosahl, 2002; Young, Klap, Sherbourne, \& Wells, 2001).

There are limited studies examining the time and cost incurred by physicians for treating patients with behavioral, emotional, and psychosocial issues. Average primary care visits last between 13 and 17 minutes (Blumenthal, Causino, Chang, Culpepper, Marder, Saglam, et al., 1999; Bryant \& Shimizu, 1988) A more recent study conducted in rural communities found that physicians spent an average of 5 to 7 minutes longer on visits where behavioral issues were raised (Cooper, Valleley, Polaha, Begeny, \& Evans, 2006). Primary care physicians see four or five patients per hour (deGruy, 1997), which is an insufficient amount of time for a detailed psychological assessment or management of mental health symptoms. Therefore, frequent or longer visits are scheduled. Additionally, physicians are reimbursed for medical diagnosis but not mental diagnoses (deGruy).

This study is based on previous work documenting that pediatric primary care visits increased in duration when behavioral concerns were identified prior to the visit and spontaneously raised during the visit (Cooper, et al., 2006). Additionally, this study calculates the reimbursement rate associated with those visits in addition to the duration of the visit. Finally, this study is a replication of a study previously approved through the University of Nebraska Medical Center Institutional Review Board (i.e., IRB # 449-07-EP).