Paula Hartman-Stein, Ph.D.,
Clinical Geropsychologist, Past President of APA,
12/2, Clinical Geropsychology

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End-Stage Renal Disease presents practice opportunities

By Paula E. Hartman-Stein, Ph.D.

A Temple, Texas group has embarked on a pioneering effort to integrate behavioral health into the healthcare system by offering services to patients with end-stage renal disease.

The Behavior Health Management Group, which includes psychologists and other healthcare professionals, recently received approval from its Medicare carrier to provide on-site rehabilitative services to dialysis patients as a result of changes made in the Health and Behavior current Procedural terminology coding system in 2002.

“We have some interesting wrinkles to iron out,” before the group’s services begin in six clinics this summer, Theodore Clevenger, CEO, said. “Rural dialysis clinics are places where behavioral health services should be delivered.”

Both government- funded and most private third party payers now accept six new codes that allow psychologists and other professionals to be reimbursed for interventions for the treatment or management of physical health problems.

Regardless of the age of the patient, payment for most dialysis-related services, including physician services, is through a monthly capitation payment (MCP). Medicare pays 80% of the MCP after the patient’s Part B deductible is met. Health and Behavior services are excluded from the MCP, and can be billed separately under Medicare Part B.

Delivering psychosocial interventions in a group setting with some semblance of privacy is another wrinkle to be ironed out, especially under the new regulations mandated by Health Insurance Portability and Accountability Act, or HIPAA. Dialysis patients sit in lounge chairs a few feet from each other for about four hours three times a week while hooked up to a machine.

The procedure is usually painless and patients usually spend the time watching TV or reading. Clevenger conducted focus groups with 40 patients and encountered only two patients who did not like the idea of receiving group or individual interventions in the room where the dialysis patients sit.

Kay Carey, Ph.D., clinical director, said the group is considering using small colorful portable screens that can be rolled up and down to separate the patients who are referred to the program and who want to receive psychosocial services during their dialysis treatments.

Common behavioral problems for patients suffering from end-stage renal disease include drinking excessive fluids, eating a poor diet, failing to engage in positive health behaviors, missing dialysis appointments and not complying with medication regimens.

Carey explained that after the clinician conducts a psychosocial assessment on patients referred for treatment, interventions will be provided either on a one-on-one basis or in a group. “We plan on inviting family members to attend the groups. We want to get the patients and their caregivers to be more actively involved in the treatment,” she said.

Clevenger said that the group’s model emphasizes the five E’s found in the renal rehabilitation literature: Encouragement, education, exercise, employment and evaluation.

He stressed that the group will use standard health measures such as the Kidney Dialysis Quality of Life and the McGill Quality of Life Questionnaire to evaluate the program.

With the constant growth and increasing costs of the renal dialysis program since its inception in 1972, it is essential that a new treatment for this population be cost-effective and show positive outcome, he noted.

The United States Renal Data System forecasts average annual growth of this population of around 4.1% for new patients and 7.7% for Medicare expenditures.

An informal Internet survey conducted by APA Division 12 listserve late last year showed that some psychologists do not use the Health and Behavior codes because they fear more hassles and possible lower income.

In a recent article, “The Future of Professional Psychology: Psychological Health Care,” in The Register Report, (Spring 2003), Ronald Levant, Ed.D., of Nova Southeastern University, reports that economic pressures will eventually force behavioral health to be integrated into the U.S. health care system. Levant says that by clinging to old patterns of practice, psychology could lose the chance to emerge as a premier health profession.

The Behavioral Management Group’s program for dialysis patients exemplifies a bold approach to what psychologists can do to improve the quality of life of a growing chronically ill population within an integrated system of care.

The National Psychologist, Vol. 12, No. 4, p. 19

Paula Hartman-Stein, Ph.D., current president of the American Psychological Association's section of Clinical Geropsychology, is a consultant in Kent, Ohio. She can be reached through email,, or you can learn more about her work by visiting her Web site,


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