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What a behavioral specialist could add to your practice.


Doctors have long been criticized for turning a blind eye to patients' psychological disorders. Now some groups are forcing the issue.


Group Practice Economics

What a behavioral specialist could add to your practice

Doctors have long been criticized for turning a blind eye to patients' psychological disorders. Now some groups are forcing the issue.

By Anita J. Slomski
Group Practice Editor

"Beth" had seen numerous primary care doctors, rheumatologists, orthopedists, and physical therapists a total of 300 times in one year. Teresa Nakashima, as family practice chair of HealthCare Partners in Torrance, CA, was chosen to somehow manage the 38-year-old woman's out-of-control visits. Beth did have legitimate medical problems—arthritis, degenerative joint disease, asthma, hypertension, and chronic pain from numerous car accidents and surgeries. Grossly obese, she needed a walker to get around. She also had a gym bag full of narcotics and tranquilizers from which she liberally partook each day.

Nakashima did something Beth's other doctors hadn't: She introduced her to a psychologist who works full time in her 10-doctor satellite in Redondo Beach. The first thing the psychologist suggested was that Nakashima give Beth a standing appointment every week in the hope that she would make fewer panicky phone calls and appointments. The psychologist also met weekly with Beth—and occasionally her two children—for about three months, to build up her low self-esteem and help her set realistic expectations about her doctors and the level of pain she'd have to accept. In times of crisis—such as when Beth's migraines intensified because her teenage daughter (also obese) refused to go to school—the psychologist stepped in. The solution: The daughter would be schooled by a home tutor as long as she maintained her grades.

The collaborative care with the psychologist has changed Beth from a nightmare patient to a manageable one. Nakashima now sees Beth every three weeks to give her a shot of meperidine hydrochloride for her migraines, keep her drug use in check, and monitor other chronic problems. "I no longer cringe every time I hear a squeaky walker wheel, thinking that she's back again," says Nakashima. And the psychologist continues to be an ally by using a part of Beth's therapy sessions to reinforce Nakashima's messages—such as limiting the use of pain pills.

The concept of integrating behavioral health with primary care isn't new. Large, capitated multispecialty groups like HealthCare Partners and Group Health Cooperative of Puget Sound have put on-site therapists in clinics and offered a variety of stress-management and mind/body classes for nearly a decade. But interest in melding the treatment of mind and body is growing in smaller groups, too, as managed care pressures make it harder for doctors to justify expensive medical workups for headaches and stomachaches rooted in depression, anxiety, or stress. "As primary care doctors become more at risk for medical costs, there's a greater incentive to consider patients' psychosocial needs," says Howard Gershon, a behavioral-health consultant with Arista Associates in Fairfax, VA.

Studies estimate that approximately 30 percent of adult primary care patients present with some sort of psychological disorder, as do up to 19 percent of children. And more than half of patients who are high utilizers of medical care suffer from anxiety, depression, or other emotional problems. One researcher found that about 38 percent of patients had at least one of 14 common symptoms, such as back pain, fatigue, headache, or dizziness. Only 16 percent of the symptoms had an organic cause; the rest were probably psychological in nature.

Yet primary care doctors have been notoriously poor at diagnosing emotional problems. One study found that they undertreated 67 percent of psychologically distressed patients by not diagnosing or misdiagnosing the problem or by prescribing incorrect or inadequate doses of tranquilizers or antidepressant medication. Other studies corroborate that primary care physicians fail to diagnose 50 percent of depressed or anxious patients. In 1996, only 3 percent of visits to FPs and general internists included mental-status exams, according to a national ambulatory care survey commissioned by several federal health agencies.

This is no small matter. Studies show that when doctors don't diagnose and treat psychological disorders, patients grow increasingly dissatisfied with their care—but they keep returning because they want their problem fixed. And the frustrated physician either makes more referrals or orders additional tests to find a nonexistent physical disease, or dismisses the "frequent flier" as a difficult patient.

Although training programs in family and internal medicine have been criticized for making short shrift of mental disorders, many doctors don't screen for depression and anxiety simply because of time constraints. "If you have a 10-minute appointment with a patient and there seems to be a psychological problem, you're afraid to ask the right questions—because the answer may leave you stuck with the patient for 30 minutes," says Nakashima.

And what if the patient is obviously depressed? Some physicians may merely prescribe an antidepressant when what the patient really needs is psychotherapy or a combination of therapy and medication.

Yet another scenario has the physician referring the patient to the health plan's behavioral carveout—frequently referred to as the "black hole." But psychologically distressed patients often don't follow through. And if they do make the necessary phone calls and begin seeing a therapist, the primary care doctor may lose track of them. "Behavioral health carveout companies have destroyed the team approach to treating a patient," says Judy Hunter, chief of pediatrics for HealthCare Partners. "I can never find out what the diagnosis is, or what medication has been prescribed."

Do early referrals save money?

The discomfort some people have about being treated by mental health practitioners often dissipates when their doctors suggest they see a psychologist or social worker "colleague" a few office doors down. "When we referred patients to our psychiatry department, only one out of every 20 would make an appointment, both because of the stigma of psychiatry and the need to go to another building," says Nakashima. "Now that I can walk the patient down the hallway to the psychologist in my clinic, one out of four makes an appointment."

At the very least, the therapist will meet briefly with the patient to establish contact and try to dispel his anxieties about therapy. When a patient is in crisis—suicidal or having an extreme grief reaction, for example—the psychologist or social worker sees him within an hour.

Physicians can't simply hand over the patient, however. The referral may take some finessing. "If patients fear their symptoms are being caused by cancer or another dreadful disease, they feel their complaints are being dismissed the moment you bring up anxiety as a possible cause," says internist Michael Getzell, chairman of the chiefs of medicine at Northern California Kaiser, which has had on-site therapists for two years. "So you say to the patient, 'We'll continue with the search for disease, but in the meantime, we need the help of a psychologist, because I know this is creating great stress for you.' Patients usually accept this; it's not a referral to a psychiatrist."

Getting the patient to see a therapist before completing a million-dollar workup for a stomachache or headache not only makes economic sense, it's also easier on the patient's ego, adds Nakashima, who refers about five patients a week to the on-site psychologist.

The most common referrals to on-site behaviorists are for depression and anxiety. Grief, noncompliance with medical treatment, substance abuse, and coping with a chronic illness are other problems primary care doctors refer. Most patients see the therapist two to six times. "There is not a patient in the world with a chronic disease who isn't depressed as well," says Bruce Pevney, a GP and addictionologist at HealthCare Partners. "If you treat only the disease and not the depression, you're not getting anywhere."

Pevney specializes in outpatient treatment of HealthCare Partners' chemically addicted patients—who are about 10 percent of the general population. Many primary care doctors are "in denial about chemical dependency because they don't know how to handle the patient," says Pevney. Or they're easily fooled. For instance, an alcoholic who stops drinking 24 hours before a visit with his doctor will probably be in withdrawal and his blood pressure will be elevated. Also, many alcoholics have cardiac arrhythmias and tachycardia. "If the primary care doctor doesn't know how much the patient drinks, he may misdiagnose hypertension or heart problems," says Pevney.

When a primary care doctor diagnoses a patient with chemical dependency at HealthCare Partners, Pevney will see the patient that day for a history and physical and will start him on detox medications to get him through the first 24 hours. He'll meet with the patient on an outpatient basis three to four times during the detox period—about four days for alcohol and eight days for heroin or Vicodin. Then patients are referred to a chemical dependency counselor at HealthCare Partners, with whom they meet three or four times a week.

Pevney's 250 outpatient detox treatments a year may be labor-intensive, but they're far cheaper—by about three-quarters of a million dollars—than treating these people as inpatients, he notes. In addition, the group saves much of the cost of treating them later on for problems associated with alcoholism and drug use, such as heart disease, hypertension, gastritis, liver disease, diabetes, anemia, bleeding disorders, and nerve damage.

"This is better primary care than we practiced 10 years ago," says Pevney. "With the integration of behavioral health into primary care, everyone is communicating with each other and the patient gets better care."

In her 11-doctor practice, pediatrician Judy Hunter refers two to three patients a week to a psychologist for behavioral and disciplinary problems, attention deficit/hyperactivity disorder, autism, depression, and noncompliance with medication. In one case, the psychologist helped Hunter break some bad news to a patient diagnosed with neurofibromatosis—the same disease the girl's mother had died of. The girl, who wanted to be a concert violinist, had a mass on her acoustic nerve and risked losing her hearing. "The psychologist helped us anticipate her questions and reactions so we would have a ready response for anything that might come up," says Hunter. "Her father and the psychologist were in the room when I told her, and it worked out well. It was collaboration between specialists, which is how medicine should be practiced."

In the managed care environment, practicing medicine cost-effectively often takes precedence. So does close collaboration with behavioral health save money? In theory it does, but most groups have no data to substantiate their savings.

"Our intuition says that integrating behavioral health with primary care not only benefits patients, it also has an economic benefit, but I can't prove that," says internist James Drinkard, medical director of Adventist Health Southern California Medical Foundation. "We need better information technology to measure it." Even without proof, however, Drinkard's group is willing to absorb the cost of referring pediatric Medicaid patients to one of its behaviorists instead of using the behavioral health carveout the state Medicaid program requires. "We just think our behaviorist enhances the medical management of these patients, especially in areas like diabetes," says Drinkard.

Northern California Kaiser studied one of its primary care sites and found that patients who were referred to an on-site behaviorist reduced their visits to primary care doctors by 20 to 30 percent, but the data are preliminary. And HealthCare Partners says it's working on analyzing the cost-effectiveness of having behaviorists on site; hard numbers are expected in six months to a year.

A study of Group Health Cooperative patients published in 1995 found that depressed and anxious primary care patients had higher medical costs ($2,390) than patients without those disorders ($1,397), because of higher utilization of inpatient and outpatient medical services. When the patients' depression and anxiety abated, their medical costs dropped, too, but were still higher than the costs accrued by patients without psychological problems. The authors caution, however, that their study wasn't large enough to draw definite conclusions about cost offset.

On-site behaviorists aren't only for large groups

FP Celestino Vega, a soloist whose practice is owned by Winter Haven Hospital in Winter Haven, FL, brought social worker Kim Ross into his practice a half-day a week about two and a half years ago. But he found enough depressed, anxious, addicted patients, and those needing marital and parenting help, that Ross now sees about 45 patients a month. The hospital pays her a salary, but Vega says her billings more than cover it. Patients fork over a $10 to $25 copay per session to see Ross, who is credentialed with most of the same managed care plans as Vega.

Scratching below the surface to find out how patients live sometimes enables Ross to alleviate a medical problem. That was the case with a 80-year-old woman who has dementia and depression and lives with her daughter. After a few sessions with both women, Ross learned that the daughter was being abused by her husband. Ross persuaded the daughter to take legal steps to get her husband removed from the home and to get treatment for her own depression. With that highly stressful situation under control, the mother has responded much better to her medication and is less confused.

In another case, Ross attended to a 45-year-old man who was sure that Vega and other doctors were "giving me the runaround and not telling me the truth about my heart condition." When Vega initially saw him in the ER, the patient angrily brushed aside suggestions that his chest pains were indicative of an anxiety attack. After a cardiac exam revealed no signs of heart trouble, Vega referred the patient to Ross. She was able to convince him that he does indeed have anxiety attacks, which they are now working to manage.

"Patients are comfortable seeing Kim because they view her as an extension of their family doctor," says Vega. "It isn't practical for me to spend a half-hour or an hour with a patient who has psychological problems. Plus, I don't have the behavioral skills she has." Vega estimates he writes fewer prescriptions for antidepressants, now that he refers mildly depressed patients for counseling. "It's very rewarding to know that the whole patient is being treated here—both mind and body," he says.

The two child psychologists who see patients at the five-doctor Children and Adolescent Clinic in Hastings, NE, are so busy they have 30 kids on a waiting list. They drive 160 miles from Omaha to work at the Hastings practice two days a week; during that time they see 26 patients—about the equivalent of a full-time psychologist's weekly caseload.

It's a great deal for the pediatricians. The psychologists are with the Munroe-Meyer Institute at the University of Nebraska Medical Center, which is putting child psychologists into practices around the state to foster collaborative care among primary care and behavioral health. The university pays the psychologists' salaries, handles all the billing, and leases space from the practice at a nominal rate. "We've had calls from several pediatric practices who want us to consider a partnership with them," says psychologist Jodi Polaha, assistant professor of pediatrics at the University of Nebraska Medical Center.

Had the university not come calling, however, Children and Adolescent Clinic, which is known for treating difficult kids, would probably have hired its own behaviorist, says pediatrician Patrick Doherty. "We could easily keep a psychologist busy four or five days a week with just our patients," he says. "Dr. Polaha has made a huge difference in helping us deal with early conduct disorders so that parents aren't coming back repeatedly. Instead of the doctors' giving medications that may sedate the kid, she does therapy to address the problem."

Polaha also sees kids with autism, anxiety disorders, learning disabilities, and migraines, as well as diabetic or asthmatic kids who aren't compliant with their medications. And she helps parents deal with common pediatric issues, such as feeding, toilet training, and sleep problems. "These doctors didn't go into medicine to deal with unruly kids and stressed-out moms saying, 'What do I do about this?' It's not fun for them," says Polaha. "Now, the doctors get those kids off their backs easily." The therapy takes a practical approach to fixing problem behaviors and involves five sessions on average.

Another way for groups to offer the services of a behaviorist is to tap into mental health organizations that are eager to expand into a primary care office. FP Frank Belsito's hospital-owned practice leases space to three employees of Pine Rest Christian Mental Health Services in Grand Rapids, MI: a full-time psychologist, a full-time social worker, and a psychiatrist who puts in four to six hours a week. "Although we have freestanding mental health clinics around west Michigan, we're focusing more on working in physicians' offices," says Pine Rest president and CEO Dan Holwerda. "Groups can purchase our therapists' time directly, or we'll do our own patient billing."

Belsito, who practices in a 15-doctor group in Grand Rapids, likes the immediate feedback he gets when he refers a patient to an on-site behaviorist. "We're finding that we get to the psychosocial problems quicker, so patients feel better quicker," he says. "If, for example, a parent requests Ritalin for an unmanageable child, I refer them to one of our behaviorists, who can test the child so we're more certain of doing the right thing. About a quarter of the time we attack the behavior with therapy instead of medication. For too long, behavioral health and primary care have been separated. That needs to be changed."

FP Milton H. Seifert Jr. has been trying to put the two disciplines together since 1972, when he created a stress-reduction program for his patients based on 12-step principles. "When I started this, I was hoping I wouldn't have to prescribe as many of the minor tranquilizers that get so abused," says the Excelsior, MN, soloist. "I never dreamed it would become such an important part of my practice. Now I even refer patients with terminal cancer because the program helps them cope." Seifert estimates that about half of his patients have enrolled.

Seifert deliberately chooses teachers or health educators to lead the program, because he doesn't want to "psychologize" the process. "We want to teach life-management skills, not develop insight," he says. The goal is to instruct patients on recognizing their emotional pain and how it affects thinking, judgment, and behavior. The problem is that insurers don't pay for this type of therapy in primary care offices. So his patients have had to pay $50 to $75 out of pocket for each of the four or five sessions. That's been a financial burden for some, and Seifert has had a hard time keeping health educators working in his practice, since they can get paid more working under the supervision of psychiatrists in mental health centers.

But Seifert is undaunted and is currently talking to state legislators about the need for health educators in rural areas to ease patients' psychological stress. Also, he's hopeful that employers will pay for his program once he convinces them of the direct correlation between psychological health and employees' job performance and attendance. "I don't know what I'd do without this service," says Seifert. "It's worked like a dream, and it's so simple. I've never found any type of therapy that works as well."

Individual therapy with a behaviorist is not the only way to attend to patients' psychological needs. Some groups offer classes designed to modify negative thought patterns. Palo Alto Medical Clinic physicians are encouraged to refer patients to a six-week Personal Health Improvement program, initially developed at Harvard Pilgrim Health Care. The class sharpens patients' awareness of their feelings and how their bodies respond to emotions, and teaches them how to cope with unpleasant events. "We're trying to teach people to deal with criticism and ask for what they want in a more productive way," says psychiatrist Bruce Bienenstock, director of psychiatry for Palo Alto. "Many people don't do these things very well, which is why they get physical symptoms."

The group also has classes tailored for chronic-pain patients. "The idea of living in pain for 50 years can cause far more suffering than the actual pain," says Bienenstock. "These patients feel depressed, anxious, and guilty about what they may have done to deserve the pain. We teach them to live in the moment, so when they get some relief, however brief, they realize they won't have nonstop pain. They get a sense that their life isn't fixed and terrible, but always becoming new. We are attempting to give patients a healing experience rather than focusing on treating disease only. People aren't just an organ system existing by itself."

When behavioral therapy meets doctors' resistance

Even with the ease of referring to an on-site behaviorist, and even with in-house mind/body courses, doctors frequently need prompting to use these resources. "Physicians were initially very resistant to on-site behaviorists," says Nakashima of HealthCare Partners. "They complained that asking patients about their emotional status would add at least one minute to every visit. We had to convince them that it takes more time to do an extensive workup for disease if the problem is really psychological."

Group Health Cooperative of Puget Sound has trained all its doctors in treating depression and, for the last eight years, has put therapists in primary care settings for patients who need more psychological help than their doctors can offer. But the on-site therapists haven't been too busy.

"About 20 percent of patients who see our primary doctors suffer from anxiety, depression, or substance abuse, but only 7 percent of our enrollees are seen by our behavioral health specialists," says psychologist Michael P. Quirk, director of behavioral health services. "And most of those patients self-refer to our behavioral health clinics instead of being referred by primary care doctors to on-site therapists. Why hasn't the integration effort moved faster? Because building a hybrid culture between primary care and behavioral health is difficult. This is a long-term strategy that's always in competition with short-term realities like seeing patients and making budget. It's a winning idea, but you need financial and management support. I think it will sort itself out over time, but I've been surprised at how slowly it goes."

The pressures of capitation may also encourage doctors to consider making better use of on-site therapists when faced with patients who have mild disorders for which medications aren't indicated, yet are often requested. "Primary care doctors may become more uncomfortable with prescribing expensive biological remedies when what the patient needs is help with coping skills," says Quirk.

And over time, doctors may develop an appreciation of what behaviorists do. "Physicians often lack knowledge of the scope of behavioral health services and the research-based evidence of their efficacy," says psychologist John Garrison of Lahey Clinic in Burlington, MA. "They may hold too narrow a perspective on the capabilities of the behavioral health professional."

Or they may simply be resistant to changing a routine. After an administrator at Palo Alto Medical Clinic discovered a patient had visited the clinic 200 times in one year, the group earmarked all its frequent visitors—those with more than 20 visits a year. Primary care doctors also were trained to screen for depression and anxiety and to refer those patients to the clinic's group therapy programs. The results have been disappointing, says internist Laurel Trujillo.

"It's hard to get physicians to change their behavior for only a fraction of their patients," she says. "When a patient comes in with a headache or stomachache, we tend to want to make sure it's not cancer or an ulcer or other things. The first thought isn't to look at the mind/body implication." Another possible drawback is that the classes cost patients $145 to $275.

Meanwhile, Palo Alto has two programs in the pipeline to curb frequent visits. One is a self-care Internet site that will prompt patients to make better decisions about when to see a physician. Another is weekly drop-in group appointments (see box below). "I'm hoping my frequent visitors will come to group appointments instead of urgent care," says Trujillo.

Sierra Health Services, a staff- and network-model HMO in Nevada, dispensed with the problem of physician referral to behavioral health by allowing members to self-refer—which nearly doubled the number of visits per thousand members. Sierra polled its primary care physicians and found that 70 percent were comfortable treating depression, but they didn't have time to screen for it. So the HMO taught doctors to give patients the Zung self-assessment tool, which determines degree of depression. Based on the Zung score and number of depressive symptoms, doctors know which medications to prescribe and when to refer the patient to a psychologist or psychiatrist.

"After doctors had used the Zung tool for a while, we repeated the survey and found that significantly more primary care doctors said they had both the time and the comfort level to treat depression," says Yvonne Riggan, director of quality improvement and research for Sierra Health Services. "And the medical records reflected a more thoughtful assessment of depression. The doctor wasn't just writing 'depressed' and ordering SSRIs; he was including the symptoms."

As the mind/body concept becomes more mainstream, and as doctors have fewer financial incentives to see "thick-chart" patients, there will come "an appreciation of how prevalent depression and other psychosocial problems really are," says James Drinkard of Adventist Health. "Then we can diagnose it earlier, instead of looking for everything else first and only then diagnosing it, which is typical today."

Drop-in medical appointments free up doctors' time while giving patients more contact

"Since I started group appointments three months ago, I've discovered so many things about my patients that I never would have during individual office visits," says FP Mark Attermeier of the Midelfort Clinic in Eau Claire, WI. "I always thought of the one-on-one setting as the gold standard, but for some conditions, it's definitely not. Group appointments are an efficient way to educate large numbers of patients. But, more important, they bring together the psychosocial and medical models in one setting. They treat the whole person rather than just the disease."

When psychologist Edward B. Noffsinger created drop-in group medical appointments (DIGMAs) in 1996 at Kaiser Permanente in San Jose, CA, he intended for primary care doctors and specialists to see more patients in less time—while simultaneously increasing both patient and physician satisfaction because of the greater number of patient-doctor contacts. After co-leading 9,000 patients in DIGMAs, Noffsinger is convinced the model works. He's now exporting the concept to other groups as a consultant.

A DIGMA operates like this: Patients either drop in or are referred to the weekly 90-minute sessions, which are led by the doctor and someone who understands group dynamics—a psychologist, social worker, health educator, or nurse. The physician can give routine injections, do thyroid exams, test range of motion for a patient with Parkinson's, treat eczema, evaluate carpal tunnel syndrome, answer questions, and renew prescriptions—in short, anything that doesn't involve a procedure or detailed exam.

DIGMAs are geared for the worried well; patients who demand excessive amounts of time from their doctors; depressed, angry, and anxious patients; and those with relatively stable chronic illnesses.

Treating patients in a group accomplishes two things. One, it leverages the doctor's time. "In a 90-minute DIGMA, a doctor generally sees the same number of patients it would normally take four and a half to six hours to see," says Noffsinger. The ideal size for primary care DIGMAs is 12 or 13 patients, about three times the number who can be seen individually in 90 minutes.

The second advantage of DIGMAs is that patients interact and share their experiences, which improves compliance. For example, a newly diagnosed diabetic who is resisting insulin therapy may encounter other patients already on insulin who can assuage his concerns—or convince him of his folly by holding up a prosthetic foot. "People gain perspective by seeing others with problems they don't have, and everyone walks out of a DIGMA thinking things could be a lot worse for them," says Noffsinger.

And patients aren't shy about discussing their medical problems. "People will talk about anything in a group—perimenopausal symptoms, erectile dysfunction, hemorrhoids, and incontinence," says Noffsinger. "Someone with hypertension may be actively attuned to a patient talking about her Parkinson's because the patient's father may have the same disease. Patients say DIGMAs are like a mini-medical school class—and better than watching ER."

The behaviorist co-leader not only makes sure the group moves smoothly and everyone gets a turn to speak; he or she also talks about how depression and anxiety often accompany medical illness, and how to recognize and treat them. "You're dealing with patients' medical and psychosocial issues as you go around the room," says Noffsinger. And that keeps patients from repeatedly calling or making frequent individual appointments with their physicians. While the behaviorist leads a discussion, the physician or medical assistant takes vital signs and writes an individual chart note on every patient. The doctor reserves 10 or 15 minutes at the end to meet with patients privately, although very few feel the need for it.

One of Attermeier's patients, a woman with spastic dysphonia and a hand tremor, improved markedly after only four DIGMA sessions. Her hand tremor embarrassed her, and she had become reclusive. "I tried working with her and sent her for counseling, but it didn't help," says Attermeier. "At the DIGMA session, however, she was accepted by the others despite her tremor. After the fourth visit, she resumed going out with her friends, and she had found another reclusive woman and was trying to help her."

Another longtime patient revealed in the group that he had been severely abused by his mother as a child—a fact that even Attermeier didn't know. Although the patient's mother was now in a nursing home with Alzheimer's disease, the patient was bringing her home every night for dinner in the hope that she would tell him she loved him. The psychologist who co-leads the group told the patient his mother would never give him her approval, especially now that she has Alzheimer's. "This hasn't brought his diabetes under control, but he has started saying No to his mother's demands, and he's expressing himself better," says Attermeier.

DIGMAs were first tested in a capitated group, which charged members a copay for the group appointment. Reimbursement is somewhat more difficult in fee-for-service situations, since there is currently no billing code for group medical visits, according to Noffsinger. Midelfort Clinic's solution is to bill each patient for an individual visit. Currently the group is writing off the cost for Medicare patients until it determines whether Medicare will pay for the group sessions.


. What a behavioral specialist could add to your practice.. Medical Economics 2000;11:149.

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