This is the first in a series of data analytic articles addressing financial and clinical trends in behavioral health practice. We base our analysis on the data in our emr and practice management system which represents a broad cross section of clinicians nationwide. We are reporting data on outpatient claims only. We have excluded inpatient and residential levels of care. The data also only represents reimbursement from the primary payer.
The first graph shows insurance reimbursement by type of visit (bear in mind the the reimbursement rate we report is based on actual insurance payments which do not include copays, co-insurance, etc). The second graph breaks down reimbursement by CPT code.
The initial visit reimbursement increased from $127.91 to $161.62. It is noteworthy that psychiatrists use 90872, the replacement for the CPT code 90801. This code not only pays better than the E and M new patient codes, but also has less onerous documentary requirements.
The follow up visit reimbursement rate increased from $62.03 to $83.71. The CPT code data on the second graph suggests that, as a result of the CPT code changes, psychiatrists may be changing the way they practice or bill for services. In 2012, 90805 and 90807, which were medication and psychotherapy follow up visits, accounted for almost 35% of all services delivered. In 2013, only 18.6% (the sum of add on codes 90833 and 90836) of follow-ups are billed for services that include psychotherapy services. So what has happened? Either 1) psychiatrists have changed their practice style and do not provide as much counseling; 2) they have not changed their practice style but are not being reimbursed by the payers for these services; or 3) they are not billing for these services, perhaps because they are getting paid well enough or forget to add the add on code.
Another significant change in psychiatric practice is that the billing profile for psychiatrists is coming to resemble that of internists and family practitioners. 99213 accounted for 42.8% of psychiatric visits in 2013 (as opposed to 2.4% in 2012) , which is fairly close to the 48% use rate of internists and family practitioners.
In summary, the 2013 CPT changes were not revenue neutral insofar as psychiatry is concerned. We don’t know if insurers anticipated this. Psychiatrists are being paid better for routine psychiatric services. It may well be that psychiatrists are under-coding follow-up visits.
CarePaths is pleased to announce that Kurt Peters, MD has accepted the position of Chief Medical Officer of CarePaths, Inc. He is a private practice child and adult psychiatrist who served for over 20 years in the US Air Force, retiring recently as a Lt. Colonel. We are also happy to report that Dr. Peters is married to a psychologist–which clearly attests to his good judgement!– and is a pilot. Over the last several months Dr Peters has provided invaluable assistance to CarePaths with a variety of practice issues, including selecting, testing, implementing and rolling out a new eprescriber, selecting a new credit card vendor, and developing new clinical tools and decision support systems. We at CarePaths are delighted to have Dr. Peters on our team–he knows the nuts and bolts issues of running a clinical practice. In the coming months he will be sharing his ideas–and listening and responding to your ideas–in this blog space.
There are six reimbursement codes for health and behavior assessment and intervention. These codes apply to behavioral, social, and psychophysiological procedures for the prevention, treatment or management of physical health problems.
The health and behavior assessment and intervention codes
96150 – the initial assessment of the patient to determine the biological, psychological, and social factors affecting the patient’s physical health and any treatment problems.
96151 – a re-assessment of the patient to evaluate the patient’s condition and determine the need for further treatment. A re-assessment may be performed by a clinician other than the one who conducted the patient’s initial assessment.
96152 – the intervention service provided to an individual to modify the psychological, behavioral, cognitive, and social factors affecting the patient’s physical health and well being. Examples include increasing the patient’s awareness about his or her disease and using cognitive and behavioral approaches to initiate physician prescribed diet and exercise regimens.
96153 – the intervention service provided to a group. An example is a smoking cessation program that includes educational information, cognitive-behavioral treatment and social support. Group sessions typically last for 90 minutes and involve 8 to 10 patients.
96154 – the intervention service provided to a family with the patient present. For example, a psychologist could use relaxation techniques with both a diabetic child and his or her parents to reduce the child’s fear of receiving injections and the parents’ tension when administering the injections.
96155 – the intervention service provided to a family without the patient present. An example would be working with parents and siblings to shape the diabetic child’s behavior, such as praising successful diabetes management behaviors and ignoring disruptive tactics.
How these services differ from psychotherapy
Until now, almost all intervention codes used by psychologists involved psychotherapy and required a mental health diagnosis, such as under the DSM-IV. In contrast, health and behavior assessment and intervention services focus on patients whose primary diagnosis is physical in nature.
The codes capture services addressing a wide range of physical health issues, such as patient adherence to medical treatment, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to physical illness. In almost all of these cases a physician will already have diagnosed the patient’s physical health problem.
If a mental health clinician is treating a patient with both a physical and mental illness he or she must pay careful attention to how each service is billed. The health and behavior codes cannot be used for psychotherapy services addressing the patient’s mental health diagnosis nor can they be billed on the same day as a psychiatric CPT code. The clinician must report the predominant service performed.
Use of the codes will enable reimbursement for the delivery of psychological services for an individual whose problem is a physical illness and does not have a mental health diagnosis. Since these codes are new, reimbursement rates from the private sector have not been determined. However, it is important that psychologists begin to use these codes now to accurately capture the services provided.
New codes to be paid with physical health dollars in Medicare
When providing outpatient care to Medicare beneficiaries, services for these patients will be reimbursed at a higher rate than psychotherapy because under current Federal regulations, the outpatient mental health treatment limitation does not apply to these new services (it only applies to services provided to patients with a mental, psychoneurotic, or personality disorder identified by an ICD-9 CM diagnosis code between 290 and 319). For example, Medicare would reduce the approved amount of a 45-minute outpatient psychotherapy session by 62.5% and then reimburse 80% of the remainder, resulting in a payment of approximately $48. In contrast, Medicare would reimburse a 45-minute outpatient health and behavior intervention for an individual at 80% of the approved amount, or approximately $59.
Federal reimbursement for the health and behavior assessment and intervention codes will come out of funding for medical rather than psychiatric services and will not draw from limited mental health dollars. For private third party insurance we expect these services to be treated under the physical illness benefits of a plan and thus not be subjected to the higher outpatient consumer co-payment found in Medicare or relegated to behavioral health “carve out” provisions.
What non-physician practitioners are eligible for Medicare Part B for reimbursement?
Non-physician practitioners who are authorized under Medicare Part B programs to furnish mental health services include clinical psychologists, clinical social workers, nurse practitioners, clinical nurse specialists, and physician assistants. Medicare does not pay marriage and family therapists or licensed professional counselors for their mental health services.
Here are the further developments:
First, Medicare now routinely reimburses H & B codes nationally, with the exception of Illinois and Wisconsin. However, the number of units allowed is often restricted.
Second, private payers are following Medicare’s lead and are also now reimbursing for H & B Codes. However, most payers, with the exception of United HealthCare, pay only for face-to-face treatment, not for chart review, report writing, etc.
Third, it is often difficult to get many private payers to authorize treatment for H & B services. Mental health is often carved out by health plans and the contractual boundary between mental health and physical health is often not clear cut. The mental health carve out company, for instance, may not authorize care for treatment of a medical condition or diagnosis, and the medical insurer may not authorize care by non-medical providers. Thus, behavioral clinicians seeking reimbursement for these services are often are left having to petition the plan.
The good news is that progress toward care integration is advancing due to new technologies and reimbursement policies. The bad news is that America’s healthcare bureaucracy seems designed to make that advance as slow and difficult as possible.
The New Integrated Care Paradigm
A variety of forces are reshaping how behavioral healthcare is delivered in the US. These changes are due to a host of forces, among them:
-The Affordable Healthcare Act (more patients for behavioral clinicians)
-Parity (better reimbursement for behavioral clinicians)
-Focus on population based medicine
-Recognition that primary care is the de factor mental health system in America, i.e. the place where most behavioral healthcare is delivered
-That medical illness comes with much higher rates of depression and other psychiatric sequelae
-That behavioral interventions can assist patients better cope with chronic illness
-That costs can be contained through care coordination between behavioral and medical clinicians.
These changes are behind the movement toward a new model of behavioral healthcare delivery: integrated behavioral care. Integrated care involves the close
collaboration and coordination of care by the healthcare team to address physical and behavioral needs of the patient. It recognizes the central role of the primary
care (called the patient’s medical home), the need for behavioral interventions to treat not only psychiatric conditions but also to support and facilitate medical
treatment as well, and the focus on populations at risk. The big change in the delivery system in behavioral care is not so much where the care is delivered as how:
integrated care means close and ongoing coordination between medical and behavioral clinicians. Integrated behavioral care takes clinicians out of their silos and
situates them squarely on the healthcare treatment team.
Integrated behavioral care portends the end of the psychiatric “carve out” whereby mental health services are managed (and funded) separately from medical services. As
behavioral health services are “carved in” to the delivery system via integrated care, the culture of mental health service delivery will more closely resemble that of
other areas of medicine and will become more standardized, accountable and outcomes driven.
What does this mean for behavioral clinicians? It means that behavioral clinicians will transition from a primarily silo model where psychotherapy is largely outside
the mainstream healthcare delivery system, to one in which it is fully integrated. It means that clinicians will have to expand their repertoire of services to include
addressing medical illness issues, e.g. compliance, lifestyle coaching, etc. And it means that the electronic medical record (EMR) will become the clinician’s
workbench: communication with the treatment team, documentation, outcomes and accountability will derive from this technological platform.
Is this new model a challenge to behavioral clinicians. Yes. In the current mental health silo model, the clinician is sovereign and practices with a great deal of
privacy. In the world of behavioral integration, clinicians will be thrown into a healthcare fishbowl—their work will be visible and their and results will be measured
and public to the treatment team and the funders of care. Psychiatric EMRs will largely automate integration by automatically communicating with other treatment
providers via the Continuity of Care Document (basically a Diagnosis and Problem list), and by routinely collecting data for standardized reporting and outcomes
tracking. In short, behavioral healthcare will become accountable as never before.
In the next several years behavioral clinicians will need to figure out how they relate to the behavioral integration movement. Some will want to work in larger
medical systems as employees. However, many, perhaps most, clinicians will want to integrate with the medical system without losing their independence. Co-location is
one option for behavioral clinicians, but probably not feasible on a widespread basis. Remote collaboration is the more likely outcome with behavioral clinicians
serving as virtual treatment team members.
So what to do? In my view, behavioral clinicians ought to consider coming together to establish affiliation groups. These affiliations would be multidisciplinary
groups that cover all behavioral sub-specializations. The groups would provide a one-stop shop for medical groups and payers. They would use a common cloud-based, ONC
certified behavioral health EMR. The behavioral EMR would insure that confidential patient information that goes beyond the needs of the medical treatment team was
kept strictly confidential and did not “leak” into the larger medical record. The behavioral EMR would also, of necessity, be cloud-based so that interoperation
(communication) between medical and behavioral clinicians could be accomplished remotely, thereby enabling behavioral clinicians to be members of the treatment team,
albeit virtually. A referral widget could be provided to medical practices so that with one click a physician could quickly identify a suitable referral source, i.e.
clinician within a geographical area with the right sub-specialization, insurance panelling, etc.
The model I am describing is not organizationally top heavy. External inspection and control management—the model of the carve out—is replaced in the behavioral
integration model with internal management via information feedback and best practices. As a result more funding goes to care, less to costly administration.
It is not too soon for clinician’s to begin to build the behavioral healthcare system of tomorrow. Replacing behavioral health 1.0, the “carve out” model, with a
“carve-in” model—behavioral health 2.0—is long overdue. Already initiatives such as I have described are being created.
For a good summary of integrated care see this website for a comprehensive overview of integrated behavioral care see http://ibhp.org
Current Procedural Terminology or CPT codes are used by psychologists and other mental health professionals in order to bill their services to an insurance company or Medicaid. The following is a list of some of the most commonly used CPT codes in mental health and psychology services.
90791 — Psychological Diagnostic Interview Examination (Includes report prep time 90885)
90785 — Interactive complexity add on (as necessary)
90832 — Psychotherapy 30 minutes
90834 — Individual therapy 45 minutes
90837 — Individual therapy 60 minutes
90847 — Family Psychotherapy with patient Present
90846 — Family without patient present
90849 — Multiple-family group psychotherapy
90853 –Group psychotherapy
96101 — Psychological testing, interpretation and reporting per hour by a psychologist (Per Hour)
96102 — Psychological testing per hour by a technician (Per Hour)
96103 — Psychological testing by a computer, including time for the psychologist’s interpretation and reporting (Per Hour)
96115 — Neurobehavioral Status Exam
96118 — Neuropsychological testing, interpretation and reporting per hour by a psychologist
Neuropsychological testing per hour by a technician
96150 — Health & Behavioral Assessment – Initial
96152 — Health & Behavior Intervention – Individual
96153 — Health & Behavior Intervention – Group
96154 — Health & Behavior Intervention – Family with Patient
96155 — Health & Behavior Intervention – Family without Patient
In 1985 I worked for a small health plan setting up a mental health provider network in western Massachusetts. We contracted with psychologists for $58 for 90806, the most commonly reimbursed procedure code. This was a deeply discounted rate that led to some grumbling from providers who were used to a higher rates from Blue Cross Blue Shield and other payers. No surprise that some providers refused to join for that reason.
I mention this because I read today that Humana and its wholly owned subsidiary LifeSynch have lowered reimbursement rates for 90806 to $58 for its Illinois providers.* Between 1985 and 2012 the cost of living has increased 78.2%! So if the 1985 rate had kept pace with inflation, providers today would receive about $103 for 90806.
And Humana and LifeSynch are not alone. This year:
Florida BCBS has reduced rates for the most commonly billed mental health procedure codes by 33 – 54%.
Kansas BCBS and Kansas City BCBS have reduced rates by 18-35%.
California Blue Shield reduced it’s already rock bottom rates by 9.1%–from $60 for 90806 to $55–when it changed managed care vendors.
The responsibility for reducing these rates in each instance was off loaded from the health insurer–Humana, Florida BCBS and Kansas BCBS, Kansas City BCBS, and California Blue Shield–to a carve out managed care company–LifeSynch (Humana), New Directions (Kansas BCBS and KC BCBS), or Magellan (California Blue Shield.)
Better that the carve out company take the brickbats than the parent company!
These reductions hit clinicians hard. But they hit them even harder when you factor in that the actual claims paid rate achieved by managed care companies tends to be significantly lower than for parent health insurance company. But more about this in my next post when I present a data analysis of several hundred thousand mental health claims.
*I just ran our reimbursement data for Magellan (n=7778) for 2011 and found that their mean payment rate for 90806 nationally was $58.65, with a mean payment for all codes of $48.12.
WHY OUTCOMES FAILED
Despite the expenditure of tens of millions of dollars and scores of outcomes initiatives over the last 20 years, there are few viable outcomes programs in operation.
Most have failed. Some examples from the private insurance market:
–Aetna/HAI’s ambitious nationwide outcomes initiative implemented in the 1990s
–VRIs multistate initiative also implemented in the 1990s.
–Pacificare Behavioral Health’s nationwide program which was terminated around 2004
–Humana’s behavioral health internet based outcomes and behavioral disease management project ended after a year in 2001
–Massachusetts BCBS statewide outcomes program terminated around 2007
A variety of states also initiated ambitious outcomes projects, such as the states of Washington and Oregon, only to jettison them after a few years operation.
JCAHO made outcomes mandatory nationwide in 2000 with its ORYX project. It was ended barely two years after it began.
Companies set up to develop and implement outcomes have also collapsed. Compass, Inc had millions in investment funding in the mid 90s and developed an outcomes system based on the well regarded work of Ken Howard. The company failed after a few years of operation. A number of other outcomes companies collapsed, as well. The few that are remaining have been drastically downsized. The business model of these companies was akin to those of medical laboratories: to sell a “lab test” of mental health functioning to health plans that would enable the plans to determine the necessity and effectiveness of treatment. They reckoned that health plans would buy these services rather than build them themselves.
The outcomes projects in operation now are implemented by true believers; they are mainly financed by providers. For instance Miller and Duncan developed a feedback informed treatment system based on the Outcomes Rating Scale (ORS). It is software based and used by clinicians mainly in the US and Northern Europe. See http://www.centerforclinicalexcellence.com/ICCE. Jeb Brown, an early champion of outcomes who spearheaded the Aetna/HAI and Pacificare projects that were insourced, has a site http://www.clinical-informatics.com in which he provides outcomes tools for clinicians. He has a number of pilot projects underway. But outside of the true believers, outcomes have not gained traction in the mental health community. This despite the fact that 1) outcomes are regarded by the American Psychological Association as an evidenced based approach; and 2) controlled studies and naturalistic studies show conclusively that outcomes with feedback to clinicians improves the effectiveness of treatment.
So the question, why have outcomes failed?
I think there are a number of reasons:
1) Most outcomes systems were developed by psychologists who eschew the medical model. Their instruments (OQ 45, ORS) measure measure general distress. The dominant health care culture is simply not interested in general distress. It is interested in diseases such as Major Depression, Bi-Polar illness, Schizophrenia, and the like. Measures that are disease-specific are of interest to the medical community. That interest turns into funding. For example, CMS will now pay PCPs to administer disease specific outcomes measures such as the PHQ 9 for depression. Behavior follows funding. When mental health clinicians do the extra work involved in collecting outcomes data, they, unlike PCPs, receive no payment for that extra work. This makes sustaining outcomes difficult; only the true believers stay with it.
2) Clinicians resistance has been a big factor in torpedoing outcomes initiatives. There are a number of reasons for this. First clinicians resent the paternalism of managed care companies that have the arrogance to attempt to micromanage their clinical practices. No physician would stand for it. Incidentally, all or almost all the outcomes projects that have been implemented, excluded psychiatrists from participating in outcomes. Why? They would not comply. Also, clinicians are rightly suspect of managed care companies. As one senior executive of a managed care company said–a company that touts its committment to outcomes–”we really don’t care about outcomes.” In addition, many outcomes instruments contain questions that constitute a HIPAA violation. Take this question from perhaps the most widely used outcomes instrument in the world, the OQ 45: “I have an unfulfilling sex life.” Aetna, Pacificare, Value Options and other companies for years routinely collected this information as part of their outcomes initiatives. Third, outcomes could be used a health care company to impair the clinician’s ability to make a living. e.g. poor outcomes could lead to loss of referrals and outcomes decision support data could result in treatment being curtailed, further eroding clinician’s income. Willed ignorance on the part of clinician’s about outcomes is then fully justified. As Sinclair Lewis remarked: “It is difficult to get a man to understand something, when his salary depends upon his not understanding it!”
3) Feasibility. Until very recently outcomes projects were expensive and cumbersome to implement–clinicians had to make an extra effort to make sure the client filled out the instrument, then it would have to be faxed to the managed care organization, etc. The lack of any tangible benefit, eg. real time feedback, contributed clinician demoralization. “Empty compliance” has often been the norm for clinicians involved in outcomes initiatives. Another factor is that clinicians involved in these projects deal with many payers. For one payer to use a procedure that is applied to, for instance, only a handful of the patient’s a clinician sees a week is rightly viewed as an unfair imposition.
1.Outcomes with feedback to clinicians improves behavioral health outcomes, but it is unlikely they will be adopted if the measure is one of general distress. Psychologists who develop these measures need to get out of their silo and develop measures that the health care community is interested in. That means disease specific instruments.
2. Outcomes need to be a standard of care. PCPs do a number of routine procedures, e.g. blood pressure monitoring. They don’t do blood pressure monitoring for one health care company but not another. It is unfair to ask behavioral clinicians to use different procedures for different companies.
3. The technology still has a ways to go–outcomes ought not to burden the clinician and should be fully automated; alerts to the patient for followup assessments should be provided via e.g. email or text message. Clients should be able to complete outcomes measures on the Internet or a smart phone. Reports should include decision support and be provided instantly to the clinician. Also, outcomes must be integrated into electronic health records. Separate outcomes systems which provide e.g. monthly reports are expensive and inefficient. Naturalistic research via Practice Research Networks would be dramatically enhanced if outcomes data and a robust set of clinical data resided in the same database.
4. While outcomes data should be available to health care companies to insure that care is medically necessary, that data should not violate HIPAA, nor should it be used punitively against the clinician.
5. Clinicians need to be rewarded for providing outcomes informed care; reimbursement rates need to go up to defray the cost of implementing these systems.
6. Effective therapists should be rewarded by higher rates of reimbursement. (h/t Ed Wise, Ph.D.)
7. Less than average therapists should be offered state of the art evidence based treatment workshops. (h/t Ed Wise, Ph.D.)
PS–New Developments question the whether feedback to clinicians improves outcomes
“Feedback informed treatment,” “outcomes informed care,” “client directed outcomes informed care” refer to the practice of providing psychotherapy treatment that is informed by real time patient-reported treatment outcomes. The method uses algorithms derived from actuarial data and compares actual treatment response with expected treatment response to provide feedback–a signal– to the clinician about the adequacy of response to treatment. Lambert and others (including the writer) developed a system that provides the following alerts: recovered (“white”), on track (“green”), no change (“yellow”), and inadequate (“red”) to inform clinicians about treatment progress. Lambert based his system on a reliable and valid instrument, the OQ 45. Another system PCOMS, also known as the ORS/SRS also functions in the same way, except that it uses a visual analogue scale instead.
The underlying theory of these systems is that decision support in the form of a feedback signal of response to treatment will enhance clinical effectiveness by improving the clinician’s treatment decision-making. For instance, a red alert tells the clinician that the client is doing poorly and is at risk for dropping out of treatment and recommends that a change in course should be implemented; a green alert indicates that progress is adequate and no change in course is indicated; etc.
What was perhaps most important about the outcomes informed care approach is that it was not tied to a particular theoretical model. Most systems of therapy that have sought to distinguish themselves as superior to others are based on a specific therapeutic model, for example, cognitive behavioral therapy. Feedback informed treatment, eschews theoretical approaches, and uses actual response to treatment–outcomes–as it’s method.
Over the last decade a considerable body of research have seemed to show that outcomes informed care, actually does lead to greater treatment effectiveness. As early as 2003 Lambert wrote that “integrating client-based assessment into everyday practice has doubled the effectiveness of counselors in some settings.” The developers of the PCOMS, Miller and Duncan, have made the case for outcomes informed care most persuasively. Here is Scott Miller’s summary of the findings of outcomes informed care:
Currently, 13 RCT’s involving 12,374 clinically,culturally, and economically diverse consumers:
•Routine outcome monitoring and feedback as much as doubles the “effect size” (reliable and clinically significant change);
•Decreases drop-out rates by as much as half;
•Decreases deterioration by 33%;
•Reduces hospitalizations and shortened length of stay by 66%;
•Significantly reduced cost of care (non-feedback groups increased
Miller recently gave a seminar entitled “How to Improve Your Practice by 65% Without Trying.” He describes the seminar this way: “Discover how to increase your clinical power and dramatically improve treatment outcomes by practicing simple techniques for gathering and using ongoing client feedback.”
Barry Duncan is equally enthusiastic writing that “When you consider that outcome informed practice improves outcomes more than anything in our field since its inception (sounds like hyperbole but it isn’t), it is really a wonder that everyone isn’t doing it.” And, “I think it is only a matter of time until it is considered standard practice.“
Well that was then and this is now. A recent randomized controlled study by Murphy, etal concluded that “Contrary to previous studies, the feedback on the client’s progression provided to the therapist had only a small effect on improving therapy outcome.” Last week on his blog Scott Miller wrote a recantation of sorts:
“In fact, the latest feedback research using the ORS and SRS found in small, largely insignificant effects! … Such findings can be disturbing to those who have heard others claim that “feedback is the most effective method ever invented in the history of the field!” And, “Consider, for example, the following findings: (1) therapists do not learn from the feedback provided by measures of the alliance and outcome; (2) therapists do not become more effective over time as a result of being exposed to feedback. Such research indicates that focus on the measures and outcome may be misguided–or at least a “dead end.” Better research designs and control for allegiance effects (which Luborsky estimates as being responsible for 69% of the variance in outcomes) will likely confirm these findings.
What can we conclude from this latest bubble of therapeutic enthusiasm? First, that the dodo bird verdict is alive and well and confirmed once again. Second, that it is probably a dead end searching for a silver bullet therapy. And third, TS Eliot had it right when he wrote, “Humility is boundless.”
This Complete EHR is 2011 Edition compliant and has been certified by an ONC-ACB in accordance with the applicable certification criteria adopted by the Secretary of the U.S. Department of Health and Human Services. This certification does not represent an endorsement by the U.S. Department of Health and Human Services or guarantee the receipt of incentive payments.
Vendor: Carepaths, Inc.
Product Name and Version: eRecord Version 3.1
Certification ID: 12212012‐1346‐8
Clinical Quality Measures certified: NQF0004, NQF0013, NQF0024, NQF0027, NQF0028, NQF0038, NQF0041, NQF0105, NQF0421
Additional Software Used: NewCropRx
Criteria Certified: Complete Ambulatory EHR
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~Kurt Peters, M.D.
Child, Adolescent, and Adult Psychiatrist Colorado Springs, CO
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Complementary Support Services, Minneapolis, MN
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~M. Colleen Byrne, Ph.D.
University of Maryland Psychology Clinic