AMA House Supports Integrated Care, Full Vaccination

Integrated care and immunizations were among the high-profile issues addressed by physicians last month at the annual policymaking meeting of the American Medical Association (AMA) House of Delegates.

Importantly for psychiatry, the House approved a report by the AMA’s Council on Medical Services (CMS) that reaffirms existing policy endorsing access to and payment for integrated physical and behavioral health care.

APA past President Jack McIntyre, M.D., who is chair of the council that wrote the report, said the report goes further to explore models of integration that have proven effective and to address policy barriers to implementing and expanding integrated care.

Specific recommendations in the report call on the AMA to take the following actions:

• Advocate that Medicaid and private health insurers recognize CPT codes that allow primary care physicians to bill and receive payment for physical and behavioral health care services provided on the same day.

• Urge state Medicaid programs to amend their state Medicaid plans as needed to include payment for behavioral health care services in school settings.

• Encourage practicing physicians to seek out continuing medical education opportunities on integrated physical and behavioral health care.

• Develop sustainable reimbursement models to fund the necessary services inherent in integrating psychiatric services into primary care.

The last recommendation was the result of an amendment to the report offered by the Section Council on Psychiatry.

McIntyre explained that state Medicaid rules (also reflected in some private insurance policies) have prohibited payment for medical care and behavioral health care on the same day. “This means patients are required to return another day, invariably leading to lack of compliance and follow-up,” he said.

The CMS report provides an overview of efforts by some states—especially Virginia, Massachusetts, and Colorado—that have developed innovative integrated care programs, as well as specific models of care that have proven sustainable and effective in providing quality care.

Prominent among these is the collaborative care model, developed by the late Wayne Katon, M.D., and Jürgen Unützer, M.D., at the University of Washington, described in the report as “among the most advanced and evidence-based integrated care models.”

The report also cites a large pediatric medical home in North Carolina—Goldsboro Pediatrics—that is providing integrated pediatric primary care. “The state is using … Medicaid waivers to provide a continuum of services to individuals with mental illnesses, developmental disabilities, and substance use disorders,” according to the report. “Through the waivers, Goldsboro Pediatrics has been supervising integrated care in six school-based health centers for more than 10 years. The health centers are integrated into the medical home through an electronic health record system. More than 5,000 behavioral health consultations are provided each year by private sector mental health professionals for at-risk students in the school-based health centers.”

McIntyre said, “The House was very responsive to the report with testimony from other physicians that integrated care is a model that needs to be reinforced and expanded.”

AMA delegates also came down firmly on the side of ending all nonmedical exemptions for common childhood vaccinations, citing recent outbreaks of communicable diseases resulting from the loss of herd immunity.

Several resolutions around this issue were adopted with vocal and largely unanimous support—one calling on the AMA to support legislative efforts to remove all nonmedical exemptions for immunization; another in support of “parent-to-parent education,” asking the AMA to support the development and evaluation of educational efforts to help parents educate and encourage other parents who are reluctant to vaccinate their children; and still another to support the dissemination of materials on vaccine efficacy to states and encourage them to eliminate philosophical and religious exemptions from state immunization requirements.

Evidence of the strength of feeling in the House around the elimination of nonmedical exemptions became apparent during the debate on a joint report by the Council on Science and Public Health (CSPH) and the Council on Ethical and Judicial Affairs (CEJA).

The language in that report reflected a belief by CEJA that there existed an ethical obligation to preserve some degree of parental discretion. “Nonmedical exemptions should protect individuals’ right to make choices about what happens to their bodies or to their children’s bodies,” the report stated. “However, the right to choose comes with a responsibility to consider the consequences of those choices for others. Public policies that limit nonmedical exemptions to circumstances in which refusals are based on well-considered, deeply held beliefs and require individuals who seek exemptions to demonstrate that they meet those criteria can balance public health and civil liberties.”

Debate on the joint report in reference committees and in the House of Delegates was vocal, and much of the testimony stated that the report did not go far enough in closing the loophole of nonmedical immunization exemptions. The report was “referred,” meaning it was sent back to the board, which may ask the two councils to rework the report; those calling for referral argued that the AMA needs to take a strong public health stance on this topic and that the only way to do so is by eliminating nonmedical exemptions entirely.

“The House was very clear in its support of allowing only medical exemptions,” said Louis Kraus, M.D., chair of the Council on Science and Public Health (as well as chair of the APA Council on Children, Adolescents, and Their Families).

Kraus reiterated that faulty research that emerged in the 1990s appearing to show an association between vaccinations and autism has been discredited and was retracted by The Lancet (where the research originally appeared). In the meantime, no environmental cause has been found to explain the recent increase in autism, Kraus said.

“In the joint CSPH-CEJA report, the CSPH came down on the side of allowing only medical exemptions, but CEJA felt that while that was ideally correct, there is an ethical obligation to respect what parents want for their children, and so its report left open an option for nonmedical exemptions. But when the joint report was debated in reference committee hearings and on the floor of the House, delegates made it very clear that outside of medical exemptions, there just is not a reason not be vaccinated.

“The reality is that we are already seeing a certain loss of herd immunity, and we are going to see more if this continues,” Kraus said. “We really have to stand for vaccinations in keeping with the recommendations of the American Academy of Pediatrics.” ■