The House of Delegates, the AMA’s policymaking body, passed a substitute resolution and an amended report by the AMA’s Council on Medical Service (CMS) addressing mental health carveouts. Considerable testimony was heard by the AMA reference committee on medical service with most agreeing that "carveouts invariably lead to carveoffs," while limited but significant testimony sought to remind the committee that "labeling all carveouts as a problem is an extreme oversimplification."
The AMA’s action comes after the APA Assembly passed an action paper calling for APA to advocate against carveouts in the private sector (Psychiatric News, December 1, 2000). The Board of Trustees approved that position at its December meeting (see story below.) The Assembly had also called on the APA delegation to the AMA to work with and support a resolution submitted to the House of Delegates by the Minnesota state delegation, as well as to further assist the AMA by delivering an operational definition of nondiscriminatory insurance coverage that included 10 principles outlined by the Assembly.
"The overwhelming broad-based support that psychiatry received," said Joseph T. English, M.D., former APA president and now chair of the APA delegation to the AMA, "is a strong indication of the growing influence of our delegation at the AMA and testimony to psychiatry’s growing acceptance within the mainstream of the house of medicine. The strong showing on this issue is evidence of the simple fact that psychiatric patients are also patients of gastroenterologists, cardiologists, neurologists, and other specialists, as well as internists and general practitioners."
The new CMS report on carveouts noted that although they can significantly reduce the cost of providing mental health benefits and that some studies have indicated that such programs increase the rate of outpatient service use, the cost reductions are attributed to decreasing the number of outpatient visits, as well as the frequency and duration of inpatient stays. The report recommended that carveouts "should adequately provide for the appropriate diagnosis, evaluation, and treatment of medical comorbidities."
In addition, the CMS report called for recertification, if necessitated by an insurance plan cap on the number of visits, by the treating psychiatrist without further information being required from the patient. The AMA should encourage third party payers to use only accredited managed behavioral health care organizations, the report said.
Finally, the CMS report recommended that "the AMA urge managed behavioral health care organizations that implement mental health carveout programs to remove any barriers from their intake procedures that interfere with the timely communication and collaboration between attending physicians and psychiatrists."
The report concluded with a statement calling on the AMA to continue to work with APA to "monitor the effectiveness of mental health carveout programs."
The CMS has been investigating carveouts since June 1995, when it presented an informational summary about mental health carveouts to the House of Delegates. A more in-depth report followed a year later. The current report sought to provide an update on the use, structure, and effectiveness of mental health carveout plans.
Two resolutions were offered by different delegations regarding carveouts. Resolution 702, sponsored by the Minnesota state delegation, and Resolution 709, brought forward by the Resident and Fellow Section of the AMA, asked the AMA to "work to encourage payers to eliminate mental health and chemical dependency carveouts so that benefits for mental health and chemical dependency are managed and administered like other health care services."
The only difference in the two resolutions was the addition in 709 of language describing the discriminatory nature of carveouts and their effects on psychiatric patients.
Testimony on behalf of APA’s delegation was led by John S. McIntyre, M.D., a delegate to the AMA and a former APA president. McIntyre informed the AMA reference committee of the recent Assembly and Board actions and directly addressed APA’s position with regard to both the report and the two resolutions.
"The Section Council on Psychiatry sincerely appreciates the thoroughness of the CMS report," McIntyre testified, "but we feel that the six recommendations [in the CMS report] do not accurately reflect the negative impact of mental health carveouts on our patients or on our physicians. We feel strongly that Resolutions 702 and 709 should be supported."
Following McIntyre, numerous delegates testified, most in favor of referring the CMS report back for revision and strengthening the resolutions to include all carveout situations. Delegates noted that the equivalent of mental health carveouts, known as "disease management groups," are now strongly affecting patients in other specialties, including gastroenterology, cardiology, and dermatology. Testimony was widespread in support of the elimination of carveouts, with delegates from 10 states and the largest specialty societies in the AMA joining APA in supporting the two complimentary resolutions.
Not all testimony, however, called for the immediate demise of all carveouts. Donald Brada, M.D., a state delegate from Wichita, Kan., told the reference committee to be careful of oversimplifications.
"Certainly," said Brada, a clinical professor of psychiatry and behavioral sciences at the University of Kansas Medical School, "carveouts are not the ideal delivery system for psychiatric treatment—in fact, I do not know of one without flaws. But I can tell you, with 10 years of experience in leadership positions in mental health carveouts, there are indeed several that offer sound psychiatric care and practice good medicine. And without them, the patients they cover would likely not have any other access to psychiatric care."
However, the majority view of carveouts as inherently flawed became the final word in the reference committee’s overview of the testimony.
"The AMA could do something here," concluded K. Lynne Moritz, M.D., an APA delegate from St. Louis, "to become closer to the heart of all psychiatrists by taking a strong stand on this very important issue."
The initial recommendation of the reference committee did just that—it called for passage of a substitute resolution opposing all carveouts in lieu of the opposition to mental health and substance abuse carveouts in resolutions 702 and 709. In doing so, it noted that the committee had heard considerable testimony favoring the strengthening of the resolutions and the CMS report. However, upon discussion of the items on the floor of the House of Delegates, Oregon state delegates objected to broadening the resolution to cover all carveouts, and the substitute resolution focusing on opposing all mental health and chemical dependency carveouts was passed by the House on voice vote.
APA delegates were successful in amending the CMS report’s preamble to state that while the AMA is opposed to mental health carveouts, it is important to protect the large number of patients who are enrolled in them. The amended report notes that the recommendations included are intended to facilitate working with carveouts while continuing to strive to integrate psychiatric care into mainstream medical coverage.
The proceedings of the AMA’s House of Delegates are available on the Web at www.ama-assn.org. Click on the icon for the AMA interim meeting and choose "Resolutions and Reports." ▪