I was reminded of the ever-changing nature of psychiatric practice after
reading a recent e-mail exchange between an APA member and a fellow Board of
Trustees member. The e-mail touched on recent developments that affect our
practice and our patients. Specifically at issue are the trends toward the
increasing managed care—like management of pharmacy benefits and the
increased assault on inpatient psychiatric care.
It is not necessary to elaborate on the utility of medications in
contemporary treatment. Yet, it is undeniable that costs for medications have
increased at a rapid rate over the last decade. This is attributable to a
number of factors including increased costs of the new drugs and, even more
so, to the large increase in the use of medications. Not surprisingly, an
escalating cost curve has drawn the attention of third parties who manage and
or pay for these benefits. This has resulted in a variety of developments that
require our monitoring and intervention.
For example, state Medicaid programs are now developing preferred drug
lists, which often incorporate so-called "fail-first," and other
clinically inappropriate mechanisms. APA, in collaboration with the National
Alliance for the Mentally Ill and the National Mental Health Association, has
been significantly involved in the 50 states where we have sought appropriate
exemptions and/or management mechanisms for psychotropic drugs.
This effort will rapidly segue into our ongoing advocacy efforts regarding
the new Medicare prescription drug program under Part D. Under the program,
effective January 1, 2006, some 7 million "dual eligibles" or
patients covered by both Medicare and Medicaid will be transitioned to
coverage under the Medicare program. The challenges to assure access to
clinically appropriate medicine under the Medicare program are
daunting—such as how formularies will be defined and the continuity of
care for patients stabilized on a drug regimen. Moreover, we are increasingly
faced with the new position of so-called evidence-based standards that will
govern the access to drugs that are deemed cost-effective and clinically
Another area of concern to APA is the growing evidence around the
acute-care and long-term-care bed shortage. The bed-shortage issue will be
compounded by a number of recent developments (Psychaitric News,
December 3, 2004). A new prospective payment system (PPS) for inpatient
psychiatric care was implemented on January 1. While APA continues to analyze
the impact of this new payment system, one fact is clear: by definition, the
new PPS methodology will redistribute the monies paid under Medicare across
all hospitals currently caring for inpatient psychiatric patients.
Concern for inpatient psychiatric care under Medicare is furthered by the
aggressive posture of several of the Medicare fiscal intermediaries who have
recently put into place overly proscriptive documentation requirements for
inpatient psychiatric care that will impact every region of the country. These
new requirements go well beyond the well-established standard of practice for
documenting inpatient services without providing evidence to support the need
for this type of documentation.
APA continues to work with the Centers for Medicare and Medicaid Services,
as well as with the fiscal intermediaries, on issues relating to inpatient
More information on APA's activities on these topics can be found on our
Web site at<www.psych.org>.
APA continues to provide individualized assistance through the APA Managed
Care Help Line at (800) 343-4671 or<email@example.com>.
Staff can provide assistance on a number of issues including pharmacy benefit
management, CPT coding and documentation, and Medicare and Medicaid. Your
calls also provide valuable information concerning current trends and can
serve as an early warning system to APA on practice-related issues. As I've
said before, your voice is one of the most important aspects of your
membership and provides the basis for the work we do. ▪