Assembly Calls for Inpatient Practice Guideline, Deals With Other Patient-Care Issues

Among the multiple proposed action papers at the May meeting of the APA Assembly in Atlanta were several with direct impact on the care that patients receive from their psychiatrist. The Assembly representatives voted, for example, to ask the APA Council on Quality Care to explore the development of a practice guideline to be added to the extensive series of APA practice guidelines focusing on inpatient psychiatric care.

The expense of providing inpatient care has for several years “been under great scrutiny by federal and state governments and insurance companies causing shortened lengths of stays and markedly fewer beds, as well as a cut in the services provided to patients.”

The cost of this care is routinely high since patients who are hospitalized are usually in crisis, and treating them at this stage is “labor and time intensive,” requiring the intervention of multiple mental health professionals. As a result, hospitals have eliminated beds and psychotherapy services. A practice guideline from APA would assist psychiatrists who serve as medical directors of institutions providing inpatient treatment but currently have “no standards on which to argue for maintenance of important treatment services” in the face of financial pressures to cut or reduce payment for them, the proposal notes.

Representatives also endorsed a proposal whose goal is to increase patients’ access to psychiatric care by eliminating one barrier to care for patients with serious and recurrent mental illness—out-of-pocket costs for receiving care. To accomplish this change in the way care is paid for, Assembly members want APA to develop an official position statement asserting that entities that manage mental health care “should waive or minimize copays, deductibles, and share of costs for patients with serious, recurrent, or disabling mental disorders, including child, adolescent, and adult patient populations. This proposal calls on APA to advocate for it on two fronts: through legislative and regulatory lobbying and state legislative outreach and through the APA delegation to the AMA, which would urge that organization to use its resources to advocate for a similar resolution.

The authors of the proposal pointed out that “the phenomenon of increasing out-of-pocket costs for patients is creating a significant barrier to care with delayed, disrupted, and deferred treatment resulting in increased severity of illness, disability, and cost of care due to the requirement for higher intensity of care” needed when a mental illness is severe or recurrent.

Also on the advocacy front, the Assembly representatives urged APA to “lobby for the elimination of the federal ‘opt-out’ provisions so that self-funded, nonfederal government health plans” would no longer be allowed to opt out of parity mandates, thus guaranteeing patients that no matter who insures them, insurance plans would all be subject to the same requirement for providing mental health care at parity with other types of medical care.

Currently, a provision of the federal Public Health Service Act permits self-funded, nonfederal governmental health plans to “opt-out” of parity by filing written notice of their intent to elect the opt-out,” according to the Assembly proposal, and when this occurs, plan participants and their families face “disadvantages and hardships” in trying to access needed mental health care through other avenues or paying for it without benefit of insurance coverage. The proposal noted, however, that “if a health plan is experiencing financial hardship, the federal parity law already includes a cost exemption for plans that demonstrate that parity compliance will result in increased costs of at least 2 percent in the first year or at least 1 percent in any subsequent plan year.”

Electronic medical records were also on the Assembly agenda in May, with representatives voting to call on APA to take steps that would result in improvements in the “efficiency and quality” of electronic medical records and the psychiatric documentation of patient care. This would involve, according the proposal, APA’s developing “specific and practical templates to improve clinical utility” of electronic medical records.

In addition to the introduction and spread of electronic medical records, technology has also had an impact on psychiatric practice through social-media websites. One aspect that has received little attention but is being raised by more and more psychiatrists is the ethical considerations that may arise when they discover patient information through “targeted Internet or social media searches.” Assembly members want APA, through the Ethics Committee and other relevant components, to develop a resource document on this topic “to provide guidance on when (if) and how to use the Internet and social media clinically” and disseminate the document to all APA members.

In other actions, the Assembly voted to:

• approve a change to its Procedural Code that would no longer allow someone to be a member of both the Board of Trustees and the Assembly.

• ratify a change to the APA Bylaws, previously approved by the Board of Trustees regarding the international resident/fellow member category. International trainees can join APA as international resident-fellow members. Benefits include free access to the same supplemental education and training program available to U.S. and Canadian residents, SET for Success, which features more than 60 online courses covering medical knowledge, clinical skills, and the business of medicine, as well as free access to the American Journal of Psychiatry.

• endorse a proposal to have the Council on Quality Care develop an Association position statement to describe “minimum uniform standards for mental health hotlines in the United States and Canada.”

• approve a proposal to have an APA component develop a position statement addressing issues surrounding the “mental health impact of the migrant and refugee crisis.” Because of the urgency of the issue, Assembly representatives wanted to have such a statement ready for review at its November meeting. ■