Assembly Discusses Fiscal Problems, Other Issues

It took a determined effort by leaders and members of the Assembly to move through an agenda of close to 50 separate discussions and votes at its meeting last month in Washington, D.C. Assembly members engaged in debates on a wide variety of patient care and professional issues, with the Assembly approving several position statements, including ones on mental health carveouts and access to comprehensive psychiatric assessment. The Assembly also passed a series of action papers on topics ranging from ECP issues to parity.

Amid those debates, the Assembly also directed its attention to APA budget issues, including a discussion and vote that recommended the postponement of the major portion of the fall component meetings in 2002 and another vote that handed off the functions of the Assembly Budget Committee to the Assembly Committee on Planning.

The broad interest and concerns over budget issues spilled over into the Sunday morning session as Assembly leaders cleared a portion of the group’s agenda for discussion of APA’s fiscal situation, thus bumping at least one action paper to the agenda of the next Assembly meeting.

This session was sparked by discussion at the close of the previous day’s plenary session when Assembly members heard reports from APA Medical Director Steven Mirin, M.D., and Treasurer Carol Bernstein, M.D. The reports painted a picture of real and projected revenue shortfalls and increased expenses, many of them unexpected, that have left the Association facing substantial budget deficits for 2001. In mid-November, Mirin indicated, APA was facing a 2001 budget deficit of between $2.5 million and $2.8 million.

Also, in late October a projected shortfall in the 2002 budget of about $2.4 million remained to be worked out, Mirin said at the meeting. He noted, however, that when the Board of Trustees meets to finalize that budget at its December meeting, it will be balanced.

Mirin later told Psychiatric News that the Board of Trustees will be presented with a budget proposal for 2002 that not only is balanced but also has a surplus and will include a restoration of $500,000 to APA’s reserves. He also said that APA has approximately $19 million in reserves.

Mirin and Bernstein attributed APA’s fiscal problems to multiple factors, including declining income from member dues, a five-year freeze on those dues at the same time that inflation has boosted most of the Association’s expenses, increased spending for new programs to benefit members and patients, increasing costs for staff salaries and benefits, and the new revenue-sharing program—a substantial transfer of funds from the national office to district branches and state associations. The extended decline in the stock market since last year has also forced APA to trim significantly the income it had projected from its investment income.

At the Sunday morning plenary session, many Assembly members expressed their concerns about the financial state of their Association, and some questioned the handling of APA’s finances by both the medical director and Board of Trustees over the last several years. Among the areas of concern expressed by several speakers was that the Assembly is not kept adequately informed of APA fiscal matters and that a mechanism needs to be developed to ensure that they are not “out of the loop.”

For instance, William Arroyo, M.D., a representative of the Southern California Psychiatric Society, pointed out that this is at least the third consecutive year that APA has been in a financial crisis. APA needs an action plan, not an action paper, he insisted—a sentiment that Assembly members applauded.

“We are like reporters at a press conference, trying to find out what is happening,” said Michael Blumenfield, M.D., of the Psychiatric Society of Westchester County. Assembly members feel some responsibility for what is happening with APA finances, he added, and APA district branches expect the Assembly to do something about the deteriorating fiscal situation.

Assembly Recorder Prakash Desai, M.D., emphasized that Assembly members need reassurance from the Board of Trustees and from management that they will soon correct the problem.

Among suggestions made by Assembly representatives in an action paper that was “passed as sense of those present” was that the Board of Trustees, Assembly, and members should receive a detailed annual report of the APA’s operations. This report should, among other things, provide a line-item listing of each category of income and expense and a description of each expenditure that would describe the specific product or products delivered, source of approval, and how the product enhances APA’s strategic missions.

And indeed both Mirin and APA President-elect Paul Appelbaum, M.D., had some reassurance to offer. Mirin stressed that the Board hears a report on the budget every time it meets and that no APA money is spent without Board approval, and it is the job of the medical director to help the APA president and Board carry out the Association’s programs and priorities. Mirin also pointed out that APA could save some $500,000 a year by moving its headquarters from downtown Washington, D.C., to Arlington, Va., in August 2002.

Appelbaum also promised that the Board of Trustees would balance APA’s 2002 budget at its December meeting, and said that APA President Richard Harding, M.D., had set up a new task force to prevent such budget problems in 2003 and beyond. Appelbaum is heading up that task force.

In fact, Appelbaum stressed, “This is an enormous opportunity for us. We have an opportunity to shape this organization for the next 30 years.”

In an interview with Psychiatric News after the Assembly meeting, Harding, said, “The Assembly acted with understandable concern about the financial status in which we find ourselves.”

He added that APA had made extensive cuts in expenditures for the 2002 budget and that the Assembly had been made aware of the need for these cuts by the medical director and the treasurer.

Harding emphasized that the APA Budget Committee “has taken advantage of the fiscal crisis to propose changes to our organization that will make it more efficient, but also more effective. While we want to pay close attention to money issues, it is equally important that we use this opportunity to make changes that will result in a better APA.”

He continued, “The Board is always eager for feedback on its actions or lack thereof. It is clear that Assembly members, with the knowledge they had at the time of their discussion, have made some clear statements to which the Board will respond.”

The next issue of Psychiatric News will include a report on the Assembly Executive Committee meeting that took place at the end of the Assembly meeting and the response of the Board of Trustees at its December meeting to the issues the Assembly Executive Committee raised.

Position Papers Approved

In addition to issues concerned with APA’s finances, Assembly Speaker Nada Stotland, M.D., led the Assembly in addressing a broad range of other concerns at its November meeting. For example, Assembly members recommended that APA adopt position statements on the following topics, and the papers will be forwarded to the Board for consideration at its December meeting:

• Access to Comprehensive Psychiatric Assessment and Integrated Treatment: When patients are referred for treatment for an apparently serious mental disorder, many managed care organizations initially refer them to a nonmedical mental health practitioner, and referral to a psychiatric physician for medication management may occur only later. The justification for this “split treatment” protocol includes presumed savings, yet these short-term savings can be more than offset by serious long-term consequences for the patient. Thus, “APA strongly supports a protocol by which any patient who is referred for mental health care should receive a comprehensive psychiatric assessment within a clinically appropriate time, [and] treatment planning should be undertaken only after an accurate diagnosis has been formulated by a psychiatrist, the clinician equipped with both medical training and a biopsychosocial perspective.”

• Carveouts and Discrimination: The separation of the funding and delivery of psychiatric and/or substance abuse services from general medical services—referred to as “carveouts”—is detrimental to providing high-quality, comprehensive care because the practice marginalizes psychiatric treatment and stigmatizes psychiatric patients. Recently, the APA Assembly passed a series of action papers stating that carveouts are discriminatory. In response APA established a work group to develop a consensus position and to advise the APA Board of Trustees. The work group has met three times, and this paper is a product of its effort.

• Minimum Necessary Guidelines for Third-Party Payers for Psychiatric Treatment: This position statement was developed in response to the U.S. Department of Health and Human Services’ privacy-rule provision that health care providers disclose only the “minimum necessary” information for a given purpose, and that providers may make their own determination about what is the “minimum necessary” information for a specific purpose. This document specifies the particular items of information that APA believes fall within the “minimum necessary” criteria for routine processing of typical insurance claims for psychiatric treatment. This is not a policy position about how much or what information should be documented in the record about mental health treatment and psychotherapy. That question will be addressed in a separate paper.

Other Actions

In addition to endorsing the position statements, the Assembly passed several action papers. Some of these recommendations will go directly to the Board of Trustees, while others are being referred to relevant components for further input. Among the proposals passed are the following:

• Each district branch should designate a member who will prepare for responding to disasters.

• Funding sources for research published in the American Journal of Psychiatry should be clearly identified on the first page of the research article.

• A “bill of rights” for persons with serious and persistent mental illnesses will be crafted to promote greater access to quality psychiatric care for these individuals and also to fulfill APA’s obligation to advocate for the patients least able to advocate for themselves.

• When physicians apply for positions at managed care companies or other health care organizations, they are often asked whether they ever have been treated for mental illness or substance abuse. Such questions are not only an invasion of privacy, but of questionable constitutionality. Thus, the Assembly is asking the Board of Trustees to reaffirm APA’s position that a personal history of treatment for mental illness/substance abuse is a private matter, while acknowledging that current impairment is relevant.

• The Board of Trustees should issue a strongly worded statement that substance-related disorders are mental illnesses amenable to diagnosis and treatment and that no program to assure access and quality care for the mentally ill is complete unless substance use disorders are included, and that all discrimination against substance use disorders must be ended.

• In a move to save a substantial sum of money and give APA leaders time to look at streamlining the committee and council structure, the fall components meeting for the year 2002, with a few exceptions, should not be held. The exceptions are the Joint Commission on Government Relations, Joint Commission on Public Affairs, committees that are constitutionally required to meet, and committees directly involved in organizing the APA annual meeting. During the period September 2002 through September 2003, the components could continue to function through e-mail and if necessary teleconference or meet at the annual meeting. In early 2003, APA’s Joint Reference Committee will evaluate component functioning to determine which, if any, components need to have a face-to-face meetings in 2003.

• APA’s current definition of an early career psychiatrist (ECP) is a psychiatrist in his or her first five years of practice or under age 40. This definition of ECP should be changed to include psychiatrists in their first seven years after becoming eligible to be a general member. ▪