APA and psychiatry scored a victory in San Diego last month as the AMA House of Delegates (HOD) voted overwhelmingly to affirm its support for nondiscriminatory treatment of psychiatric illness by the insurance industry.

The action came in the wake of the high-profile decision in November by UnitedHealthcare, the nation’s second-largest managed care company, specifically to exclude mental health services from a new policy eliminating precertification and utilization review for other physician-ordered medical services covered by its plans.

The UnitedHealthcare action outraged psychiatrists and brought a sympathetic response from the AMA. In his opening remarks to the House of Delegates, AMA President Thomas Reardon, M.D., expressed guarded optimism about the UnitedHealthcare decision but criticized the exclusion of psychiatric services from that action.

"Now, we’re not naïve," remarked Reardon. "We don’t think we’ve achieved a cure-all. This decision doesn’t address mental health, for one thing—and that’s a major issue."

After criticism, UnitedHealthcare pledged in December to phase out precertification for psychiatric services within 18 months.

The resolution originated after Delaware psychiatrist Janis Chester, M.D., sent a draft to her state medical society, Chester told Psychiatric News. It was strongly supported by APA and other organizations in the AMA Section Council on Psychiatry. The AMA adopted an amendment specifically addressing utilization review and precertification procedures, offered on the floor of the house by psychiatrist Thomas Allen, M.D., a delegate from the Maryland State Medical Society.

Although the resolution adopted by the AMA does not specifically mention UnitedHealthcare, it calls for the AMA to "petition insurance companies to treat patients with psychiatric illness no differently than they treat any other patients with respect to utilization review and precertification policies, and to afford the same degree of authority to psychiatrists as they afford to all other physicians."

The resolution also calls on the AMA to develop model state legislation to address these issues and asks the AMA Board of Trustees to have the AMA Council on Medical Service "revisit these and other issues of mental health carveouts and report back with policy recommendations" at the house’s next interim meeting in December. 

David Fassler, M.D., vice chair of the Section Council on Psychiatry and a delegate from the American Academy of Child and Adolescent Psychiatry, implored the house to support the resolution in view of the UnitedHealthcare decision.

"We all followed with considerable interest the news regarding the decision by UnitedHealthcare to eliminate their burdensome utilization review procedures," said Fassler. "And we were not surprised to learn that the mechanisms and administration of the precertification review and approval process cost far more than any savings generated by the denial of care. Unfortunately, as we learned several days later, this decision, which was described in the Wall Street Journal as ‘a watershed event’. . .will not apply to the treatment of psychiatric disorders. . . . The AMA has long been a reliable and effective advocate for parity and for improved access to mental health treatment. We need active and involved support and immediate action on this critical and timely issue."

Sara Charles, M.D., an alternate delegate from APA, noted that UnitedHealthcare "got wonderful PR out of this" but "we and our patients" were left out. Urging support for the resolution, she noted that "AMA policy supports parity. This really means that care for mental illness should be covered the same way as for all other medical illnesses, and psychiatrists should have the same freedom as any other physicians in choosing the most appropriate treatment for their patients. We believe that psychiatric services should be subject to the same peer and utilization review as other medical services. This may be the first step, the beginning of more retrospective kinds of reviews; we would ask, though, that as members of this body and as physicians that even if that is one of the outcomes of this initiative by UnitedHealthcare that we be treated equally—we and our patients—in this."

Jeremy Lazarus, M.D., who chairs APA’s Joint Commission on Government Relations, spoke as a delegate from the Colorado Medical Society. "Although we’re concerned about respect for ourselves as psychiatrists," said Lazarus, "it’s really an issue of fairness for our patients. Even in those states where there’s parity for the mentally ill—there are about 24 states now—only one state has nondiscriminatory utilization review."

"A person killed by suicide, a medically treatable condition, is just as dead as a person who dies of cancer or heart disease," remarked Jeffrey Akaka, M.D., a member of the Section Council on Psychiatry and a delegate from the Hawaii Medical Association.

Carol Bayer, M.D., a New Orleans psychiatrist in private practice, is an alternate delegate from the Louisiana State Medical Society and one of the few who expressed opposition to the house’s adopting the resolution.

"It’s a nice, feel-good resolution," Bayer told Psychiatric News. "But the way that it’s written won’t help us because UnitedHealthcare doesn’t deal with us," she observed. Bayer was referring to the fact that UnitedHealthcare’s psychiatric services are provided through a wholly-owned subsidiary, United Behavioral Health, which shapes its own policies regarding utilization review and precertification. Bayer said she would have preferred that it be rewritten with "much stronger" language and brought back at the AMA’s annual meeting this June in Chicago.

The House of Delegates took action in these other areas:

• Nonphysician Prescribing: The House of Delegates reaffirmed existing policy in opposition to nonphysician prescribing and resolved to collaborate with specialty societies to develop programs to educate the public about the difference in education and professional standards between physicians and nonphysician health care providers.

• Seclusion and Restraint: The house formally opposed the Health Care Financing Administration’s interim final rule on the use of seclusion and restraints, including the one-hour rule. The language of the resolution noted that "the use of restraints and seclusion is a medical decision and should not be dictated by government agencies" and added that "when a physician is not physically present, a properly trained and authorized health care professional may institute seclusion and restraints when this is clinically appropriate. In such cases the physician shall be contacted immediately. The patient must be examined by a physician within a period of time that meets an acceptable clinical standard."

• Impaired Drivers: The house adopted the recommendations of a report outlining the physician’s legal and ethical obligations with respect to reporting physical and mental conditions that may impair a patient’s ability to drive. The report stated that "the physician’s role is to report medical conditions that would impair safe driving as dictated by his or her state’s mandatory reporting law and standards of medical practice."

The American Society of Addiction Medicine opposed adoption of the report’s recommendations, and at the AMA’s annual HOD meeting in June, opponents had succeeded in getting the matter referred for further consideration. The Section Council on Psychiatry also opposed the initial version of the report, but opinion on the revised version was equivocal. Concerns centered on placing physicians in the role of policemen and undermining the trust essential for effective psychotherapy, as well as the possibility that the report could be invoked to hold liable physicians who fail to report a patient who subsequently causes a traffic accident. The revised version of the report addressed some of these concerns, but many members of the Section Council continued to express misgivings.

The report stated that before reporting, the physician "must be able to identify and document physical or mental impairments that clearly relate to the ability to drive" and that "the driver must pose a clear risk to public safety." The report further states that "physicians should disclose and explain to their patients this responsibility to report."

The house also adopted a related resolution urging the AMA to "study diversion programs for impaired drivers with treatable conditions, including their impact on physician liability."

• Discriminatory Group Insurance: The house voted to refer to the AMA Board of Trustees a resolution asking the AMA to review group insurance products available to AMA members to ensure nondiscrimination against members with mental illness. Currently, the AMA-sponsored disability insurance for members limits benefits if the enrollee is disabled due to mental, nervous, or emotional disorders. APA has offered to work with the AMA in locating nondiscriminatory insurance for members.

• School Violence: The house adopted a recommendation in a report on school violence asking that the AMA "collaborate with the U.S. Surgeon General on the development of a comprehensive report on youth violence prevention, which should include such issues as bullying, racial prejudice, discrimination based on sexual orientation, and similar behaviors and attitudes."

Reports and resolutions from the AMA meeting are available on the Web at <www.ama-assn.org>.