Much to the chagrin of many psychiatrists and a sizable number of their patients, carveout companies often determine how much mental health care patients can receive and sometimes whether individuals are eligible for any care at all. At its October meeting in Philadelphia, APA’s Board of Trustees approved a statement that puts the Association on record as "strongly opposed to discriminatory carveouts."

The call for APA to take a formal stand on the effect that carveouts have had on psychiatric care arose in the Assembly, which in May passed a statement condemning this managed care practice of separating mental health care from all other types of care as harmful to patients. The Assembly paper stated that carveouts stigmatize mental illness, isolate psychiatrists, and interfere with the ability to coordinate physical and mental health care.

The Assembly’s proposed statement went to the Board in July, but the Trustees wanted more input from relevant APA components, particularly the Committee on Universal Access to Health Care and the Council on Psychiatric Services.

The statement that came out of the components’ review and went to the Board last month changed the Assembly’s blanket condemnation of carveouts to a condemnation of "discriminatory" carveouts.

The reason for this change was the argument by several reviewers that not all carveouts are deleterious to patients. In the public sector, carveouts have provided a steady funding stream and increased access to treatment for many poor people who would have otherwise gone without psychiatric care.

While this limited upside does exist, the statement points out, discriminatory carveouts are legion and should rightly be condemned. The statement describes discriminatory carveouts as those that interfere with the doctor-patient relationship, limit access to specialty care, impose extreme administrative burdens, provide financial incentives to reduce care, and reinforce discrimination against patients with mental illness.

In other actions at its October meeting, the Board voted to take these actions:

• Referred the results on an all-member questionnaire on APA election guidelines to the Elections Committee "to guide its decisions" when the committee reviews election procedures after the 2001 balloting is complete.

• Ratified an executive action authorizing the use of Web-based voting in addition to paper ballots in the 2001 APA election.

• Expanded the charge of the Committee of Hispanic Psychiatrists. This will allow the committee to "foster involvement of all Hispanic psychiatrists in APA academic/scientific activities to increase awareness, sensitivity, and responsiveness of colleagues to cross-cultural issues," encourage Hispanic psychiatrists to become active in APA components and on the Board and Assembly, enhance communication with committees representing other minority groups, and "keep abreast of legislative actions that affect Hispanic populations."

• Authorized the Committee on Women to seek outside funding for the production and distribution of "pocket mentors." These booklets would be given free to all psychiatry residents and describe issues ranging from the clinical to the personal that are critical to negotiating psychiatry training successfully. Assembly Speaker-elect Nada Stotland, M.D., explained that the booklets are basically "survival guides" for residents. The Association of Women Surgeons originated the concept, she noted.

• Approved a five-year extension of the Commission on Psychotherapy by Psychiatrists.

• Deferred to its December meeting a proposal from the Committee on APA/Business Relationships to join two organizations representing the health-insurance concerns of major corporations—the Washington Business Group on Health (WBGH) and the Health Enhancement Research Organization (HERO). Trustees wanted more time to weigh the WBGH’s support of managed care and more information about HERO, which uses grant money to conduct studies of health systems. The committee urged that APA join both groups as a way to influence business decision makers, the leading purchasers of health insurance in this country.

• Authorized a request from the New York State Psychiatric Association for $20,000 to educate state legislators on "scope-of-practice issues," particularly granting psychologists prescribing privileges.

• Approved a change in APA’s "Procedures for Handling Complaints of Unethical Conduct" that eliminates one of the possible sanctions for ethics violations, that of "admonishment." The three remaining sanctions are reprimand, suspension, and expulsion. It also allows district branch ethics committees the option of concluding a case "without a finding" when minor infractions have been found to occur. It was thought that this option is a way to "put greater emphasis on education and rehabilitation" without landing a case in the legal realm—a step that is sometimes taken to prevent information from being reported to the National Practitioner Data Bank.

• Endorsed a statement from the AMA that defines "medical necessity" as "services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner that is (1) in accordance with generally accepted standards of medical practice; (2) clinically appropriate in terms of type, frequency, extent, site, and duration; and (3) not primarily for the convenience of the patient, physician, or other health care provider."

• Backed a moratorium on capital punishment in the U.S. until a time when "jurisdictions seeking to reform the death penalty implement policies and procedures to assure that capital punishment, if used at all, is administered fairly and impartially in accord with the basic requirements of due process." The statement notes that psychiatrists, "due to their involvement in and familiarity with the criminal justice system, have become aware of the weaknesses and deficiencies of the current capital sentencing process," including the way in which the process affects mentally ill and developmentally disabled persons.

• Approved procedural guidelines by which APA will consider requests from district branches and state societies for funds from APA’s Commission on Public Policy, Litigation, and Advocacy. The guidelines include consideration of the national significance of a proposed legal or other activity, a proposed activity’s relevance to APA’s strategic goals and priorities, and how involved the district branch or state society will be in addressing the issue. Guidelines also explain how the commission will evaluate requests for funds to support litigation, including considerations of cost, likelihood of success, precedential value, and availability of other options.