Collaborating With the AMA: Issues Important to Psychiatry

By Harold I. Eist, M.D.
APA President

As part of our reaching-out campaign over the past year, we have enhanced our connections to the AMA and deepened our involvement with it. We have encouraged our members to join the AMA--to both strengthen the AMA and expand our influence within the house of medicine. Dr. John Seward, executive vice president of the AMA, Dr. Mel Sabshin, our medical director, Dr. Stormy Johnson, AMA president, and I have written two letters at AMA expense to all 42,500 APA members encouraging them to join the AMA. Currently, slightly more than 10,000 APA members belong to the AMA.

The AMA's House of Delegates was recently reorganized in response to the AMA's recognition that specialty organizations require and deserve wider representation if they are to contribute more fully to the organization. Clearly, this was a forward-looking action designed to bring disparate medical organizations together to increase our impact and effectiveness in the face of corporate attacks on our medical institutions.

APA's delegation has now doubled, from one to two members under the new configuration, and we recently came close to getting a third delegate, missing by only three hundred votes (more details on this will appear in the next issue of Psychiatric News). The more of you who join, the larger our delegation will become. A larger delegation can only benefit our proactivity and the likelihood of success for our initiatives.

The AMA gave us strong support during the parity battles. Dr. Lonnie Bristow, immediate past president of the AMA, stated, "The AMA will not rest until we have full parity for the mentally ill." The AMA is working closely with us as we continue our parity struggles, but we do need to maintain the intensity of our involvement to retain its strong support.

The AMA has joined with us in our struggle to preserve confidentiality as we have labored to correct the serious deficiencies of the Bennett bill, or the Medical Privacy Act of 1996. The bill has undergone significant revisions on the basis of joint action, by ourselves and others, but we need to keep our shoulders to the wheel to assure the legislation will truly protect the privacy of our citizens and assure that the doctor/patient relationship will not be pirated for information that will result in a multibillion dollar windfall for the computer and information-for-sale industry. These groups are lobbying Congress to do what will be in their interest, shrouding their actions in a patina of a greater good for the public.

We also need the AMA's continuing assistance to correct the deficiencies of the "administrative simplification" aspects of the Kassebaum-Kennedy legislation, which retain many of the breaches of confidentiality we have largely blocked in the Bennett bill.

We held a small board-to-board meeting with the AMA in Palm Desert, Calif., at its annual Legislative Institute in January, at which we collegially discussed mutual concerns, shared interests, and some differences. Our staff also met with the AMA's staff to discuss our shared legislative interests. We are deeply grateful for the AMA's assistance with an APA membership insurance problem; without that assistance, solving the problem would have been far more difficult. Attending this meeting were both our current medical director, Dr. Sabshin, and our medical director-designate, Dr. Steve Mirin. Just as we were impressed by the caliber of the AMA leadership, AMA leaders were impressed by the quality and effectiveness of our leadership.

Dr. Percy Wooten, president-elect of the AMA, struck by our positive involvement with our membership and the clear energization of American psychiatry, asked me about my toll-free 800 telephone line (see box on page 3) and how it worked, indicating he planned to install one during his presidency.

We have some continuing differences with the AMA about its American Medical Accreditation Program (AMAP) for credentialing physicians. The plan will be open to both AMA members and nonmembers, with nonmembers paying a higher fee for the service. AMAP, which our Managed Care Committee discussed extensively, as have other APA components, is designed to reduce the time and expense of credentialing by managed care organizations (MCO's), hospitals, and other organizations. Many members are on a number of panels and hospital staffs and would find one-stop credentialing helpful in both time and money saved.

However, we have enduring questions about this program and therefore are organizing an APA-AMA conference about it. Dr. Joseph English, our AMA delegate, will host the conference, at which APA leaders and AMA representatives will be able to discuss the pros and cons of the AMAP from a psychiatric perspective.

We have confidentiality concerns related to record reviews and office audits. The AMA knows of the importance of these issues to psychiatry because of our work on the Bennett bill and our state confidentiality initiatives. We are concerned about the impact of this credentialing on the doctor/patient relationship if patients learn that any third party, even the AMA or APA, will be looking at deeply private information. We need to work out more fully the relationship between specialty boards and state licensing boards, which already credential physicians, and AMA credentialing. Will there be confusion between board certification and credentialing? Will credentialing be seen as a super-certification? If so, will it water down the significance of board certification? Will it be a substitute for board certification? Will it lend legitimacy to the managed care industry, which is egregiously attacking our field by, for instance, including such organizations as NCQA on the AMAP Board? NCQA's psychiatric criteria are woefully inadequate and, in fact, as they currently stand, are hazardous to the health of those suffering from mental illness. There is a risk in doing credentialing for MCO's, of inadvertently supporting their use of the process to delay or block access to panels. Keeping people waiting, requiring them to make minor corrections, having them refile, and then--after all the nit-picking--noting that the application is out of date are totalitarian techniques for forcing conformity and compliance.

The physician profiling part of the program appears particularly problematic. The science and technology assessing the complexity of the patients being treated by a given physician and tying that into practice patterns and success rates is not currently available. The nuances of these situations are profound and difficult to quantify. Physician profiling is primitive and, where it has been done, has caused problems for both physicians and the public. In Pennsylvania, for example, where cardiac surgeons are being profiled according to mortality rates of their patients, it is difficult to get cardiac surgeons to operate on the seriously ill, high-risk patients. Nobody wants to go to a doctor with a high mortality rate. Will profiling deteriorate into "economic credentialing" whereby those who provide less service are seen as more effective or those who provide more service are decertified? Some of the Medicare profiling done on psychoanalysts has been threatening and a clear attempt to get them to reduce the amount of psychotherapy they provide, without consideration of patient diagnosis, need, or physician practice pattern and subspecialty.

The patient satisfaction survey aspects are complex and problematic in different ways for all specialties but, in the case of caring for individuals suffering from psychoses, involuntary commitment may lead to angry criticism of the physician even though, at a later time, the patient, and his or her family, may express gratitude.

Who will develop these surveys? Will they mimic the inadequate, self-serving surveys of the MCO's? In the clinics I ran for the poor and near poor, I sent surveys to every patient who left the organization. I accumulated approximately 25,000 of these over the years. We had a 15 percent response rate, 80 percent favorable and 20 percent unfavorable. I had the sense that it was primarily the satisfied or highly satisfied and the dissatisfied or seriously dissatisfied who responded. Certainly, these simple distinctions are crude. For those who lack the grudge of involuntary commitment, what part did positive and/or negative transference play? Was forgiveness a factor in responses? Or competitiveness? Or any of a hundred other issues that could influence response patterns?

Will the credentialing process recognize the unique elements within each specialty area, particularly psychiatry? The AMA, we know, is committed to working with us and other specialties in this area, but this must be explained and clarified.

We are pledged to continue working with the AMA. At the joint AMAP conference, I will carefully and thoughtfully examine, with the AMA's representatives, areas of common ground and shared interest, toward the end of not only easing the credentialing burden of our members but also maintaining the high-quality-care characteristic of American psychiatry and American medicine.

(Psychiatric News, March 7, 1997)