 |
 |
|
|
January 15, 1999
A variety of actions germane to psychiatry was initiated by nonpsychiatric delegations to the AMA House of Delegates (HOD) during the HOD's meeting last month in Honolulu.
The contentious issue of how "medical necessity" should be defined, which has increasingly impacted the practice of psychiatry under managed care, was the subject of a resolution adopted by the HOD. It was introduced by the Oklahoma delegation.
The resolution from the Reference Committee on Medical Practice and Facilities accepted the recommendations of the AMA Council on Medical Service regarding definitions of "screening" and "medical necessity."
The resolution asked the AMA to adopt the following definition of medical necessity: "Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease 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." The resolution further asked that the AMA incorporate the above definition in its "Model Managed Care Services Agreement" and specify that "usage of the term 'medical necessity' must be consistent between the medical profession and the insurance industry. Carrier denials for noncovered services should state so explicitly and not confound this with a determination of lack of 'medical necessity.' "
Testimony on the issue revealed a consensus that having the AMA advance a definition of medical necessity was necessary to challenge effectively definitions by the federal Health Care Financing Administration and the insurance industry.
The HOD adopted a resolution affirming the importance of educating physicians about the role of family caregivers, including those providing care for mentally ill relatives. The resolution from the Reference Committee on Education was introduced by the Pennsylvania delegation.
It asked that the AMA "(1) encourage medical schools and residency programs to prepare physicians to assess and manage caregiver stress and burden; (2) continue to support health policies that facilitate and encourage health care in the home; (3) reaffirm support for reimbursement for physician time spent in educating and counseling caregivers and/or home care personnel involved in patient care; and (4) support research that identifies the types of education, support services, and professional caregiver roles needed to enhance the activities and reduce the burden of family caregivers, including caregivers of patients with dementia, addiction, and other chronic mental disorders."
The Young Physicians Section played a key role in introducing resolutions on scope of practice and reporting impaired drivers that were adopted or referred by the HOD.
The Reference Committee on Medical Education backed a resolution opposing the "autonomous practice of medicine by nonphysicians." The resolution touched on nonphysician medical practice in areas including nursing, psychology, and optometry. It asked the AMA to "continue to actively oppose legislation allowing nonphysicians to engage in the practice of medicine without physician (M.D., D.O.) training or appropriate physician supervision" and also asked the AMA to "continue to encourage state medical societies to oppose state legislation allowing nonphysician groups to engage in the practice of medicine without physician training or appropriate physician supervision."
The HOD referred back to the AMA Council on Ethical and Judicial Affairs (CEJA) the report on the conflict between public safety and confidentiality when physicians deal with impaired drivers.
The report sparked debate, with psychiatrists from various delegations pointing out the potential legal perils that might be faced by physicians should the AMA support a resolution stating that physicians are obligated to report impaired drivers. The report focused on the "ethical obligations of physicians when faced with patients whose driving ability is impaired by physical and mental conditions." It addressed state reporting laws and the "fundamental conflict between the responsibility physicians have to individual patients and their responsibility to society."
CEJA made two controversial recommendations. One stated that "where clear evidence of substantial driving impairment implies a strong patient and public safety threat and where advice to discontinue [driving] is disregarded, physicians have an ethical duty to notify the Department of Motor Vehicles of the medical conditions impairing safe driving." Controversy also ensued following the recommendation that stated "where an impaired driver continues to drive despite license removal after reporting, the physician's responsibility to intervene further includes involving the patient's family and reporting to authorities."
Most of the testimony surrounding the report focused on its shortcomings. The most frequently heard concern was that approval of the report by the AMA could ultimately lead to physicians being held legally liable either for failing to report an impaired driver or, conversely, for breaching patient confidentiality. Similar concerns were expressed by the AMA Section Council on Psychiatry, which focused on confidentiality issues.
Those supporting the report testified that the precedent for reporting impaired drivers was already established in past CEJA opinions that outline the physician's reporting responsibility.
A controversial resolution supporting the study of heroin as an addiction maintenance drug, introduced by the Medical Student Section, was not adopted. The HOD rejected the resolution from the Reference Committee on Science and Technology, which asked that the AMA "support research into the therapeutic use of heroin as a Schedule I drug in the context of addiction treatment, for those patients for whom other standard methods have been tried and have failed."
"Testimony was vigorous both for and against this resolution," the committee report notes. The Medical Student Section recounted the promising findings in European trials for controlled administration of heroin to treat addiction and argued that science, not politics, should be the final arbiter.
In two separate but related measures the HOD acted to affirm the AMA's opposition to physician-assisted suicide, but referred for further review a measure urging the AMA to lobby for easier prescribing of narcotics for the seriously ill.
The Reference Committee on Amendments to Constitution and Bylaws reviewed a resolution introduced by Hawaii delegate Calvin Kam, M.D., and adopted by the HOD.
It asked that the "AMA strongly oppose any bill to legalize physician-assisted suicide or euthanasia, as these practices are fundamentally inconsistent with the physician's role as healer."
A resolution from the Reference Committee on Science and Technology, which urged the AMA to lobby federal and state authorities to liberalize regulations pertaining to the prescribing of narcotics to the terminally ill, was referred to the AMA Board of Trustees for further review.
This resolution, titled "Expediting Pain Control for Terminal Patients," observed that "the current public interest in physician-assisted suicide is driven in part by the public's impression that terminal pain is common and poorly controlled. . . " and that the current array of federal and state laws governing outpatient prescriptions for narcotics are "cumbersome, complex, and in some instances contradictory, deterring adequate prescribing. . . ." This results in bureaucratic delays in dispensing medication to the terminally ill, causing needless suffering, the resolution said.
Testimony in the reference committee was divided, with those opposed focusing on the risks of drug diversion and those in favor focusing on the physician's primary responsibility for alleviating suffering, the committee report said. Many who spoke encouraged linking this resolution to the AMA's end-of-life-care project.
The resolution asked the AMA "to lobby Congress and drug enforcement agencies to permit the prescription of Schedule II medications by fax and electronic data transmission."
At the recommendation of the Reference Committee on Medical Service, the HOD referred to the AMA Board of Trustees a resolution urging the AMA to work for "affordable health care insurance for adults with congenital and/or childhood disease."
This resolution called for the AMA "in collaboration with other state and national medical societies and other interested parties, and in the absence of universal health care insurance coverage, to work to pursue an appropriate mechanism for ensuring affordable health care insurance coverage for adults with congenital and/or childhood disease."
The reference committee report noted that most testimony dealt with suggested wording changes. "Witnesses also noted that the resolution should be clarified to address childhood-onset disease as well as disorders, and include psychiatric and neuropsychiatric disorders as well as addiction," the committee report said.