March 5, 1999

As the first two states-Massachusetts and New Jersey-begin to offer physicians the AMA's new national accreditation program, an APA task force is continuing to evaluate each element of the project and the extent to which APA should participate in the program's development and implementation.

Known as the American Medical Accreditation Program (AMAP), the initiative is envisioned to be a tool for comparing the performance of individual physicians "against national standards, criteria, and peer performance."

The AMA has been careful to assure physicians and specialty societies that the AMAP is not designed to replace or supplant specialty board certification, such as that offered by the American Board of Psychiatry and Neurology, but to establish a "national benchmark" for assessing "physician quality." The program is intended, the AMA explains, to "define, demonstrate, and document quality physician care."

The program will evaluate how well physicians' performance and practices measure up against their peers in five areas.

• Credentials, which covers type of licensure, any DEA license restrictions, and disciplinary actions.



• Personal qualifications, which will include data on ethical behavior, CME participation, peer reviews, and a performance self-assessment.



• Environment of care, which assesses office operations and records through a site visit by AMAP contractors.



• Clinical performance, which will employ standardized measures of the patient care process and provide feedback to physicians.



• Patient care results, which will involve instruments to assess clinical outcomes and patient satisfaction.

Criteria to be evaluated in the last two program segments have not yet been finalized, but will address factors such as whether the physician orders appropriate laboratory tests, makes diagnoses that are consistent with evaluation findings, develops treatment plans that are consistent with those diagnoses, either under- or overutilizes consultants, offers preventive and screening services, and does not use diagnostic and therapeutic procedures that put patients at undue risk.

AMAP officials told medical specialty societies in October that while its staff will specify the criteria for a performance-measurement system and "identify and define core sets of performance measures" to assess these two program segments, the program will rely on the specialty societies "to develop, test, and define" these performance measures. APA and other specialty societies will have to use their own funds to conduct this part of the project. Although participation in the AMAP is voluntary, the AMA hopes that health plans, hospitals, and managed care organizations will view this national accreditation option as a way to avoid duplicative systems they now use for evaluating physicians' credentials and responding to increasing demands that care be of the highest quality.

APA is generally supportive of the AMA's new venture, but it is carefully evaluating each step and segment of the AMAP program to assess its potential impact on APA members.

APA Task Force Review

The mission of the APA task force is to keep decision makers up to date on the AMAP's continuing development and explore areas that could be problems for psychiatrists or their patients.

The task force is also charged with making recommendations on the extent to which APA should involve itself in the program, particularly in development of the benchmarks that will be used to measure criteria for the clinical performance and patient outcome segments. "If APA signs onto the program, it is committing its resources" to developing these measures in a format that will serve the needs of the accreditation program, said task force chair Sara Charles, M.D.

One unsettled issue the task force is currently evaluating is the proposal from the AMAP governing body to make certification by a board of the American Board of Medical Specialties (ABMS), such as the ABPN, a prerequisite for AMAP certification by 2005. Being board certified would confer additional points toward gaining AMAP certification.

Charles explained that unlike several other specialty organizations, primarily surgical ones, APA does not require board certification as a membership prerequisite, though it has always encouraged it. Yet if APA endorses the AMAP, and that program mandates board certification before it will accredit physicians, APA will be in the awkward position of backing a program that requires board certification while it does not insist on this same credential for membership, Charles noted.

There is also concern among those evaluating the AMAP about APA's endorsing a program that requires board certification when approximately 28 percent of APA members are not board certified, Charles said.

APA will also have to determine whether psychiatrists' practices could be affected depending on whether they choose to seek or forego AMAP certification. If the AMAP catches on but does not mandate board certification, the public may view these as two equally important benchmarks, and board certification could become devalued, an outcome APA would look on as undesirable. For this reason, Charles noted, the task force generally supports the concept of making board certification an AMAP requirement.

Solo Practitioner Concerns

Further exploration of the AMAP segment that deals with the "environment of care" is also on the task force's agenda. Task force members raised the issue with the Board of Trustees at its December meeting of whether special concerns of psychiatrists in solo practice or working in jails or prisons will be met by the proposed framework. The pertinent issues include the ability to meet preset standards for record keeping, staff performance, and the condition of and equipment available in a physician's office. The AMAP plans to evaluate these and other criteria as part of on-site reviews conducted by its contractors.

The APA Trustees decided that these environment-of-care standards "must make clear differentiations for types of practice, such that requirements suit the type of treatment being provided and ensure that good clinicians are able to gain accreditation regardless of the setting in which they practice." Psychiatrists cannot, for example, routinely be held to the same infection control requirements in their offices as other physicians, Charles said, nor should they be expected to have a staff member trained in CPR on duty during office hours.

The APA task force is also exploring a specialty societies' initiative that requires the AMA to turn the AMAP into a separate entity. The APA Board of Trustees voted at its December meeting to have the task force continue to "investigate the advisability" of having the AMAP operate as an entity distinct from the AMA and whether to make such independence a requirement of APA's full support of the project.

The Board also endorsed the task force's suggestion that "APA continue to involve itself in discussions with the AMAP, suggesting improvements to program standards and activities that are important to psychiatrists, but to refrain from making any commitments for future participation" until APA's concerns are adequately resolved.

The future of the AMAP is by no means assured, Charles said. "Its success is predicated on the assumption that managed care entities will require AMAP accreditation for participation on provider panels. These companies have been slow to join and need to see a clear advantage before they adopt the AMAP requirement."

The AMAP's Web site address is www.ama-assn.org/med-sci/amapsite/index.htm.