March 19, 1999

By James H. Maier, M.D.

As APA sharpens its focus on ways to improve communication among its district branches, its leaders, and the central office, Maine's experience of the past year offers some encouraging success stories. APA's support and legal muscle have been quickly mobilized in response to several pressing and distressing concerns from our small state district branch of only 160 members.

Some months ago, Green Spring (a regional managed care Goliath) began to exasperate local clinicians with the introduction of an obsessively detailed, six-page, outpatient treatment report form. Green Spring reviewers were requesting far more information than we or our patients were comfortable disclosing, and a series of critical media stories and letters to the editor began a counterattack.

A related but even worse assault on patient confidentiality took the form of threatened site visits to the offices of participating psychiatrists-Green Spring reviewers demanded access to three complete patient records and rationalized this intrusion by saying it was needed to satisfy NCQA requirements (Psychiatric News, August 7, 1998).

APA's Managed Care and Litigation Fund committees were alerted by urgent e-mail from southern Maine psychiatrist Jerry Collins and others. A threatened lawsuit by APA now puts teeth to an earlier resolution of the Maine Psychiatric Association (MPA) Executive Council asking Green Spring to delay implementation of measures that we believed would be misleading to patients and violate community standards of practice. David calls for reinforcements; Goliath blinks, as APA lawyers stand "on the courthouse steps" ready to file suit if Green Spring tries to proceed.

More recently, Maine psychiatrists confirmed what many of us had suspected: that local pharmacists were furnishing or selling to pharmaceutical companies and their representatives specific data on our prescribing patterns. Once again a series of e-mails brought this ethically questionable practice to the attention of MPA members to mobilize them to protest to appropriate state officials and APA leadership. We anticipate this issue will resonate with concerns of our colleagues at all levels of APA, and we are again confident that APA guidance and support will back up any efforts by the Maine district branch to expose and debate this issue.

Two additional issues of concern to Maine psychiatrist Richard Fortier, M.D., the MPA representative to the APA Assembly, resulted in regionally supported Assembly action papers, which were passed enthusiastically at the Assembly's November meeting.

When a managed care company refused to approve comprehensive integrated treatment rather than simple medication management for one of his patients, Dr. Fortier was told that it was "company policy" not to authorize payment for psychotherapy by psychiatrists. Fortier then complained to the company, the parent insurer, and the Maine Bureau of Insurance. In response, the company denied the existence of such a policy, but suggested the practice was an "industry standard." Although this particular denial was later overturned, it led directly to a national-level APA initiative on this crucial issue. APA's Division of Government Relations will be providing help to other district branches whose members are appealing denials to state attorneys general, insurance bureaus, and so on.

A second action paper drafted by Dr. Fortier has galvanized APA to develop and publicize a forceful position insisting on parity in employer-sponsored disability programs. While courts at various levels continue to deliberate about whether arbitrary two-year caps on psychiatric illness and other forms of discrimination against our patients violate the Americans With Disabilities Act (ADA) (Psychiatric News, April 4, 1997; March 20, 1998), this call to action arising from Maine is challenging APA to act as the "conscience and voice of American psychiatry." This language in the vision and mission statement was in fact developed by a Maine focus group with the help of early career psychiatrists at an Assembly reception and is consistent with the state motto "Dirigo" (I lead).

Taking a longer view of the DB/APA connection over a decade, Maine has enjoyed growing success at placing members in positions of responsibility in APA governance and on committees working on behalf of our patients. From a time when only one or two Maine psychiatrists served in influential positions within APA, some eight or nine MPA members hold or recently held positions on the Membership, Ethics, and Assembly Executive committees; Council on Aging; Consortium on Psychotherapy; and Joint Commission on Public Affairs.

We welcome with enthusiasm the trend of our members-in-training and early career psychiatrists' becoming more active at the Area Council and national levels.

Our small state district branch is grateful for repeated visits from APA presidents Eist, Sacks, and most recently Muņoz at a "best ever" Area Council meeting in Ogunquit. These visits by a new generation of activist, circuit-riding APA presidents help our members to feel connected to the national organization. Even more significant has been APA's quick responsiveness to issues arising locally. E-mail and list serves are playing a huge role in bringing district branches and APA leaders closer together, and the new energy and imagination in Psychiatric News' reporting of district branch issues will also help to forge stronger ties.

We encourage other district branches to share their successes in this vital process.

Dr. Maier is in private practice in Portland, Maine, a deputy representative to the APA Assembly, and Area 1 representative to the Joint Commission on Public Affairs.