Issues

Maintenance of Certification (MOC): Most psychiatrists agree that board certification by the American Board of Psychiatry and Neurology is a worthwhile credential. The transition from lifetime to time-limited certification was met with limited resistance from diplomates. Once the ABPN rolled out requirements for Maintenance of Certification, phased in over several years in a complicated way, resistance exploded. In particular the requirement for Performance in Practice, with surveys of patients, peer comments, development of plans for improvement, and re-surveys to determine progress, struck most as needlessly complex, cumbersome, and make-work, as well as needlessly costly. The need for MOC, with all its components, was presented by the ABPN as a requirement of the American Board of Medical Specialties (ABMS) with little ability for a member board to modify. Different specialties have had different responses to the process, but there has been enough backlash that the ABMS has fostered the creation of a Vision Initiative to make recommendations for changes to the system. The draft report, with options for comment, can be found at   https://visioninitiative.org/commission/draft-report/  

My concerns about the process come from the old saw about the tendency of power to corrupt. Unfortunately, both ABMS and ABPN are monopolies, and so have absolute power over credentialing. They have been benign for much of their existence, but seem less so of late. Internal pressures, reaction from diplomates, and APA lobbying have brought the cost of the exams down, and led to a pilot project less reliant on the secure exam, and more liberal PIP modules. APA must continue the pressure, as well as consider how best to deal with the monopoly aspects.

Scope of Practice: The push for prescriptive authority by non-physicians has been relentless over the past several years, and is one of the reasons I first became involved in the Pennsylvania Medical Society and the AMA. New Mexico authorized psychologist prescribing only after the medical society there dropped its opposition. It is clear that without our medical colleagues our protests about the inappropriateness of such scope expansion, would not win. What APA and the district branches have faced is the question of scope by other practitioners, such as physician assistants and certified registered nurse practitioners, who have prescriptive authority. Most health care systems embrace these “mid-levels” (not a term they like) as ways to extend the reach of physicians (“physician extenders” is even less popular.) These groups have argued that they provide care that is necessary and will never be met by the limited supply of physicians, let alone scarce psychiatrists. Is there a role for psychologists to join this group, with some degree of additional training on a par with what physician assistants have, and with similar supervisory or referral requirements? Can APA even take a position in opposition to a class of professionals, without raising concerns of unreasonable restraint of trade? It is clear that we have to carefully consider our position and strategies, especially since as a profession we are committed to ensuring access to psychiatric care for those in need.

Phantom networks: Nearly twenty years ago, the Pennsylvania Psychiatric Society filed suit against Magellan on behalf of our patients, alleging unfair practices such as this. Our suit went all the way to the US Supreme Court, with our standing to bring suit on patients’ behalf being challenged. The Court refused to hear the case, letting the lower court ruling in our favor stand, but we could not carry on endlessly, as Magellan was prepared to do, so we settled for some improvements in business practice. In this fight we received substantial support from APA and the AMA Litigation Center, and established the right of physician organizations to bring such suits. APA is continuing the work of demonstrating the inadequacy of psychiatric care provided in managed care plans by filing suits alleging violations of parity, and seeking information about the actual number of claims filed by psychiatrists which plans claim to have. This work should be done by states’ attorneys general or insurance commissioners, but we have had little success in getting this moving.

Increasing suicide rates: A 30% increase in rates of suicide over the past 12 years in the US is an alarming public health problem. The public has a right to expect our profession to provide a strategy to understand and address the problem. Just as the American Academy of Pediatrics is the trusted source for information on the health of children, we need to be the source to frame the questions and develop interventions, in collaboration with our partner organizations.

Ligature risk mitigation: The decision by CMS to take an absolutist approach to making psychiatric units safer by requiring expensive retro-fitting and staff increases, has led to the closure of many psychiatric hospital beds. The APA has been collecting data concerning the unequal application of the rules in different parts of the country, as well as the unintended (but real) consequences of diminished access to inpatient hospital beds. It has become an almost ideological fight, as well as becoming an interesting blame game, with CMS and the Joint blaming each other for the requirements. Certainly one hospital suicide by hanging prevented is worth a lot, but it becomes a different equation when patients are unable to receive care and die by suicide in the community.

Workforce: There are far too few psychiatrists to begin to serve those in need, even in the areas of the country where our density is fairly good, let alone in rural America and the rest of the world. APA’s efforts toward collaborative/integrated care, with partnerships between psychiatrists and primary care physicians, is a model which continues to expand our reach, though slowly. Advances in tele-psychiatry, particularly concerning the ability to bill for services, are another front which can help address the geo-access problem. The increasing popularity of psychiatry as a specialty, with increasing numbers of applications to our residencies year over year, is a heartening development. Increasing residency slots is happening, again slowly.