|ARIZONA PSYCHIATRIC SOCIETY NEWSLETTER||
Following the President's Message, this edition offers all of us the opportunity to congratulate our newly appointed APA Distinguished Fellows and Fellows. In our first article, Dr. Espinoza, a Phoenix psychiatrist, shares his insights on evidence based psychiatry, his career experiences and his role as a patient advocate.
The next group of articles revolves around clinical practice. There is information on the successf of the APS to counter the psychologists' efforts to prescribe medications. Dr. Marwah succinctly brings us up-to-date on the billing code changes, while Ms. Groppenbacher from Johnson & Johnson Health Care Systems highlights health care issues in the post-election era. An Arizona perspective is presented on the controversial topics of gun control and solitary confinement.
Our last section is on community, national, and local reports. We are pleased that NAMI Arizona accepted our invitation to share their activities and perspectives on mental health. Through Dr. Bastani's diligence and hard work we have a detailed summary of the APA Assembly's many activities. A report by Drs. Amini and Koster on the member-in-training fall social event is followed by Dr. Taylor-Desir's thoughts on the APA's leadership initiative about early career psychiatrists.
We close with reminders about CME programs and the importance of joining the APA.
On behalf of the Newsletter Committee and the APS, season's greetings, and we wish all of you a healthy and happy 2013.
By Tariq M. Ghafoor, MD, President, Arizona Psychiatric Society
Colleagues and Friends . . . Hope you and yours are enjoying the holiday season in good health and peace. Speaking on behalf of the Arizona Psychiatric Society, we're also doing quite well actually. It's been very busy for many of us during these last several weeks; high activity on several fronts. First and foremost, I'd like to sincerely thank those members of our Legislative & Executive Committees who have devoted their time and substantial energy to help us in our fight against the Psychologists' Application for Prescription Privileges. In this regard, I'd like to extend special thanks to our Lobbyist, Mr. Joseph Abate, as well as ad-hoc volunteers such as Dr. Jason Caplan, who did an extraordinary job in helping us with the cause. In recent days, along with Mr. Abate, some of these members met with several key lawmakers to educate and convince them that the attempt by psychologists to gain prescription privileges via legislative process is ill-conceived and ill-timed. Those efforts have prevailed, with the reported withdrawal of the 2012 RxP as detailed below. I do believe, however, that this issue is unfortunately here to stay, and we must stay ready to effectively deal with it both now and in years to come. On another front, our Education Committee finalized the agenda for our Annual Meeting next April (Saturday, April 13, 2013), which will be held at the Ritz Carlton in Phoenix; final touches are being given to the speaker list and specific agenda items. We are confident that in line with our past gatherings, this will be an exciting and wonderful meeting. Here, I'd like to specially thank Dr. Ole Thienhaus of the University of Arizona College of Medicine in Tucson for his input and contributions for speaker selection and various other preparations for the meeting. It's a delight to have active participation from Southern Arizona in our Society's activities. To further this, I'm excited to announce that the Arizona Psychiatric Society is a collaborator on the University of Arizona 21st Annual Psychopharmacology Review Course, scheduled for February 18 to 22, 2013 at the Westin La Paloma in Tucson, Arizona, and the Society is sponsoring the Wednesday evening (February 20, 2013, 7:00 to 8:30 p.m.) dessert reception. We hope that you will come and visit us there. On a personal note, while you're reading this, I will be on my way to visit my home country, Pakistan, for the first time since I came here to the US, almost 30 years ago..!! I will be in touch upon my return....Wonderful Holidays and Happy New Year...!!
NEWEST DISTINGUISHED FELLOWS AND FELLOWS
The American Psychiatric Association has elected the following Arizona Psychiatric Society members to the status of Distinguished Fellow of the APA:
Carlos Carrera, MD, DFAPA
Michael Cleary, MD, DLFAPA
Mariam Cohen, MD, DLFAPA
Richard Gottlieb, MD, Psy.D, DFAPA
Gary Grove, MD, DFAPA
Elizabeth Kohlhepp, MD, DFAPA
Mary Catherine Nowlin, DO, DFAPA
These Society members will be honored at the APA Annual Meeting in May with a President's Reception and a Convocation of Distinguished Fellows.
In addition, the following members of the Arizona Psychiatric Society were approved for Fellow status by the APA, and these Fellows will be honored during the Convocation ceremony in May:
Mercedes Agudo, MD, FAPA
Jason Caplan, MD, FAPA
Steven Eickelberg, MD, FAPA
Deborah Fernandez-Turner, DO, FAPA
Allan Goldberg, DO, FAPA
Marcelle Leet, MD, FAPA
Dorothy Piekut, MD, FAPA
Christopher Wiegand, MD, FAPA
On behalf of the entire membership of the Arizona Psychiatric Society, we congratulate these newest Distinguished Fellows and Fellows of the APA on their distinguished careers and thank them for their continued support and membership in the APA and our Society. We would also like to recognize the extra efforts of the Dr. Jehangir (Jay) Bastani, Arizona Representative to the Assembly, as a champion of these deserved recognitions, and would also like to recognize and thank the many Distinguished Fellow members in the Society who provided letters of support to these worthy candidates.
APS: MEET FELLOW MEMBER - BRIAN ESPINOZA, MD
Brian Espinoza, MD attended the University of Michigan Medical School, graduating in 1990, followed by residency training at The University of Texas Southwestern Medical Center at Dallas. His first three years after residency were spent working in a group practice in Dallas, Texas, and later, a private practice in Clearwater, Florida. The following five years included an adventure in locum tenens, working in various practice settings from outpatient clinics to forensic state hospitals, ranging the four corners of the Mainland, in addition to Alaska and Hawaii. This led Dr. Espinoza to Phoenix, where he has spent the past ten years in a private, hospital-based practice, along with his wife of sixteen years, and their two children, ages eight, and twelve.
Areas of Interest include utilizing evidenced based medicine to achieve optimum results for patients, specializing in the assertive use of neuromodulation (Electroconvulsive Therapy and Vagus Nerve Stimulation) in medically refractory patients. He considers the highlight of his career, which is ongoing, to be encountering patients that have been labeled "Frequent Flyers" at local hospitals, and converting them to permanent outpatients using the above mentioned approaches.
Dr. Espinoza was attracted to psychiatry as it encompasses the interface between brain and behavior. His favorite part of the field is that the knowledge base is ever expanding, and, as a result, psychiatrists are becoming more integrated with, and respected by, our colleagues in other medical specialties.
Dr. Espinozaʼs advocacy for psychiatry includes membership in not only psychiatric associations, but also, their respective medical association counterparts, such as the American Medical Association, and Arizona Medical Association. Efforts include advocating directly for his patients, when insurers wrongly deny appropriate care.
Dr. Espinoza makes sure to serve as the Doctor of The Day at The Arizona State Legislature on an annual basis (a program maintained by the Arizona Medical Association for its members). This experience reveals the day to day details of how our political process works, and provides an opportunity to meet and speak with local representatives. He considers this a true honor, as physicians are the only profession to be invited to be represented every day the State Legislature is in session, and are appreciated by our elected representatives.
His suggestion for grassroots advocacy in psychiatry is to keep current on the ongoing developments in the field and find your passion in those emerging knowledge bases. Accordingly, our instincts will follow on how we can serve our patients, and our specialty.
Dr. Espinoza wishes to thank the hospital staff who support his endeavors of evidenced-based medicine and patient-first care, at Aurora Behavioral Health Hospitals, Banner Behavioral Health Hospital-Scottsdale, and St. Lukeʼs Medical and Behavioral Health Centers.
PRESCRIPTION AUTHORITY APPLICATION WITHDRAWN
As the President's Message detailed, and as our membership was previously advised, a new Sunrise Application by Psychologists Seeking Prescribing Privileges ("2012 RxP") was submitted on August 31, 2012. Since that time, many members of the APS Executive Council and Legislative Committee, working with APS Lobbyist Joseph Abate, and in concert with the Arizona Medical Association Lobbyist, the APA, Psychologists Opposed to Prescribing Privileges for Psychologists (POPPP), and the AMA, have researched issues, prepared position and educational materials, and participated in meetings with the stakeholders and with members of the Committee of Reference.
As a result of these combined efforts, the APS Lobbyist has just learned from House of Representatives staff that the psychologists' group has withdrawn its 2012 RxP. All members of the APS Legislative Committee participated in these efforts, but recognition is particularly due to the APS Lobbyist Joseph Abate and APS Legislative Committee members Tariq Ghafoor, Carol Olson, Gretchen Alexander, Jason Caplan, Elizabeth Kohlhepp, and Payam Sadr, who also made time to travel to the State Capitol to meet with legislators, and to Roland Segal and Robin Reesal who worked extensively on researching and preparing written materials.
As in the prior year, it is important to emphasize that the involvement of the influential Arizona Medical Association was crucial to our success, as the Arizona Psychological Association has a very effective advocacy program and a PAC which is a significant donor to Arizona legislators.
Although RxP 2012 has been reported as withdrawn for this session, the APS Lobbyist assures us that the issue is not likely to go away, and that our membership should continue to prepare to respond to future scope of practice issues. Your grassroots efforts, in maintaining positive relations with the legislative representatives in your area, attending fundraising and other political events, staying involved in APS, and communicating with legislators when issues arise can make all the difference. Thank you to all for their contributions and please continue to make that difference.
Sign-up to attend a political fundraiser where you can meet and speak personally to key members of the Legislature. Staying in contact with legislators, especially those who you know personally, is critical. Please contact the APS Lobbyist, Joe Abate, with any questions, at 602-380-8337.
CPT CODING UPDATE
By Gurjot K. Marwah, MD, APS Member
GOODBYE 90801, 90862, 90805 . . . As we look forward to the New Year, we have to get ready for big changes in CPT codes used for billing, which go into effect on January 1, 2013. As a psychiatrist, for the first time ever, we will be paid by the complexity of the work we do with our patients, not a flat fee. The APA's efforts are ready to bear fruit with the hope of improved reimbursements for all psychiatrists in the long run.
On November 18, 2012, I attended a day long conference in the windy city of Chicago, focused on the CPT changes. I have to candidly admit that the new codes appear complex and daunting at first look, especially for a psychiatrist like me who is not familiar with E/M (evaluation and management) Codes, and works exclusively in outpatient setting. I have a hunch that a lot of my colleagues might be sailing in the same boat as me.
Let's be clear. These changes will affect all psychiatrists. Here I am presenting an overview.
1. Psychiatric Diagnostic Evaluation 90801 has been deleted. Instead, psychiatrists will use diagnostic evaluation with medical services (90792). Psychiatrists have the option of using E/M codes (99XXX) in lieu of 90792. Refer to the cross-over chart included with this Newsletter, the listing of E/M codes most likely to be used for psychiatry, and the new CPT Manual, 2013 edition, which is currently available, for all details.
New Evaluation (Diagnostic Evaluation with Medical)
90792 or E/M Codes: 99201 - Straightforward Add-on Therapy:
99202 +90833 (16-37 minutes)
99203 - Moderate +90836 (38-52 minutes)
99204 +90838 (53+ minutes)
99205 - High
When psychotherapy is done during the same session, one of the new psychotherapy add-on codes (indicated by the + symbol) will be added. An add-on code is a code that can be used in conjunction with another primary code (E/M Code).
2. 90862 for Pharmacologic Management Eliminated. It is replaced with appropriate E/M codes (99211 through 99215) to report this service based on complexity (not amount of time spent). For a typical 90862, for which you currently spend 15 minutes, in the new E/M coding it may be 99213. A patient just needing a prescription refill might be 99212. A complex situation may require you to use 99214 with appropriate charting of key components of diagnosis and treatment.
This change will benefit Psychiatrists by permitting them to use an E/M that reflects the psychiatric and medical complexity of each patient. If psychotherapy is also done in the same session, it will billed as an add-on code based on time spent in doing psychotherapy.
Follow - Up (Med Checks) Therapy (Add-on to Med Checks)
99211 +90833 (16-37 minutes)
99212 +90836 (38-52 minutes)
99213 +90838 (52 or more)
3. 90785: A New Add-on Code for "Interactive Complexity." One single add-on code for interactive complexity (+ 90785) may be used when the patient encounter is made more complex by the need to involve people other than the patient. This code replaces all other interactive psychotherapy codes. It can be added on to initial evaluation codes like 90792, with psychotherapy codes, with non-family group psychotherapy code (90853) and with E/M Codes when used in conjunction with psychotherapy services. Please refer to the CPT Manual for specific guidelines for documentation and description of what constitutes an interactive complexity. Child psychiatrists will use this code more often.
4. 90839 - Psychotherapy for a Patient "in crisis" New Code. This code can be used when a practitioner performs an urgent assessment and history of a crisis patient and arranges disposition. To defuse this crisis, the practitioner might need to mobilize other resources. This code was developed at the behest of the National Association of Social Workers, hence likely to be used by social workers. It is expected that psychiatrists will generally use a higher level of E/M code when evaluating and providing care for a patient in severe crisis instead of 90839.
5. Use of E/M Codes Mandatory for All Psychiatry. When providing medical services (including medication management of our patients), psychiatrists will use different E/M codes listed in the new CPT Manual 2013 Edition. These codes are based on the following criteria:
1. Site of service (inpatient, outpatient, nursing facility);
2. Type of service (initial visit, consult, existing patient); and
3. Level of service (which can be determined in two ways - history, exam, and medical decision-making (documenting by the "elements") or time spent in counseling and coordination of care (documenting by "time").
6. Psychotherapy Codes Have Been Simplified. Psychotherapy codes will be based ONLY on time and can be used for psychotherapy done in ALL settings (hospital, outpatient, or nursing home). Be aware that counseling and psychotherapy are NOT the same. Discussing prognosis, risks and benefits of treatment options, reviewing importance of compliance, risk factor reduction, patient and family education is likely to fall under counseling.
To simplify, I recommend starting off and familiarizing yourself only with those codes that are relevant to YOUR work, starting by site (the location of your work).
The APA is contacting all major insurers to help transition into the new codes. It is likely that new individual contracts will need to be drawn in the near future and may take several months in 2013.
With All The New Changes Less Than A Month Away, What Can You Do To Prepare?
- Learn how to select and document E/M Codes (99XXX series) by accessing a FREE online CME introductory course on E/M coding for psychiatrists for APA members at the APA education websitethe APA education website.
- A wide array of educational materials focused on CPT coding changes, specifically live recorded webinars, have been developed by the APA and can be found on the APA website at the member-only APA web resources on CPT coding changes.
- Contact APA's coding staff with individual questions pertaining to your specific needs by e-mail to firstname.lastname@example.org or by calling the Practice Management Hotline at 1-888-343-4671.
- Purchase a 2013 edition of the AMA CPT Manual at the AMA online bookstore, wrap it in shiny, festive holiday wrapping paper, write a loving note to yourself, and put it under the Christmas tree. Believe me, it might be the most valuable gift you get this year!
POST-ELECTION HEALTH CARE STATUS
Contributed by Shannon M. Groppenbacher, Director Healthcare Policy and Advocacy, Johnson & Johnson Health Care Systems
November 6th elections -- presidential, congressional and gubernatorial -- will have an important impact on many parts of the U.S. economy including the health care industry. The elections set the broad path for implementation of the health care reform law (the Affordable Care Act) at both the state and federal levels, and they are likely to impact outcomes in the deficit reduction and tax policy areas.
The election results reinforce the current status quo in many regards. In addition to the reelection of President Barack Obama to a second term, the Senate remains in the hands of Democrats and the House remains in control of Republicans. The president will still face a divided Congress.
In the Senate, Democrats gained two seats, for a 55-45 majority. Senate Majority Leader Harry Reid (D-NV), Minority Leader Mitch McConnell (R-KY) and Senate Finance Committee Chairman Max Baucus (D-MT) all retained their leadership roles.
Republicans retained firm control of the House of Representatives, losing a number of seats, but maintaining a 233-194 majority with multiple races still to be decided. House and committee leadership are expected to essentially remain the same.
Affordable Care Act
The president's reelection essentially guarantees that the Affordable Care Act (ACA) will survive as originally envisioned by Congress and the president. Speaker John Boehner stated that the House will not be passing any additional bills to repeal the law in its entirety. However, it's possible that the Republican-controlled House will continue attempting to delay implementation of the act and all of its parts, and there may be efforts to disrupt the law as it is implemented in the states. While the president's first term will be remembered for the passage of the health reform law and the fact that the Supreme Court upheld it, in his second term he will have to fight for the law's implementation.
CMS recently released a number of regulations (e.g., essential health benefit rules) that will be the framework of the new law. While some governors and state legislatures will actively support implementation of the new law, others, notably the governors of Texas and Louisiana, are likely to continue expressing concerns and may elect to have their states not participate fully in the new law.
Fiscal Cliff and Deficit Reduction
The "fiscal cliff" represents the expiration of Bush-era tax cuts along with significant across-the-board spending cuts in the federal budget. These cuts to defense and domestic programs, are referred to as the "sequester." Mandated by the current Congress in 2011, they could total $800 billion in 2013. A Congressional Budget Office analysis projects the possibility of a second recession in 2013 if Congress does not address the fiscal cliff in some way before the end of the year, thereby stopping the sequester cuts from being implemented.
As part of addressing the fiscal cliff, Medicare physician payment rates could be reduced an additional 27 percent to match the sustainable growth rate (SGR), a formula for Medicare growth enacted in 1997. Such payment cuts could prompt an exodus of physician providers from Medicare. Congress has historically stepped in at the last moment to postpone any cuts to physician payments based on the SGR. Doing so this time would cost an additional $11 billion over the next year, further complicating debt-reduction efforts.
The key political leaders and the balance of political power remain unchanged by the 2012 U.S. elections. However, the pressures on health care from government continue to be intense.
GUN CONTROL AND SOLITARY CONFINEMENT UPDATES
Your Arizona Psychiatric Society presented information and recommendations In connection with Resolution 16-12: Gun Control, which was originated by the Pima County Medical Society and dealt with restriction of firearms from Arizona citizens found to meet Seriously Mentally Ill eligibility criteria, and which was referred by the Arizona Medical Association 2012 House of Delegates to its Public Health Committee.
The ArMA Public Health Committee moved to recommend to the ArMA House of Delegates that Resolution 16-12 as written be struck, that ArMA undertake an educational effort to inform Arizona physicians and citizens about Arizona commitment laws, that gun safety be approached as a public health issue, and that ArMA encourage appropriate study and public education. The ArMA Executive Committee has approved this new Resolution for presentation to the June 2013 ArMA House of Delegates.
APS President Tariq Ghafoor is participating in a Committee organized through the Arizona Foundation for Behavioral Health working to prepare legislation relating to the use of solitary confinement. Those efforts are ongoing, with the target of introducing legislation in late 2013.
UPDATE FROM NAMI ARIZONA
By Jim Dunn, M.Ed/C, CPRP, Executive Director/CEO
NAMI in Arizona underwent strategic restructuring earlier this year in partnership with the statewide Affiliate leadership emerging "better, stronger, faster" with a renewed sense of purpose and agreement on roles and responsibilities across the state.
The Arizona Affiliates agreed to "own" the "Grass Roots" education, operation, programming aspects of administering NAMI's many powerful signature programming and established the "Affiliate Council" as a means of communication and structure.
Thanks to this partnering, the NAMI Arizona state organization has been free to focus on Public Policy, Legislative/ Governmental Advocacy, Fundraising/Development, and carrying the United Arizona NAMI message across the State from one Affiliate to the next.
NAMI Arizona is now playing a significant leadership role in several statewide initiatives: The Arizona Justice Alliance, The Arizona Peer and Family Coalition; Mental Health American "Association of Associations" and the Future Directions Peer/Family Run Leadership Effort; along with being "at the table" and a valued contributor to many others including The Arizona Council of Human Service Providers, the Maricopa County Association of Providers, and The Arizona Department of Health Services/Division of Behavioral Health/Office of Individual and Family Affairs.
More on this partnering follows:
1. First and foremost, NAMI Arizona remains undivided and intensely loyal to the mission and purpose/sustainability of the Arizona Affiliates with the goal to offer ever-increasing cost-free programming to individuals and families across the state and nurturing new and powerful opportunities to grow new affiliates and partnerships. This support is shown through ...
a. Sharing office space for affiliate board meetings, trainings, educational, and volunteer program activity.
b. Hosting affiliate council meetings and teleconference.
c. Fund-raising activity/income shared with affiliates across the state.
d. Legislative/governmental advocacy supporting affiliate membership.
e. Connecting with and carrying the NAMI voice from one affiliate to the other.
f. Cultivating community partnerships that further the achievement of individuals and families within the NAMI affiliate family.
2. The Arizona Justice Alliance has been spearheaded by Mary Lou Brncik of David's Hope, Dana Naimark of the Children's Action Alliance, and Caroline Isaacs with American Friends Service Committee and includes 40-70 organizations from across the state determined to address the unfortunate connections between criminal justice and mental health. NAMI Arizona continues to play an important role in establishing this group and has hosted the past three strategy meetings. Our Kick-off Event October 30th is designed to attract/solidify Alliance partners and identify action steps to address three goals of:
a. Increase Diversion Opportunities and Programming to keep juvenile and mentally ill away from incarceration;
b. Expand CIT Effectiveness via fostering a "Responsive Community Approach" that provides resources and options to First Responders, Individuals, and Families; and
c. Increase Earned Early Release usage as it's known to encourage good behavior and reduce recidivism.
The "Responsive Community Approach" is directly tied to current NAMI Arizona board commitment to effectively expand CIT effectiveness by educating, informing, and connecting the community in a way that best meets the needs of first responders and individuals/families with mental health concerns.
The Alliance has invited Clarke Romans of NAMI Southern Arizona and Dan Haley of HOPE Inc. to facilitate the CIT portion of the discussion and hope to apply lessons learned from the Tucson community regarding connecting and engagement in a way that can preclude tragedy.
3. The Arizona Peer and Family Coalition is a statewide group of individual, peer, and family run organization and community leaders dedicated to extending peer and family leadership into all aspects of Arizona's behavioral health care. NAMI Arizona's Interim Executive Director currently occupies the President role and we host many of the monthly meetings at our state office. The Coalition is currently working on legislation to remove the stigmatizing definition of a "mentally ill person" currently found in the Arizona Revised Statutes and has earlier published a position paper on the Arnold V. Sarn Agreement.
4. Many of the same Arizona Peer and Family Coalition members participated in an Arizona State Health Department Office of Individual and Family Affairs (OIFA) initiated St. Luke's Health Initiative Technical Assistance Partnership called Future Directions which presented background and a position paper recommending 13 specific items to the Arizona Department of Behavioral Health regarding Peer and Family system integration. The group continues to meet on a recurring basis with the Deputy Director regarding specific peer and family, recovery-based initiatives and issues impacting the Peer and Family Run organizations.
5. Mental Health America is currently resurrecting their Arizona operation with Cheryl Fanning and Clarke Romans both on the board of their only program the "Association of Association". Cheryl represents NAMI Arizona and Clarke represents the Behavioral Health Coalition. The group is in its infancy still settling on their guiding principles, but determined to be powerful partners in the community.
6. The Arizona Council of Human Service Providers consists of more than 90 providers across Arizona (including all four RBHA's) determined to promote and maintain a comprehensive continuum of services that help Arizona's children, families and adults build lives of quality and self-sufficiency. While membership fees range from $750 to $12,000 per year, NAMI Arizona participates Pro Bono and has benefited from the council's media and grant-writing training. The Council has tremendous respect/impact in the community providing powerful leadership in legislative and governmental advocacy to include hiring expert consultation to better understand the Affordable Care Act. The council meets monthly as a group in addition to a recurring monthly meeting with the Deputy Director of the Arizona Department of Health.
7. The Maricopa County Association of Providers consists of more than 70 providers within Maricopa County and NAMI Arizona also gets to participate at no cost. This group has tremendous influence on the conduct of behavioral health services in Maricopa County and they greatly value NAMI Arizona's peer and family voice.
A lot of the same people participate in several or all of the groups above and have expressed great appreciation for NAMI's involvement in the community and with their organization. They recognize our common cause and welcome our leadership in facilitating a "Responsive Community Approach" that provides better outcomes for all while reducing inefficient administrative burden. For more information, please contact Jim Dunn at 602.885.4166 or email@example.com.
REPORT FROM THE APA ASSEMBLY
APA ASSEMBLY REPORT WASHINGTON DC. FROM NOV. 9-11; 2012, by Jehangir B. Bastani, MD, DLFAPA, Arizona APA Assembly Representative
Action Papers originate at the grass-root level in the District Branch (DB) and Area Council from where they, are eventually brought to the Assembly for discussion. If passed, they are referred to the Board of Trustees for necessary action. This Assembly was unusual since the Action Papers that were deliberated and passed had a direct bearing on the practicing psychiatrist. The Assembly was marked by its animated discussion amidst the collegiality and respect for the presenters and the discussants. The following papers were passed and a most of you can identify with the issues as it impacts you.
- Voted to recommend APA study the extent of the problem of misleading insurance carrier network practices and, in coordination with other agencies/entities identify potential solutions. It was noted that this is a significant problem affecting patient access to care and that the problem of "phantom networks" has not gotten better. It refers to a list of providers, who are not taking new insurance patients, may have retired or enrolled a one-time basis but in reality there may be few.
- Requested that the APA develop a position statement regarding the management of sensitive information via health information exchanges (HIE's).
- Asked the APA to engage an independent educational consultant to help assess whether the procedures promulgated in the ABPN MOC program meet appropriate educational standards and are relevant to the practice of psychiatry and asked the APA to setup a committee or select an existing committee to work with the consultant.
- Requested that the APA update the position statement on mental health carve-outs that was developed ten years ago.
- Requested that the APA develop a position statement on prior authorizations for psychotropic medications. There was extensive testimony about the increasing problems with prior authorizations. It was noted that this problem is not only negatively affecting patient care but also leading to psychiatrists retiring from practice because of the administrative burden of obtaining prior authorizations. The testimony on the floor of the Assembly was the need for urgent action.
- Requested that the APA develop a resource document on treating women with serious mental illness of reproductive age and pregnancy planning.
- Urged the APA to lobby the ABPN to designate lifetime diplomates as "Lifetime Certified not participating in MOC and not required to do so."
- Asked that the APA develop a member home or face page on the website that will give people a user friendly way of accessing the site, and also that the APA develop mobile apps (Android and iOS) to allow easier access from mobile phones and tablets.
- Requested the APA conduct a survey of residency training program graduates designed to identify the adequacy of psychiatric training in preparing graduates for their professional lives.
- Supported the APA providing administrative support without cost for educational programs that are being put on by district branches that are not accredited providers of CME.
- Asked that APA reexamine the current selection criteria of some APA research fellowships only available to US citizens or permanent residents and consider open programs to all APA members.
- Requested that the APA change the ECP member dues structure to equalize the changes in dues across the period of transition to regular membership based on percentage increase per year.
- Voted to eliminate the requirement that members have to have been General Members for five years before applying for APA Fellowship.
- Voted to add International Fellows and International Distinguished Fellows to the membership categories for APA members.
- Voted to oppose government intrusion into the dialog between physicians and their patients about reproductive choices.
- Asked for there to be a resource document developed on rape.
- Requested that the Ethics Committee and the Council on Communications develop a position statement on ethical dilemmas faced by psychiatrists in the use of the internet in communication with patients, marketing, patient education, etc.
- Called for the creation of a Task Force to develop a document that explains the importance of psychotherapy performed by psychiatrists.
- Called for expansion of the Principles of Medical Ethics with Annotations for Psychiatry to include information about how public statements by psychiatrists about crimes, criminal defendants, and crime victims need to be moderated in order to avoid potential negative consequences.
- Voted to support the DSM-5 criteria as presented to the Assembly and to forward them to the Board for final approval.
- Requested that APA Staff and the Assembly Executive Committee representatives initiate a program of voluntary site visits to district branches for APA administrative consultation and targeted financial support.
- Asked that the APA Staff and the Committee on Procedures investigate options for using Audience Response Systems during Assembly meetings.
- Established a Task Force on Psychiatric Diagnosis to assist in the ongoing review and update of DSM-5.
- Requested that APA set up a means for distributing email communication from Assembly Representatives to their constituents.
- Asked that the APA request the FDA clarify that it is inappropriate for managed care companies to imply that the FDA supports denials of coverage for medications prescribed "off-label."
APA Workgroup Reports
Board Workgroup on Psychiatry and HealthCare Reform - Paul Summergrad MD
Dr. Summergrad updated the Assembly on the workgroup. The workgroup's findings will be presented in the Spring of 2013. We have entered a period of dramatic, rapid and consequential changes in the health-care system. The roles for everyone will change. The workgroup asked Milliman to do an update on the cost of care for people with mental health and substance use issues, which will be useful in supporting the recommendations of the workgroup and in highlighting the importance of addressing these issues. Milliman provided a preliminary analysis that the cost of medical care for patients with psychiatric disorders is more than 300 billion dollars a year (looking at all costs, not just psychiatric). The report will talk about integrated care, and financing healthcare. The focus of the recommendations from the workgroup is what is best for patients. The group thinks that there is a wealth of evidence suggesting that psychiatric care is cost effective. The group will describe core principles of effective collaborative care: patient centered care teams, population care, measurable outcomes and evidence based practice. Psychiatrists are well positioned because of our strong leadership skills. On the other hand we have an apparently lower rate of salaried employment, and we have a relatively low rate of psychiatrist participation in insurance based care, there is limited involvement in health information systems, and less clear data about outcome measures. We need to take a leadership role in defining models of integrated care that are effective. We also need to be more effective in setting up effective ways of coordinating state and federal activities.
Members Communication Award - Scott Benson MD
This Award honor APA members or groups of members who have developed and maintained effective communication tools with their members. The competitive aspects of the awards programs encourage engagement of members and innovation in new technology for communication.
Awards are presented for outstanding effort in five categories: Overall Communication Plan; Newsletters and eNewsletters; Regular message updates; Blogs; and Websites. The Awards for 2011 were given to three DB's for continuing excellence with their eNewsletters -
- the New Jersey eNewsleter
- the Pennsylvania eNewsletter
- the Wisconsin eNewsletter
Assembly Workgroup on DB Business Health - Melinda Young MD
Some of the District Branches are out of compliance with state and/or federal laws that applies to non-profit corporations, including the requirement for annual tax filings. This carries potential liability for the executive officers of that DB, which is comprised of the DB's Council members. Additionally, if the DB is out of compliance, the APA's Directors and Officers insurance may no longer cover the DB and it's Council. Although each DB is a separately incorporated non-profit, and is separate from the APA, it is nonetheless in the APA's best interest, and in the best interest of all DBs and all members, that each DB maintain good business health, in part due to the multiple levels of financial entwinement among the DBs and the APA, and the potential for liability carrying over for all. Given this, the Assembly has undertaken the job of assisting DBs and their boards of trustees (their Councils) with assessing their business health. A group of experienced DB Executive Directors, working with the APA attorney, have developed several questionnaires for each DB to use as tools in self-assessment. The Assembly Work Group on DB Business Health is working out the details for finishing and providing the questionnaires to each DB.
Treasurer's Report- APA CFO Teri Swetnam PhD
Dr. Swetnam said she was expecting a break-even budget. Publishing revenues are projected below budget by $3.6 M due to decreased book sales (primarily DSM IV), subscriptions, and display advertising. Meeting revenues are below budget $1.7M due to reduced income from registration and exhibits. Expenditures are below budget by $2.8M, due to vacancy savings, lower royalty expenses and reduced costs of insurance. Membership continues to trend downward (loss of about 900 members per year) but revenues from membership are relatively stable. Non-DSM publishing revenue is staying roughly the same. Registration and course fees were up a bit from the Philadelphia meeting and it is anticipated that they will go up further at the San Francisco meeting. DSM-5 development will have cost the APA about 25 million dollars.
DSM-5 Update - Glenn Martin MD
Dr. Martin presented a review of the work of the Assembly Committee on DSM-5. The role of the Assembly Committee was to ensure vigorous Assembly involvement in DSM-5. The committee's expertise was primarily as clinicians who use the DSM. More than seven years ago the Board of Trustees began the process to produce an updated, revised DSM. David Kupfer, M.D. and Darrel Regier, M.D. were named co-chairs of the Task Force. Roger Peele, M.D., WPS Representative has represented the Assembly on the Task Force.
The work of the revision was undertaken by Workgroups of experts in the diagnostic categories. Their work has been reviewed at multiple levels - Scientific Review Committee, Clinical and Public Health Committee, and forensic experts. For the last two years the Assembly Committee on DSM-5, chaired by Glenn Martin, M.D., has participated in the review of the criteria sets providing comments to the Summit Group and the Board. He noted that the Assembly had previously voted to remove the multi-axial system and had recommended not to implement cross cutting dimensional measures in version 5.0. The committee reviewed all criteria sets and background material (there were 10 conference calls). The chair participated in the summit (12 calls) in the Board of Trustee review meetings (4).
David Kupfer (Chair) and Darrel Regier (Vice Chair) from the DSM-5 Task Force gave an update. The plan is to distribute the DSM V texts at the Spring 2013 Annual Meeting in San Francisco. In it is a nine page document that discussed some of the rationales for the revisions and guiding principles. The strict categorical approach of DSM-IV had resulted in very high levels of NOS diagnoses (in Eating Disorders and Personality Disorders the largest number of diagnoses were in the NOS category), so the goal was to reduce use of what will now be called NEC. The workgroup tried to align the chapters for disorders that were more similar and to follow a developmental organization. Cultural variations are discussed in much more detail in the text. The Task Force also wanted to think of DSM 5 as something that would be more frequently and more readily updated.
A single spectrum diagnosis (Autism Spectrum Disorder) replaces Autistic Disorder, Asperger Disorder, and Pervasive Developmental Disorder NOS. The condition is now differentiated from social communication disorder by the presence of behavioral features. In schizophrenia the changes included the elimination of separate treatment of bizarre symptoms and the elimination of subtypes. In bipolar disorder the main changes were the inclusion of energy / activity as a criterion A symptom for hypomania/mania, and removing the requirement for mixed presentations to meet criteria for both depression and mania. In major depression the main change was eliminating the bereavement exclusion. There is a new diagnosis - Disruptive Mood Dysregulation Disorder to try to reduce the premature diagnosis of bipolar disorder in children and adolescents. Premenstrual Dysphoric Disorder will be moved into the main section. Also Binge Eating Disorder will be moved from the diagnoses for further study to the main section. In anxiety disorders, the main changes are further clarification of Criterion A (stressor) for PTSD and removing chronic vs. acute distinctions and adding with dissociation specifiers. Somatic Symptom Disorder takes out the idea of medically unexplained symptoms and focuses on excessive distress as the defining characteristic of the new condition. Substance use disorders were changed by the consolidation of dependence and abuse categories and creating a continuum of mild, moderate and severe disorders. In cognitive disorders, the term Neurocognitive Disorder will replace Dementia and there will be a mild version as well as the more severe form described previously as dementia. All DSM-IV personality disorders will remain intact and be located in the main section of DSM-5. In section III there will be a trait based diagnostic approach which will be available as a set of diagnoses for further study.
There has been a very thoughtful review by Paul Appelbaum and the Council on Psychiatry and the Law of this Manual, looking for unintended consequences, potential for misuse in the courts and increased liability for psychiatrists. Most of the identified issues have been resolved. Next steps will be:
(1) December 2012 - Submit final DSM-5 manuscript to APA Publishing (after Board approval).
(2) May 2013 - Presentation of the DSM-5 at the Annual Meeting in San Francisco.
The Assembly considered and passed a Resolution to recommend the diagnostic criteria to the Board of Trustees for approval.
Committee on RBRVS, Codes and Reimbursements Report - Ron Burd MD
In November the Centers for Medicare and Medicaid Services (CMS)released the final codes with relative values which will be implemented on January 1, 2013.Code 90862 has been deleted. Psychotherapy with E&M is now coded as E&M with psychotherapy added on (in other words two codes). If there is no medical evaluation and management you can use just a psychotherapy code. 90863 has been added as a code for pyschopharmacologic management by a prescribing psychologist, Physicians should NEVER use this. E&M codes must be covered now by insurance companies. Psychiatric diagnostic evaluation has been split into one for psychiatrists (90792) and one that does not include medical decision making. CMS ended up establishing interim values that did not have much to do with the nature of the work and ignored the recommendations from the Relative Value Scale Update Committee (RUC). The APA website has a CPT coding crosswalk, as well as an online course on E/M coding (get CME for preparing!), live and recorded Webinars on E/M coding. You can also access APA CPT Coding Network for questions by email.
Profile of Courage Award- Dr. Hershfield
Dr. Hershfield gave the Profile of Courage Award to Dr. John de Figueiredo of Connecticut. Dr. de Figueiredo was recognized for his courage and calm in handling a violent confrontation in the psychiatric emergency room in which a patient grabbed the loaded gun of a police officer serving as a security guard. Several shots were fired and both the patient and the security guard died. Throughout the incident Dr. de Figueiredo conducted himself in an exemplary fashion.
Early Career Psychiatrists Initiative - Steve Koh, MD
Dr. Koh talked about the need to focus on mentoring and professional development at a local DB level in order to reverse the decline in membership among ECP's. The APA sponsored a workshop for ECP representatives from all of the areas. The group decided to develop a project designed to help ECPs deal with the Maintenance of Certification process. The plan is to make the materials available APA website.
Report from Assembly Committees
Access to Care - Joseph Mawhinney, MD, Chair
The workgroup is requesting vignettes and case examples of problems getting access to care. Initiatives from the group has included the development of state legislative and regulatory initiatives relating to phantom panels, continuity of medication, waiver of out of pocket costs for patients with severe persistent mental illness. Other actions include developing legislation on a uniform Medicaid formulary; establishment of task forces on Dual Eligible, Parity, integrated care and Level of Care criteria.
Assembly Workgroup on Maintenance of Certification (MOC)
The Assembly MOC Taskforce is charged with studying and evaluating the processes of MOC and MOL as well as communicating with the Board. Our next steps will be to have a short series of conference calls to review the current literature that has been provided by Dr. Hales regarding MOC from both the ABMS and ABPN. Heard from people who attended our meeting during the Assembly their concerns from the members about what they should actually do for their practice and career regarding MOC.
Communications - R. Scott Benson, MD, Chair
The interim Chief Information Officer of the APA, Eric Fishman, gave a very helpful presentation about several initiatives to support better communication with members. The APA will be offering Salesforce.com access to the district branches, allowing them to access the database of members in their district branch. In the next year the APA will implement the ability to do email blast communications from representatives to their constituents. Assembly members would submit their content to the APA IT department would then send it to the Assembly member's constituents (this letter would be an example).
Membership Engagement / Mentorship - Harry Brandt, MD, Chair
Discussion focused on ways of engaging MIT's and ECP's in the activities of the APA. How can the APA get out information about fellowship and leadership opportunities? Couple of ideas gained support:
(1) This committee felt that a group of MIT's and ECP's should be invited to the President's Reception at the Annual Meeting, and these individuals should be paired with senior leadership. The ECP's and MIT's who attended that reception noted it was a valuable experience for both the junior members and senior leaders, and gave the newer members a greater sense of connection and belonging.
(2) The committee identified that the materials sent to new MIT and ECP members should be much more comprehensive, helping new members to better understand the value of membership and many opportunities as available to APA members, and better connecting new members to the organization. One committee member noted that she happened upon an APA fellowship by doing a Google search, but many of her peers who had joined, were unaware of such opportunities. Another suggestion was that Dr. Oldham's slide set orienting people to the many facets of the APA be linked for download in an email welcoming new members. Further, the newer members at the meeting felt there should be more personal connections as a phone call from the DB, senior members, and APA leaders to new members.
I would like to thank Peter Forster, MD of the California Psychiatric Association for reporting the Assembly activity and have included his reporting on the progress of the DSM 5 section, the Board Workgroup on Psychiatry and HealthCare Reforms and the Action Papers.
By Mona Amini, MD, and Felicitas Koster, DO, APS Members-in-Training
The Annual Arizona Psychiatric Resident Mixer held in October at Black Chile Grill in the Biltmore Fashion Park was a success! Residents from both Banner Good Samaritan Medical Center and MIHS Psychiatry Programs attended the event. Participants agreed that the social mixer was a unique opportunity to gather in an informal setting to increase collegiality among the residents. In the future, APS plans to expand the resident social mixer to provide psychiatric residency physicians statewide the opportunity to mingle with their Phoenix colleagues as well. University of Arizona residents interested in participating in the development of these plans, please email Teri (firstname.lastname@example.org) for more information.
EARLY CAREER PSYCHIATRIST PERSPECTIVE:
THE VALUE OF MEMBERSHIP
By Monica Taylor-Desir, MD, MPH,
APS Early Career Psychiatrist
In September during the APA components meeting, I had the opportunity to gather with a group of thirteen other early career psychiatrists and general members that were selected to participate in an APA leadership initiative. As we began to discuss various topics, a recurring theme was what our colleagues considered the benefit or value in being a member of the APA and being involved in the associated district branch. Many of you may immediately identify the value of membership as CME and maybe an opportunity to socialize or network during the year. Yet there is so much more available. As an early career psychiatrist, I spent my first four years working in Winslow, Arizona after transferring from Atlanta, Georgia. I remember how much I relied on the APA for CME, but I realize now that if I had found a way to actively participate in my district branch, I may have had a richer experience.
The APA has many resources to support the depth and breadth of its membership, whether you are in medical school, residency, fellowship, or you are a well rounded and experienced lifer. During this year, I will work with Teri Harnisch to send a brief monthly e-mail highlighting an aspect of the APA resources. This will include resources for maintenance of certification, support for figuring out those changing CPT codes, how to effectively communicate with your legislature, interacting with the media, health care reform, and utilizing committees. So stay tuned... you may find that with a growing awareness the value of your APA membership will increase.
CME INFORMATION; APS ANNUAL MEETING DATE
SAVE THE DATE: April 13, 2013 at The Ritz Carlton, Phoenix, Arizona for the Arizona Psychiatric Society Annual Scientific Meeting, theme "Management of Aggression through the Lifespan."
Join us for the 21st Annual Psychopharmacology Review Course from February 18-22, 2013 at the newly renovated Westin La Paloma in Tucson, Arizona! This 5-day live event brings together outstanding faculty from the University of Arizona and across the country to provide comprehensive psychopharmacological updates in a comfortable schedule and setting. Up to 25.0 AMA PRA Category 1 Credits(s)™ available. Online registration is available today at the meeting website for this optimal learning experience. Presented by: University of Arizona College of Medicine, Department of Psychiatry, in collaboration with: Arizona Psychiatric Society, Arizona Nurses Association, and Arizona Psychological Association.
Grand Rounds for the Department of Psychiatry Banner Good Samaritan, January 2013, Medical Education Ampitheater (12:00 to 1:00 pm): Friday, January 11, 2013, *Substance Abuser in the Elderly, Ole Thienhaus, MD; Friday, January 18, 2013, *Ketamine for Treatment of Depression, Jeffrey Brichta, DO; Friday, January 25, 2013, *The Risks and Benefits of Marijuana Legalization: A Psychiatric Perspective, Michael Dekker, DO. *Banner Health designates this live activity for a maximum of 1 AMA PRA Category 1 Credit™.
Borderline and Beyond: Extensions of the Technique of Mentalization Based Therapy for Personality Disorder, Peter Fonagy, Ph.D., Saturday, February 9, 2013, Workshop 9:00 am to 3:00 pm, University Club of Phoenix. Click here
for a flyer or visit www.swpsychoanalytic.org
for more information.
Beat the rush and register for the 2013 APA Annual Meeting in San Francisco, May 18-22, focused on the theme "Pursing Wellness Across the Lifespan." Save $50 (early bird registration rate). Register for the meeting and housing by January 24, 2013 for the best fees and rooms. Visit the APA Annual Meeting website
to obtain more information and to register.
For additional information regarding these or other CME offerings, please visit the APS website
. Events may be submitted to Teri (email@example.com
) to include in the calendar for the members.
RENEW YOUR MEMBERSHIP TODAY
If your 2012 dues are unpaid, please contact the APA today--act now to administratively reinstate by December 31st. Thanks to those members who have already paid your dues for 2013. Thank you for the important choice you make in being a member of the Arizona Psychiatric Society and advocating for our profession and the mental health needs in our community.
If your e-mail or mailing address have recently changed, please contact Teri (firstname.lastname@example.org
, 602-347-6903) to update the same. Please be on the look-out in January for an invitation to the Winter Social.
Wishing you a safe and happy holiday season!