APA 2006 Candidate Responses

The Academy has solicited responses about three issues of concern to the Academy from the above American Psychiatric Association (APA) president and president-elect candidates. The issues are:

1. At present there is insufficient reimbursement to support consultative services in general medical settings that limit the ability to diagnose and treat the mental health needs of the complex medically ill.
    
2. In outpatient primary care settings, Medicaid has refused to pay for two doctor visits on the same day, yet 50% of the often burdened, complex medically ill patients will fail to make a return trip to the clinic on a separate day for a psychiatric visit. This current system compromises an already underserved population.
    
3. Funding at the NIMH suffers from "siloing," creating barriers for the cross-institute and cross-specialty research required to address the problems of the complex medically ill with mental disorders.

Below are responses from the four candidates. We trust that this will help you to be as fully informed as possible about their views on these matters as you make your choices in the election. APA members are reminded that ballots must be received by 5:00pm EST Monday, February 6, 2006.

Response from Jack Drescher, MD

I am responding to your three questions regarding professional issues of concern to the members of the Academy of Psychosomatic Medicine.

Questions 1 and 2 raise the important issue of treating psychiatric disorders in the primary care setting. Advocating for this needed patient care should be an APA priority.

What in these fiscally conservative times can we do to increase government and insurance funding for needed medical services? As increased funding and issues of mental health parity are political issues, they will require political solutions.

Unfortunately, when our professional organizations seek to increase funding for the services that our members provide, we are perceived to be acting in our own self interest, rather than in the interest of the patients we serve.

Therefore, we have to acknowledge that our professional organizations cannot bring about these needed changes alone. We need to build political coalitions whose goal is to increase funding for needed services and to achieve parity.

To do this, APA (and your organization as well) needs to strengthen relationships with patient advocacy groups. The harm done by bureaucratic restrictions that do not address patient needs (as in the Medicaid restriction on two doctor visits a day) need to be highlighted. It is primarily the stories of patients (whose concerns are supported by the voices of their doctors) that have a greater impact on the media, the public and sometimes even the politicians.

One good example of using the patient perspective to affect health care policy can be found in a December 13 New York Times article (http://www.nytimes.com/2005/12/13/health/13case.html). The article presents the case of a medically ill woman who has undoubtedly been treated by consultation-liaison psychiatrists. This woman’s story makes the case for the kind of care people sometimes need—and cannot easily get. Furthermore, the case is not an abstraction, but a deeply personal message that the average person can understand. Such understanding conveyed to the general public increases support for change.

In a similar vein, the New York State Psychiatric Association is partnering with patient advocacy groups to seek insurance parity. Political momentum towards parity is growing in New York as a result of the 2001 suicide of 11 year-old Timothy O’Clair. The parity legislation is now known as "Timothy's Law." A tragic outcome resulting from inadequate insurance coverage for a depressed child is something both the public and legislators understand.

As APA President, I would foster a greater link between our legislative and public affairs components (which are not coordinated enough today, in my opinion) to advocate in the public arena for needed health care reforms.

Regarding question 3: APA should make use of its current relationships with NIMH to raise awareness of problems created by “siloing” to the NIMH leadership.

In addition, overcoming the bureaucracy of entrenched interests (“siloing” being just one example) requires disseminating clear messages from affected populations whose interests are not met by bureaucratic structures. NIMH, like most government bureaucracies, can be made to respond to appropriate political pressure.

APA, with the support of groups like APM, can take the lead by bringing patient and health care advocacy groups into the discussion. When our interests really do serve the needs of our patients, patient groups will freely and willingly join in.

If I am elected President of the APA, I will strongly support moving forward on these issues and concerns.

Jack Drescher, MD
December 22, 2005

Response from Carolyn B. Robinowitz, MD

Thank you for your letter of December 12, 2005, inviting my comments about several issues related to Psychosomatic Medicine. I am pleased to respond to your questions, as well as to give you a sense of my background and interest. I fully support each of the issues you have raised, and if elected, I anticipate developing strong and ongoing liaisons with the Academy, and will contact APM leaders for input on these and other related issues. Tom Wise is one of my trusted advisors. I also support Dr. Carol Alter’s efforts to develop a conference leading to a “white paper” to demonstrate the role and importance of med-psych co-morbidities, and providing data and directions for our advocacy efforts..

You may not know that I began my work in Consultation-Liaison Psychiatry—as a child and adolescent psychiatrist working with pediatricians both at Children’s Hospital in Washington DC (and later at George Washington University School of Medicine) and at the University of Miami School of Medicine. My interest in and support for the subspecialty continued throughout my career. From 1974-76, I was a member and chair of APA’s then Subcommittee on Psychiatry and Primary Care Education. As a Director of the American Board of Psychiatry and Neurology (1979-1986), I led ABPN efforts to identify appropriate subspecialties to receive Certificates of Added Qualification, and followed that effort with spearheading APA leadership at the Residency Review Committee for Psychiatry and the Accreditation Council for Graduate Medical Education to allow the recognition of psychiatric subspecialties. As a participant in a conference chaired by Bob Pasnau, addressing APA and ABPN recognition of psychosomatic medicine, I wrote (with APA Past President Carol Nadelson) an editorial, "Consultation Liaison Psychiatry as a Subspecialty" published in General Hospital Psychiatry, 13:1–3, 1991. As an early supporter, I think my involvement was important in obtaining the formal recognition and approval by the various organizations.

In the nineties, I was dean of Georgetown’s school of medicine as well as professor of psychiatry and worked closely with Steve Epstein, Tom Wise and Rich Goldberg to strengthen the C-L program there—a program now strengthened considerably with the addition of Carol Alter and with plans for a post residency fellowship using multiple resources and settings. In my current clinical practice, I work closely with internist and pediatrician colleagues in consultative and collaborative roles.

As APA Secretary-Treasurer, a primary concern has been APA fiscal stability. Since I became Treasurer, APA’s budget has been balanced, long range financial planning has been reinstated as has replenishment of the reserves; we have undergone a highly positive audit, and financial information has become more transparent. As a Board member, I also have addressed important public policy and advocacy issues, especially access to care and appropriate reimbursement for care. I agree that we must strongly advocate for sufficient reimbursement to support consultative services in general medical settings, and that the results of a conference as mentioned above will do much to provide supporting data for the importance of these services in diagnosing and appropriately treating the mental health needs of persons with complex medical illness.

I also share the concerns about the limitations of Medicaid reimbursement—especially for those with complex medical illnesses. Of course, I support using APA resources to inform and enlist policy makers, and involving as advocates, our members who work in this important area. As an APA Delegate to AMA’s House of Delegates (as well as a member of the AMA Council on Science and Public Health), I have been working to inform our colleagues in the House of Medicine, as well as AMA policies on these important issues.

Finally, I agree with your concern about NIH/NIMH approaches to funding, and the importance of avoiding silos in research, education, or clinical care. Science does not lend itself to that kind of “slicing.” APA’s Council on Research can address the complexities of these research issues and how to avoid such separation and isolation.

Thank you for this opportunity. If you have further questions or would like additional information, please let me know.

Carolyn B. Robinowitz, MD
December 19, 2005

Response from Prakash Desai, MD

Thank you for raising these important issues. Before I answer them one by one, let me relate what sprang up in my memory with your letter. When I was a medical student in India, our college library had one shelf of books in one case devoted to psychiatry. Among them were books by Franz Alexander, Phyllis Dunbar, Overstreet and others. All dealt with psychosomatic medicine, that being the most popular branch of psychiatry. And that's how I ended up in Chicago for my residency. One senior psychiatrist later told me "the West split Psyche from Soma, they have to work to put it back together."

As for the issue of insufficient reimbursement to support consultative services, I'm afraid psychosomatic specialists are not alone, but that does not make it any less of a problem. The discriminatory coverage, i.e., co-payment under Medicare affects us all, and from where other third parties take their lead. That has to be our first agenda, and I believe the APA has been working on it. The next step would (or at the same time) be to work with employers and insurers, and demonstrate the total savings in medical costs when psychiatric issues are properly addressed. In short, we must insist that all forms of psychiatric services be treated on par with rest of Medicine.

The Medicaid question is a relative one. As I understand it, this varies from state to state. Our efforts have to be at the state level where there is this problem. This why I advocate that we strengthen our advocacy efforts at the state level.

As far as NIH and NIMH go, I see that in research efforts, especially social sciences, there is a greater emphasis on interdisciplinary work. But here, I'm afraid, we have to work with our own colleagues, those on study sections and our research council to more forcefully advocate for that kind of work.

I hope to invigorate our advocacy both for our patients and our profession. I'll also advocate for greater access to care as I'll argue for greater access to information and resources for our members and DBs and SAs.

Thank you for giving me this inopportunity to respond.

Prakash Desai, MD
December 23, 2005

Response from Donna M. Norris, MD

Thank you for your invitation to share my views on the important issues outlined in your recent letter and, particularly, addressing them as a potential APA officer.

As you know, advocacy for care to the underserved in our country is and must continue to be one of the highest priorities for the APA. The APA must actively partner with the Academy since we are already aligned and share common goals.

Your questions — 1) regarding insufficient reimbursement to support consultative services in general medical settings which limit the ability to diagnose and treat the mental health needs of the complex medically ill; 2) Medicaid's refusal to pay for two Dr. visits on the same day; and 3) funding at NIMH suffering from "siloing," creating barriers for the cross-institute and cross-specialty research required to address the problems of the complex medically ill with mental disorders — emphasize the complexity of the problems for physicians dedicated to the care of underserved communities.

Our patients with complex medical illnesses with psychiatric disorders often need comprehensive diagnostic and treatment resources. State-of-the-art scientific research is necessary if we are to offer treatments based on best clinical practices.

There is no one solution to any of these problems, but many options to consider. These include how to address the finances of the kind of care we value. With current financial support for Medicaid under threat, there is less encouragement that there will be any increase in funding for complex medically ill patients unless the entire financial structure of the outpatient health care system is fundamentally reformed so that there is access to the best possible care. Perhaps, with businesses increasingly rejecting the burden of higher costs for health care, we must weigh in on this possibility. This is a problem not just for psychiatry, but for other medical subspecialties as well. The APA must continue to be a leader in health care advocacy. In partnership with the AMA, other specialty and subspecialty organizations, and patient centered advocacy groups, the APA must continue to advocate against federal cuts to programs which support the care of the mentally ill and for a more responsive health care delivery system.

It is a poor and impractical model of patient care which limits payment for needed consultative services to one service when more that one service is medically indicated. I endorse a position which strongly lobbies for change in this current discriminatory practice and I support a joint Psychosomatic Academy, APA and government relations push to educate legislators to the critical need for changing this practice.

With respect to the "siloing" barrier in NIMH research, this affects psychiatry as well as other medical disciplines. The recent article by Elias A. Zerhouni in the New England Journal of Medicine, "Translational and Clinical Science-Time for a New Vision," presents a plan of opportunities for change in an old system. We must be proactive and use our political clout and savvy to keep abreast of new challenges impacting our field. We must be committed to keeping on top of any changes which potentially affect the capability of the field to support clinical research and critical bench research in the neurosciences. The Academy of Psychosomatic Medicine promotes the type of research identified in the NIH new vision. This expressed "new philosophy" at NIH may herald change which will bring down the "silo" affect.

If elected as an officer of the APA, I look forward to discussing these and other concerns of the Academy regarding ways in which the APA will work with you to better serve the needs of our most vulnerable medically ill patients with psychiatric disorders.

Donna M. Norris, MD
December 20, 2005

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