AMERICAN MEDICAL ASSOCIATION - RESIDENT AND FELLOW SECTION

Resolution: 4
(A-01)

Introduced by: Christina Sebestyen, MD, Delegate
Massachusetts Medical Association - Resident Physician Section  

Subject: Impact of Biodiversity Loss on Human Health

Whereas, Biodiversity loss is occurring at unprecedented rates approximating one-thousand times the rates naturally predicted and rivaling the great extinctions of the past, and one-quarter of all species are anticipated to be extinct by the completion of the next half century; and

Whereas, Biodiversity loss will result in the deprivation of many potential new medicines that could benefit our patient population as is evidenced by the fact that 57% of the 150 most prescribed drugs, such as penicillin (fungus-penicillium), aspirin (willow bark), digitalis (fox glove), and taxol (pacific yew), are derived from plants, animals, and microorganisms; and

Whereas, Biodiversity loss will result in the emergence and resurgence of infectious diseases via disruption of compositions of species (hosts, vectors, predators, infectious agents) in an ecosystem, as exampled by the Hantavirus pulmonary syndrome outbreak in the Four Corners region after a prolonged drought followed by significant precipitation that increased pine nut supplies and therefore increased deer mice populations (the vector of the Hantavirus); therefore be it

RESOLVED, That the American Medical Association support legislation that protects regions of high biodiversity density from destruction and that restricts the proliferation of causal factors of biodiversity loss.

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AMERICAN MEDICAL ASSOCIATION - RESIDENT AND FELLOW SECTION  

Subject: Mercury Exposure and the Reduction of Fish Consumption

Whereas, Mercury is a pervasive pollutant in the environment that results from industrial pollution into the air with subsequent contamination of water sources and that has properties that allow for bioaccumulation through the food chain into fish; and

Whereas, Mercury disrupts cell division and migration of cells in the developing brain of rodents and interferes with chromosomal replication; and

Whereas, The 1999 National Health and Nutrition Examination Survey measured blood and hair mercury data and approximated that 10% of women have mercury levels within one tenth of potentially hazardous levels; and

RESOLVED, That the American Medical Association develop and implement an educational campaign to encourage the adoption of the FDA recommendations for fish consumption by women of reproductive age and young children.

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AMERICAN MEDICAL ASSOCIATION - RESIDENT AND FELLOW SECTION  

Resolution: 6
(A-01)

Subject: Cost-Effectiveness of Medicaid Eligibility Criteria for the Seriously Mentally Ill

Whereas, The American Medical Association’s (AMA) most current positions on mental health care are reflected in the following statements:   

1. H-285.956 (CMS Rep.2, A-96; Modified: CMS Rep.6, I-00), which outlines AMA’s opposition to mental health carve-outs, and advocates for MCO’s adherence to nine principles of conduct and accountability, including assisting PCPs and other physicians in managing behavioral disorders, appropriate reimbursements to health care providers with ease of opportunity to appeal treatment restrictions, and provision of ongoing assessment of patient outcomes and satisfaction.   
2. H-345.999 (A-62; Reaffirmed: CLRPD REP.C, A-88; Reaffirmed: Sunset Report, I-98; Reaffirmation A-99), which is the AMA’s Statement of Principles on Mental Health, and recognizes the ongoing need to improve the care and treatment of the "emotionally disturbed", through improving knowledge and resources in this field of medicine; the role of the physician as a citizen, community leader, and in a position to advocate for and guide effective mental health programs, in addition "to solving the many problems in the..… field".; and

Whereas, One-half of this sub-population (or 2.6% of the adult population) have severe, persisting mental illness, which include schizophrenia, bipolar disorder, refractory depression, severe panic disorder, and obsessive-compulsive disorder; and

Whereas, Seriously mentally ill patients require longer and more intensive treatment programs, such as inpatient care, residential programs, out-patient follow-up, and case management, in order to treat acute episodes and prevent relapses and re-hospitalizations; and

Whereas, Seriously mentally ill patients retain the potential to recover from illness and return to past levels of social and occupational functioning through newer medication and psychosocial treatments; and

Whereas, This "spending down option" may subsequently impair the recovering mentally ill from transitioning back to the community and re-establishing themselves as independent and contributing citizens; therefore be it

Fiscal Note: No significant fiscal impact

FURTHER BACKGROUND INFORMATION ON MENTAL HEALTH COVERAGE 

1. According to the 1999 Surgeon General’s Report on Mental Health (www.surgeongeneral.gov/library/mentalhealth), and based on pivotal epidemiologic surveys, including the Epidemiologic Catchment Area Study (Regier et al, 1993), and the National Comorbidity Survey (Kessler et al, 1994), 9% of all US adults have a mental disorder; 5.4 % of the population have a "serious mental illness", and 2.6% of the population have a "severe, persisting mental illness" (Kessler, 1996) (NAMHC, 1993). In addition, 0.5% of the population received social security disability benefits secondary to mental illness. The direct cost of mental illness was reported at $69 billion/year, or 7.3% of total health spending (Rice and Miller, 1996). The indirect costs, as reported in 1990, was $78.6 billion, and 80% of this cost was attributed to chronic disability.   
2. Severe mental illness (schizophrenia, bipolar disorders, refractory depression, obsessive compulsive disorder, other anxiety disorders), often present in late adolescence and early adulthood. The potential disability burden is great, due to lengthy morbidity of such illnesses, as compared to mortality.     
3. Medical advances have been achieved in both psychopharmacologic and psychosocial treatments of the severely mentally ill. Particularly, the advent of atypical anti-psychotic medications has resulted in equivalent or improved efficacy for treating disorders in thought process and thought content and perception (as compared to conventional neuroleptics). These new medications have also been found to cause less cognitive side-effect impairment and improve on various negative symptoms, such as apathy, alogia, affect flattening (Nemeroff, 1998). Thus pts might be able to more readily transition back to previous level of job and social functioning.   
4. Initial and recurrent presentations of severe mental illness often require longer hospitalizations, and transitions to residential settings, before re-entry back into the community. (Lieberman, 2001, personal communication), recently presented data on first break psychosis pts who were treated with the newer atypical neuroleptics, and demonstrated 55% pts achieved significant symptom improvement (greater than 50% reduction in symptoms) and return to original level of social and occupational functioning, at 12 weeks following admission; however, 85% pts achieved treatment response after a one year period.   
5. Eaton et al, 1992, who is based at Johns Hopkins School of Hygiene and Public Health, examined psychiatric case registries from three European cities (Australia, Denmark, England), and reported that "hospitalizations for schizophrenia tend to cluster earlier rather than later in the treatment career, suggesting progressive amelioration, rather than deterioration".   
6. Currently, patients with serious mental illness, or severe, persisting mental illness, who receive health care benefits from managed care organizations, have limited services available, outside of medication visits, and limited psychotherapies. The MCO’s provide little direction in the types of care which would most benefit the severely mentally ill. There are no provisions that such pts receive coverage for case management, community support, job re-training, social skills training, directed cognitive behavioral therapy, which are interventions beginning to show improve outcomes of severely mentally ill, as measured by number of relapses and rehospitalizations, improved social behavior, reduction of psychotic symptoms (Bustillo et al, 2001).   
7. Chronic institutionalization of the mentally ill is both costly for the system, and demoralizing and stigmatizing for the individual (1999 Surgeon General’s Report on Mental Health).   
8. On the otherhand, individuals who have well-informed health care providers, may have applied for and been granted Medicaid coverage, upon meeting the financial criteria for Medicaid eligibility. Coverage is granted for the "categorically needy", which include the "institutionalized individuals with income and resources below specified limits".   
9. According to HCFA and Health and Human Services policy, each State has the option to establish a "medically needy program", to extend eligibility to otherwise qualified persons, with too much income to qualify for the "categorically needy" group.    
10. This option allows for "spending down" of personal resources, and the incurring of substantial medical/remedial care expenses to offset their excess income (or assets), to achieve Medicaid eligibility. This "program" was established due to problems encountered by the chronically medically ill, and the elderly ill population, who often require nursing home level of care. Seriously mentally ill patients are also required to spend down, in order to gain Medicaid benefits, which provide significantly wider health care coverage, including a variety of psychopharmacologic and psychosocial treatments, necessary for on-going rehabilitation and assistance in transitioning to community living and re-integration back to past occupational and social functioning.   
11. HCFA has imposed limits on the transfer of assets, and establishment of trusts, for individual seeking Medicaid eligibility. Provision for spousal impoverishment was made, in acknowledgement of the significant cost of health-care incurred by one ill spouse, while the other remains actively living in the community.

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