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In the wake of the Senate votes to acquit President Clinton of the two articles of impeachment, the House and Senate now seem poised to move forward with legislative matters that have been pressing since the last Congress. Priority issues for the Congress include patient protection in managed care legislation, privacy, and Medicare restructuring. APA will continue to press top priorities including mental illness parity, and physician practice issues.
We face unusually difficult challenges. Federal legislation and new regulations governing the use of seclusion and restraints are expected in the wake of reports of 142 deaths involving seclusion and restraints over the past decade. This, coupled with allegations of extensive fraud in Medicare's partial hospitalization benefit and apparent antipathy by Medicare carriers toward psychiatric services in general, means that psychiatry will be under intensive scrutiny in the coming months. Ominously, the Guam legislature became the first U.S. jurisdiction to give psychologists prescribing authority.
On a positive note, APA continues to work closely with Senators Domenici
and Wellstone and Representatives Roukema, Wise, and DeFazio on their "full
parity" legislation, is busy preparing for the 1999 Federal Legislative
Institute and the APA Annual Meeting, and is an active participant in planning
meetings for the forthcoming White House Conference on Mental Health.
Patient Protection Debate Begins
Patient protection legislation is high on the priority list in both the House and Senate this year. There is already a proliferation of bills in both bodies; most of these are identical or reworked versions of the major patient protection bills from the previous Congress.
As this report goes to press, the Senate Health, Education, Labor, and Pensions ("HELP") Committee is the "first out of the blocks" with patient protection legislation. The Committee, chaired by Senator Jim Jeffords (R-VT) will mark-up S. 326, a patient protection bill developed by Senator Jeffords on March 17-19. The Jeffords bill establishes general patients' rights in managed care (i.e., plan information, access to pediatric and ob/gyn care); requires plans including ERISA plans to establish expedited internal and external appeals procedures, prohibits premium weighting based on genetic information, and establishes some safeguards of patient medical records. As of this report, Committee Republicans were expected to offer few, if any, amendments; Committee Democrats were likely to offer up to 20 amendments, including a point-of-service amendment by Senator Paul Wellstone (D-MN) supported by APA.
To-date, other leading patient protection bills already introduced include: S. 6, the Patient Bill of Rights Act of 1999 sponsored by Senator Tom Daschle (D-SD) (the Senate Democrats’ bill) and its House Democrats’ counterpart, H.R. 358, sponsored by Representative John Dingell (D-MI); the Senate Republican leadership bill, S. 300, sponsored by Senators Trent Lott (R-MS) and Don Nickles (R-OK); a revised version of the "PARCA" bill - now known as the Access to Quality Care Act - H.R. 216, sponsored by Representative Charlie Norwood (R-GA); H.R. 448, last year's problematic House-passed bill; and, S. 374, a "centrist" managed care reform proposal sponsored by Senator John Chafee (R-RI). Notably, the new Norwood - or "AQCA" - bill dropped a controversial provision in the PARCA bill calling for non-discriminatory payment of non-physicians that was a major bone of contention with the physician community.
The procedural situation in the House is much less clear than the Senate. Several weeks ago, Commerce Committee Republicans were prepared to move patient protection bills piecemeal through the Committee, breaking each issue (i.e., gag rules, ER access, point-of-service, appeals, etc.) into separate bills and considering each separately. This trial balloon was shot down. The latest report is that the Committee leadership is proposing to break patient protection into two main bills: one including gag rules, ER access, specialty care access, and point-of-service, and a second including many of the more controversial provisions in last year's House leadership bill (HealthMarts, MEWAs, confidentiality, etc.) No word yet on a schedule for mark-up.
APA has issued an Action Alert (via fax, E-mail, and the APA web site)
urging our members to write their Senators and Representatives in support of
comprehensive patient protection legislation. The suggested letter is also
available in downloadable format and for sending as an E-mail in the "Write to
Congress" section of the APA web site.
Seclusion and Restraint
As previously reported, Congress is likely to consider new legislative standards for the use of seclusion and restraint in response to articles in the Hartford Courant alleging more than 140 deaths over the past 10 years of psychiatric patients in seclusion and restraints.
Two main approaches have emerged to date. A draft bill by Senator Joseph Lieberman (D-CT) would apply current federal nursing home standards on seclusion and restraints to psychiatric or other facilities with mentally ill patients. The Lieberman bill would also establish uniform reporting requirements of deaths and serious physical or psychological injury under restraint, and would require HHS to set up a national data bank on seclusion and restraint, available to health professionals and the general public. The Senate Subcommittee on Labor-HHS Appropriations has scheduled a hearing on seclusion and restraint for April 13. APA has tentatively been invited to testify.
A draft House bill by Representatives Diana DeGette (D-CO) and Pete Stark (D-CA) would establish sweeping new standards for seclusion and restraint use for any facility receiving any federal funds from any source. The House bill would also require reporting of "sentinel events" (deaths and serious injuries) to a third party and require facilities to give open access to "citizen monitors" 24 hours a day, 7 days a week. The House bill is advocated by the protection and advocacy community, and by some patient groups, including NAMI, which is taking a leading role.
In addition to the Federal bills and pending hearings, the Joint Commission on Accreditation of Healthcare Organizations has scheduled hearings on seclusion and restraint in the San Francisco suburbs, Atlanta, and Alexandria, Virginia on March 29, April 6, and April 13, respectively. DGR has disseminated information to the District Branches alerting them to the field hearings; APA will likely testify at the Alexandria hearing.
In response to these developments and at APA Medical Director Steven M. Mirin, M.D.'s express direction, APA convened a conference on seclusion and restraints with the National Association of Psychiatric Health Systems and the American Academy of Child and Adolescent Psychiatry. The objective of the conference was to develop a joint statement of general principles on the use of seclusion and restraints; that draft is now being circulated for comment and approval among conference participants. It is also APA's intention to develop "best clinical practices" guidelines for dissemination to the field.
Dr. Mirin has met at length with representatives of NAMI to discuss their
concerns. NAMI, along with the protection and advocacy community, has made
enactment of tough standards on seclusion and restraint a top priority. APA
has also met with the CMHS, provided extensive comments on proposed
legislation, and briefed key Hill staff. APA continues to work with all
parties to ensure that any legislative or regulatory "solutions" achieve the
overarching objective of ensuring the best possible clinical care while
protecting the health and safety of patients and staff.
Psychologist Prescribing Heats Up
In the closing hours of its 1998 session the Guam legislature became the first jurisdiction in the U.S. to give psychologists prescribing authority. On December 29, the Democratic governor of Guam vetoed a broad-based allied health care bill that included a provision giving psychologists prescribing authority. The next day the veto was unanimously overridden by the overwhelmingly Republican Legislature (12R-3D). The bill was sponsored by the chairman of the Health Committee, who was later defeated in the November election.
Grouping psychologists with physician assistants, the law gives these "allied health professionals" the authority to prescribe medications as a "delegated authority" of a Collaborative Practice Agreement with a physician. In addition to the requirement of a collaborative agreement - which must be approved by the Guam medical, pharmacy and allied health boards - a psychologist need only complete "a nationally and professionally accepted pharmacological curriculum in the area of mental health psychology."
The Guam prescribing law was the handiwork of one of two state-credentialled psychologists on the island. The spouse of a physician, this psychologist is regarded as a well-connected "wheeler dealer", and chairs Guam's Board of Allied Health Examiners, one of the boards that must approve the collaborative agreement of a prescribing psychologist.
APA DGR is already working with local psychiatrists to develop a strategy
for dealing with the new law; all avenues are under active consideration.
Privacy
Senate "HELP" committee Chairman Jim Jeffords along with Senator Chris Dodd (D-CT) has introduced new privacy legislation that contains improvements over last year’s bill. Most significant is their inclusion, following APA urging, of provisions insuring the privacy of patients who pay for services out of pocket, and protecting all state laws more protective of privacy than the proposed federal law. Nevertheless, significant additional changes are still needed in this legislation to insure patient privacy.
APA prefers legislation introduced by Senator Patrick Leahy (D-VT), and
Senator Edward Kennedy (D-MA) that is based on the principle of informed,
voluntary non-coerced consent before the use or disclosure of medical records
privacy. Congress is under an August 1999 deadline to enact patient privacy
legislation. Without Congressional action the Secretary of Health and Human
Services is authorized to promulgate privacy regulations.
Practicing Physicians Advisory Council
APA has provided input to the Practicing Physicians Advisory Council (PPAC)
on regulatory/administrative problems physicians have been facing with
Medicare with proposed solutions. The PPAC recommends Medicare policy changes
affecting physicians directly to the Health Care Financing Administration. APA
expressed general concern about the adversarial mindset of HCFA national and
regional staff as well as local carriers toward physicians, noting APA member
experiences with:
Copies of the full comments can be obtained from DGR.
White House Conference on Mental Health
Planning work is already underway on the forthcoming White House Conference
on Mental Health. The White House has just announced that the Conference date
is June 7 although no location has been set. APA is currently participating in
pre-conference planning meetings on seven general topics: Science &
Research; Children & Adolescents; Insurance & Financing; Service
Capacity & Provider Issues; Stigma & Rights; Public Sector; and,
Recovery. The topic planning meetings are designed to provide the substantive
framework for the Conference.
APA 1999 Federal Legislative Institute
The 1999 Federal Legislative Institute will be held on April 11-14 in Washington, D.C. at the Washington Court Hotel. Participants will receive panel briefings from key Hill staff on general health policy issues including patient protection and privacy legislation, and on mental health legislation in the 106th Congress. Participants will also hear keynote addresses by federal legislators and other experts, attend a special White House briefing on health policy initiatives by the Clinton Administration, and receive expert "how to" training before embarking on two days of visits with Senators, Representatives, and their key health staff.
On April 12, the Jacob Javits Public Service Award will be presented to
Representative Ben Cardin (D-MD) at a dinner in his honor. Representatives
Peter DeFazio (D-OR) and Jim Ramstad (R-MN) will also receive Distinguished
Legislator Awards. Receiving the Distinguished Legislative Advocacy Award for
outstanding advocacy to APA members for their work on behalf of the profession
and patients will be Helen Foster, M.D. (Virginia), Kathleen Thomsen-Hall,
M.D. (Arkansas and Massachusetts), Captane Thomson, M.D. (California), and
Jeffrey Akaka, M.D. (Hawaii). A reception honoring the 106th Congress will be
held on April 13.
Children's Issues
Early activity by Congress and the Administration on children’s mental health are focused on violence prevention and juvenile justice. The Center for Mental Health Services (CMHS) has issued its request for applications for funding under its KDA program for school-based services aimed at violence prevention. CMHS has joined with the Departments of Education and Justice, which already have school violence prevention programs in order to coordinate services and maximize funding. An APA-supported amendment by Representative Obey resulted in $40 million being added to the fiscal year 1999 CMHS appropriations for school-based mental health services.
With the support of the APA, Senator Paul Wellstone introduced the Mental Health Juvenile Justice Act. Similar legislation has been introduced in the house. The bill will ensure that juveniles entering the juvenile justice system will receive screenings for mental and emotional disorders and referrals for needed treatment. Senator Wellstone will be seeking to attach parts of his legislation to larger juvenile justice and crime prevention legislation, which is expected to move in the 106th Congress.
Punitive juvenile justice legislation has also been introduced in the House and Senate. The bills are modeled on S. 10, which the Senate failed to pass in the waning days of the 105th Congress. Hearings on the legislation have begun in the House. However, the Senate has opted to bypass committee consideration of the measure and hold it on the floor so the bill may be brought up at any time. APA joined other child advocacy organization in opposing S.10 and will actively work to defeat such legislation in the 106th Congress.
As of this report, 53 states and territories have submitted plans to the
Health Care Financing Administration (HCFA) for the State Children’s Health
Insurance Program (SCHIP). Plans from 50 states and territories have been
approved. APA will be watching as several states seek to amend their plans to
ensure that adequate mental health coverage is provided. While implementation
of the SCHIP program has been nearly nationwide, enrollment of qualified
children has been extremely low. The White House, in conjunction with the
child advocacy and business communities, has launched a major outreach effort
to help enroll children. APA is participating in these efforts.
Veterans' Mental Health Care
At the request of APA President Rodrigo A. Muñoz, House Veterans Affairs
Committee member, Representative Bob Filner, recently contact the Department
of Veterans Affairs (DVA) to express concern about the selection process for
the DVA’s Chief of the Mental Health Strategic Health Care Group. Thomas
Horvath, M.D, vacated this position at the end of 1998. Representative Filner
expressed his concern that the process to select Dr. Horvath’s replacement be
open and include representatives of mental health providers, including APA.
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