Area 5 meeting in Dallas, Texas on March 11-12, 2023
By John P.D. Shemo, MD, DLFAPA
The Area 5 council held its spring meeting, mostly in person, in Dallas on March 11 to March 12, 2023. There was a moderately good turnout, with several virtual attendees. Attendance was somewhat impacted by delay in site confirmation, which then impacted travel.
As is usual at Area meetings, there was broad discussion regarding practice and legislation issues in the various district branches and review of Action Papers being prepared by Area representatives.
As a little historical background for new PSV members, when the American Psychiatric Association Assembly was started, the distribution of psychiatrists in the United States and Canada was rather different than is currently the case. Thus, New York and California are each Areas unto themselves, two of the seven geographic Areas in the Assembly.
Area 5, in which we reside, extends from Virginia and West Virginia to the north, Texas and Oklahoma to the west, and Florida and Puerto Rico to the south, and also includes the military district branch. It therefore has a large voting influence in the Assembly.
In addition to the work done by Assembly representatives at the Area and full Assembly meetings, many representatives also have various committee and work group assignments which require research and additional meetings. The results of this work are then also presented and discussed at Area and Assembly meetings.
I am including two reports I presented at the recent Area 5 meeting to demonstrate the types of issues we address.
The first, to Dr. Herman, occurred in my role as Area 5 representative to the Bylaws Committee. It addressed a review of a proposed bylaws changes regarding the petition process for Board of Trustees nominations. Mine was the only “no” vote. In this email, I explained my reasoning, as the vote was done by email rather than in the context of a live discussion/vote.
Dear Dr. Herman:
As per our recent email communication, I have below attempted to outline my concerns related to the American Psychiatric Association (APA) Bylaws Committee response to the recently submitted report of the Nominating Committee regarding proposed changes to the petition process for Board nominations.
As background, I have been a member of the APA long enough to have been honored as a distinguished life fellow in 2012. I have served on the Board of Directors of the Psychiatric Society of Virginia (PSV) for 31 years, including a term as PSV president, and have been PSV representative to the APA Assembly literally, since the last century, currently in my ninth term. I have served on several committees including the Rules Committee, the Nominating Committee, and now the Bylaws Committee. I have served also as an assembly liaison to the DSM Steering Committee and the Adhoc Committee for review of APA practice guidelines, the Work Group on Healthcare Reform and Parity and the Caucus on Maintenance of Competency. I have served several times as a member or chair of Action Paper Reference committees.
I outline the above to reference my long history of involvement with the APA and my strong allegiance to the function of the APA, but also in the context of my expectation that some of my concerns may be interpreted as negative criticism rather than an attempt to find ways to strengthen APA as an instrument of support for our members and our patients.
Most of the historical references I mention below are based on my own observation, but some are based on the mentoring I received during my early years in the Assembly, much by members no longer with us.
I also wish to clarify that the concerns I express will have no bearing on my own future with the APA. I have no plan or intent to ever seek a Board position, nor are my comments aimed at assisting any colleagues with any such intent that is known to me.
My concerns regarding the APA Board nomination process are related to procedures, as outlined in attachment 1 of the report of the APA Nominating Committee we reviewed, dated December 10-11, 2022.
It is very unclear to me why the current Board of Trustees would have final approval of nominations to the next Board. Would that not be like a current U.S. President having final approval of the candidates from both parties for the upcoming U.S. Executive Branch election?
To my recall, the last time there was a highly contested, issue-based campaign for the APA presidency was in 1993 and 1994 when H.E. twice ran for president and on the second occasion won, serving as president in 1996. His candidacy, as those of us present at the time will recall, was in large part driven by the candidacy of an individual with strong ties to the then arising insurance “managed care industry.” His success was occasioned by a threatened and thereby energized APA electorate.
The obvious concern with having a current board in the position of having “final say” over upcoming candidate selection is the creation of a self-perpetuating hierarchy.
As we are aware, the original APA was an association of the physicians, not yet called “psychiatrists,” who were the heads of the original state mental asylums. The APA has, to a large degree, remained administratively top heavy.
Given the above referenced self-perpetuating structure of the nominating and election process, I am concerned about the very limited time period in which potential alternatives to the selected candidates will be allowed to express their concerns and offer alternatives.
Two potential solutions would be to have future Boards selected by the Assembly, as representatives, as a body, of the entire membership, or find a way to significantly increase the number and diversity of membership who do vote in elections – both in terms of geography and “career paths.” Current voter turnout for elections is not democratically representative of the membership.
As a reminder, recently, three years in a row the assembly voted in favor of a solution to this problem of poor voter turnout. Since most APA members, to become or remain members, must pay yearly dues or they lose membership, the proposal was to attach the ballot for APA offices, including Trustees, to the annual dues statement which also goes out to all non-dues paying members as it also contains the solicitations for yearly donations to the APA PAC, and/or Foundation. The Board took no substantive action on these passed Action Papers, perhaps in part knowing that the recommendation would never be passed as a referendum due to the low response to all APA mailings except the dues and donation notice. The percentage of members that must vote to pass a referendum is significantly higher than the number required to elect officers. That percentage required to pass a referendum has not been reached in an election for many years.
Actually, the last time a referendum was proposed, it “passed” with a majority of positive votes but was not implemented because the voter turnout percentage was inadequate, even though the referendum would still have passed even if all the required extra votes had been negative.
A final issue of concern regards the proposed strict limitations on the allowed time for a potential challenge to the Board-endorsed nominated slate of candidates for Board positions. The reality is that members of the Nominating Committee, per the APA bylaws, must ultimately, before serving, be endorsed by the Board. The recommendations of this already Board-endorsed Nominating Committee then are being subject again to Board approval.
The timeframe for any challenge to the outcome of this process seems to clearly favor individuals engaged with systems in which they have staff resources and communication networks. This strongly favors a challenge from inside rather than outside the already referenced hierarchy.
I apologize for this response being so lengthy, but to paraphrase Mark Twain, I didn’t have time to make it shorter.
The second communication is addressed to Maureen Maguire, JD, Associate Director of Payer Relations and Insurance Coverage. Below is her request titled “Feedback Requested: CMS Proposed Rule” and my response.
Subject: Feedback Requested: CMS Proposed Rule
We are reaching out to you, as you’ve previously expressed interest in helping APA better understand issues around Medicare Advantage plans. CMS has issued a proposed rule that is asking for feedback about utilization management and the use of prior authorization in Medicare Advantage plans. It would help us a lot if you could share your thoughts/experiences to the following questions as they relate to Medicare Advantage. If you don’t have the percentages that are asked for in the questions, that is ok, please provide whatever your relevant experience has been with Medicare Advantage. Please share feedback with Maureen Maguire, cc’ed here, by COB Monday.
Please share any feedback to the following questions posed by CMS:
- Currently, how often do doctors without expertise determine medical necessity?
- What percentage of these determinations are appealed and what percentage of these appeals are overturned?
- Of the overturned appeals what percentage of cases have medical complications specifically arising from delays?
- Of the upheld appeals what percentage have adverse medical complications directly attributable to the lack of original treatment?
- What is the average cost of these consequent adverse medical complications?
Thank you very much for your help with this. Please let me know if you have any questions.
Maureen A. Maguire, JD
Associate Director- Payor Relations and Insurance Coverage
American Psychiatric Association
800 Maine Avenue SW, Suite 900
Washington, DC 20024
Desk: 202.559.3730
John Shemo to Maureen Maguire
RE: Feedback Requested CMS Proposed Rule
Maureen, I also do not have “the numbers”. I never receive a reply when I ask such questions of the insurance companies. They, of course, maintain that this is proprietary information. I suspect it would only be obtained by subpoena. Another important issue we are dealing with, however, is the practice of “seamless conversion”. This refers to the ability of insurance companies to enroll a member of its “marketplace” or other commercial plan into its Medicare Advantage coverage when that individual becomes eligible for medicare. They do need to send the person a letter. However, persons becoming eligible for medicare are flooded with so many mailings from proprietorial insurance companies trying to recruit them, that this particular letter gets lost in the flood.
The “seamless conversion” then takes effect in 60 days unless the member specifically does the paperwork of opting out. Medicare has apparently refused to name the companies that have sought or received approval to do seamless conversion. It is my understanding that Aetna, United Health Care and Humana are doing so. Cigna, Anthem and Blue Cross/Blue Shield have apparently declined to reveal if they are doing so. This seamless conversion apparently takes precedence even if the person, unaware of it, enrolls in traditional Medicare. One final issue, I have found that I frequently can get patient care denials overturned when I specifically quote from the APA Practice Guidelines. My time spent as Assembly Liaison on the Practice Guidelines steering committee has paid dividends!
John P.D. Shemo, MD, DLFAPA
Medical Director and Principal Investigator
Psychiatric Alliance of the Blue Ridge
Clinical Research Center Associate Clinical Professor, University of Virginia
1228 Cedars Court, Suite 103
Charlottesville, VA 22903
434-984-6777/ph
Sherin Moideen, MD will be joining Adam Kaul, MD and me as PSV Assembly representatives at the upcoming Assembly Meeting in May in San Francisco. As always, we are open to observations and concerns of PSV members that might be helpfully addressed by the APA.
