By John P.D. Shemo, MD, DLFAPA
Assembly Representative
Psychiatric Society of Virginia
As a slight deviation from the usual Assembly report, I will use an Action Paper presented at the May 2022 meeting to illustrate for the PSV membership what an Action Paper is, how it is created, and how it “lives or dies.” This particular paper actually lived, but did require some life support.
In brief, any member of the Assembly can submit an Action Paper. It can actually be written by any APA member whose name can be on it, but it must be submitted by an Assembly member.
Once it is written, the Action Paper must be submitted in a prescribed format. Many Assembly members involved with a paper will post it on the Assembly website for review and comment prior to formal submission, and often do some rewriting based on the feedback from the Assembly members who have read it on the website.
The submitters usually also discuss the paper at their Area meetings (the APA has seven geographic areas made up of the district branch representatives in that area and also some representatives from various allied organizations).
There is a due date by which all final versions must be submitted.
The papers are then assigned to one of five reference committees, usually consisting of 10 to 12 individuals, one from each Area and a couple from allied organizations and members-in-training. This committee will meet electronically a couple of times to deliberate on the papers for which they are responsible. At the full Assembly meetings, held twice a year, the papers are discussed at reference committee open meetings at which any Assembly member can participate. After this open meeting, the reference committee goes into closed session and decides whether it will support the paper, not support the paper, or support it with changes they have made, hopefully based on the input they received in the open meeting. This was a procedural change instituted at this particular meeting. In the past, any Assembly member, including the paper author(s) could sit in on the closed reference committee meeting. They could not speak unless asked a question by a reference committee member, but they could “witness” how the decisions and changes were made. That is, to my mind, important because the decision of the reference committee goes on a “consent calendar.” This then is the final fate of the paper unless any member of the Assembly, when the reference committee report is presented at the full Assembly meeting, requests that a paper be pulled from the consent calendar and be debated by the full Assembly. If this occurs, the paper is pulled and such a debate is held with the speaker of the Assembly having the responsibility to conduct the debate in such a way that there is a fair distribution of time given to those wishing to speak pro or con. The vote is then held. If the voice vote is clear and convincing, the vote stands.
But, again, any member can call for a “vote by strength,” if they disagree with the speaker’s ruling that the voice vote was clear and convincing. If this call is supported by several members in a couple of Areas, a vote by strength then occurs. This means that each district branch representative casts a written
ballot that specifies how many APA members they represent. Organization representatives get only one vote as all their members are also in one of the district branches.
If the paper passes in any of these ways, it typically goes to a relevant APA, not Assembly, committee to review and comment. It then, by decision of this review committee, may or may not go to the board of directors who are free to, and have, ignored papers passed even multiple times by the Assembly.
With this background information, the following example is an Action Paper presented at the May 2022 Assembly meeting.
It was a rather unique Action Paper in that it was submitted after the Action Paper deadline. It represents a response to what is happening with “Medicare Advantage.” This was discussed at our latest Area 5 meeting and was felt to be so time sensitive that it needed to be addressed at the May Assembly meeting. The original intent was that this be addressed as a discussion under “new business” at the Assembly meeting. APA apparently requested that it be submitted as an Action Paper despite the expired deadline for Action Paper submissions. Area 5 agreed to this request with the understanding that the “author” of the paper be listed as Area 5 and not myself as an individual.
The paper was then given to a reference committee to review that was in fact chaired by a member who is a medical director for an insurance company with a heavy involvement in “Medicare Advantage.” The reference committee essentially “gutted” the paper. Area 5 then got it pulled from the reference committee consent calendar and it was debated on the floor of the Assembly with more time spent on this paper than all the other Action Papers combined.
Assembly members from around the country spoke, giving examples of what had happened to their patients under 11Medicare Advantage.” By a strong majority, the paper was passed with modifications that came from the Assembly floor reversing the modifications that had been made by the reference committee. A critical modification is that the “emergency work group” referenced in the “Be It Resolved” section must present a plan for APA response by the next Assembly meeting.
Below then, is a copy of the original paper as presented to allow you to see the actual structure of an Action Paper. What was finally passed was very similar except as noted above.
ACTION PAPER
Title: Establishment of an Emergency Work Group to Formulate an American Psychiatric Association Response to Concerns About Potential Negative Consequences of “Medicare Advantage” Programs for Patients with Mental Illnesses.
Whereas:
- Psychiatrists treat two groups of patients who are eligible for Medicare coverage: Older patients with mental illnesses who statistically have higher general medical needs than the elderly without comorbid mental illness, and younger patients with mental illnesses so severe and persistent that they are on disability and have been so for more than two years.
- “Medicare Advantage” is not Medicare. It is a proprietary insurance product the acquisition of which requires the patient to forego actual Medicare coverage.
- If an individual registers with Medicare at age 65, they pay a set premium which may be increased for all participants periodically. If the individual does not register for Medicare until they are older than 65, they will pay a higher premium for the rest of their life. If they switch to “Medicare Advantage” and then recognize its disadvantages for them and switch back to “real Medicare,” they do not go back to their original premium, but rather will have the premium they would pay if they had not started Medicare until their now current age, and pay this higher premium for the rest of their life. This reality is not clearly deJineated in the “Medicare Advantage” solicitations.
- The percentage of patient premiums used by Medicare for administration is low since they do not require an extensive workforce engaged in the denial of care. Proprietary “Medicare Advantage” plans have high administrative costs driven by their need for a workforce focused on care denial, the existence of high advertising costs, and the amount they retain as profits. This substantially higher amount used by “Medicare Advantage” plans for these non-patient care diversions are overwhelmingly derived by one mechanism, treatment denials. As we know, the need for mental health parity laws to exist is driven by the practice of proprietary insurance entities targeting this politically and economically vulnerable population for such treatment denials.
- In their advertisements, proprietary “Medicare Advantage” programs tout their large provider networks and promise potential customers that they will be able to “keep their doctors.” In fact, APA research has demonstrated a strikingly high occurrence of false provider networks. The reality being that if a patient cannot find a network “provider,” the plan pays much less or nothing.
- Patients are being bombarded with multimedia advertising for these proprietary “Medicare Advantage” plans (using the name Medicare) with little access to the clarification that these plans are not Medicare and have significant disadvantages for many individuals with a mental health disorder.
- Medicare has seemed to not have responded to proprietary insurance entities using the word “Medicare” in their product names, creating the impression that Medicare may wish that, in the face of increasing longevity, patients not be on the role of Medicare, or at least have a higher premium because they were, even briefly, on an alternative option.
BeIt Resolved:
- That the American Psychiatric Association establish an emergency work group to formulate an APA response to the incomplete and misleading information being disseminated about “Medicare Advantage” by proprietary insurance companies which negatively impacts our often most vulnerable patients.
- That the APA bring these concerns to the attention of other organiz.ations such as the American Medical Association to formulate cooperative efforts to address this problem.
- That district branches of the APA at the local level be provided resources to encourage practicing psychiatrists to help educate their patients about the risk of their being given misleading or incomplete infonnation about the potential disadvantages of “Medicare Advantage” products.
- That the American Psychiatric Association work with other aligned medical and patient advocacy groups to encourage Medicare to discourage proprietary insurance entities from using the word “Medicare” in their products.
Author:
- Area 5, American Psychiatric Association Assembly of District Branches
Estimated Cost: TBD.
Key Words:
- Medicare Advantage
- Medicare
- Proprietary Health Insurance Products
APA Strategic Priorities:
- Advancing Psychiatry
Reviewed by Relevant APA Component:
- Rules Committee
The one “resolve” that was dropped was the fourth, in which I asked that the proprietary insurance entities not be allowed to use the word “Medicare” in their product advertisements since, by definition, you must leave Medicare coverage to get “Medicare Advantage.” This seemed to occur because “legal counsel” pointed out that the word “Medicare” is not copyrighted so anyone can use it as they wish. However, I will note that any person may call themselves by whatever name they wish. It need not be the name on their birth certificate. However, they may not use a name if their intent in doing so is fraudulent, i.e.: you could not call yourself “Joe Biden” if you were trying thereby to get contributions. I do contend that proprietary insurance entities calling themselves “Medicare Advantage” when you need to go off “real Medicare” to get them is fraudulent.
It will, of course, be interesting to see who APA actually puts on the above referenced “emergency work group.”
While I have a bias that there would be clear benefit to our members and patients if the APA were restructured to more closely resemble the administrative structure of the AMA, I trust that nothing said here is interpreted as not recognizing the critical importance of our having a strong and united professional organization with broad and diversified membership and leadership.
As always, Adam, Varon, and I are open to suggestions from PSV members regarding concerns that could lead to the formulation of an Action Paper.
