BULLETIN NEW YORK STATE PSYCHIATRIC ASSOCIATION Summer 2009, Vol. 52, #2 • Bringing New York State Psychiatrists Together President's Message: Albany Report Guidelines or Mandates–That is the Question By Richard J. Gallo and Barry B. Perlman, MD
By C. Deborah Cross, MD NEWS FLASH!!! NYS Senate resumes passing Legislation after t the May APA tial for conflicts of interest five weeks of gridlock and bill to make Timothy’s Law perma- Assembly a major and to guide their deci- nent becomes law. A topic of interest was a sions about relationships report by Paul S. with industry.” It went on Since writing this report, there have been two important developments in Appelbaum, MD, past presi- to say that “These steps are Albany: dent of the APA, and cur- necessary to protect public 1) Senator Pedro Espada, Jr. has returned to the ranks of the Senate rent Chair of a Workgroup trust in the integrity of the Democrats, which again provides his Party with a 32-to-30 Majority in on Relationships between profession and to promote the upper house; and Psychiatrists and the the well-being of our Pharmaceutical and Medical patients.” 2) The Senate unanimously passes Timothy’s Law permanency bill and it Device Industries. (This is signed into law by Governor David Paterson on the following day. C. Deborah Cross, MD The body of the report Workgroup was established spelled out 11 recommen- by the APA Board of Trustees in 2008 dations in several sections. The first sec- t seems each year the “End of Hiram Monserrate, the other and presented their report to the Board tion, “Recommendations Relevant to all Session” Albany Report remarks Democratic Senator who aligned him- on March 15, 2009.) The report, as is Psychiatrists”, listed the following. I about the bizarreness of the self with the GOP, has since returned Assembly custom, was assigned to a Legislative Session and how it was to the Democratic Conference creating 1) Gifts: “The APA recommends that an even 31-31 split, without a Reference Committee made up of repre- psychiatrists and trainees not accept stranger than preceding years. We can sentatives from all the Areas and other now state unequivocally that all previ- Lieutenant Governor to cast a tie- gifts of any value from pharmaceu- breaking vote. groups such as MITs, ECPs, etc. The tical, device, and other commercial ous reports were overstated by compar- debate on the report was extensive. Dr. entities, and that psychiatrists not ison to the 2009 legislative session as Session Stats Appelbaum testified (the Reference display products with commercial we continue to observe the unprece- For those of you who keep track of Committee model is based on the simi- logos.” dented goings-on in the State Senate. such things, the 2009 Legislative While the New York State Assembly Session produced 15,161 bills (as of lar model at the AMA where people 2) Food: “The APA recommends that come in front of the Reference adjourned its “regular session” in an June 29, 2009), with the Assembly the same rules that apply to gifts in orderly fashion on June 23, 2009, the passing 1,242 and the Senate passing Committee and “testify” regarding the general should be applied to food:” issue at hand). Numerous other people New York State Senate looks to be only 262 to date. So far, 183 bills have The recommendation goes on to nowhere near concluding its business, passed both houses: 67 have become also spoke. The issue was quite contro- state basically that no free food versial. I will very briefly summarize the as of the time we wrote this report. As law, 6 have been vetoed, and 22 are should be supplied for educational anyone with access to a news media awaiting action by the Governor. main points in the report; however, I or social functions in hospitals, urge all of you to access it through the source knows, on June 8, 2009, 30 Thus far, the 2009 Legislative Session clinics and offices and psychiatrists Senate Republicans and 2 Senate APA web site. (I believe that the report has yielded important successes for should not accept food that is being Democrats put on the floor a motion NYSPA, as well as some disappoint- is going to be circulated to the entire paid for by pharmaceutical or to adopt a resolution of the Senate that ments. APA membership for comments at some device companies. gave the GOP control of the chamber State Budget Issues time in the near future.) and elected Senator Pedro Espada Jr. as 3) Medication samples: The recom- The 2009-2010 budget was a mixed bag In brief, there was a two paragraph “President Pro Temp” and Senator mendation is that psychiatrists limit with regard to NYSPA’s interests. The introduction which stated “The Dean Skelos as “Majority Leader.” The the use of free samples to situations overall appropriation for the NYS American Psychiatric Association (APA), legality of the vote under the parlia- where it is clearly in the interests of Office of Mental Health, which we therefore, offers these recommendations mentary procedures of the upper comment on annually, was relatively to educate its members about the poten- house and the question of whether the generous as proposed by the Governor [See President’s Message on page 2] house was actually in session when the and increased through negotiations vote occurred are at the core of the with the Legislature. A significant win ongoing power struggle and resulting for NYSPA and our Timothy’s Law Spring Area II Council Meeting dysfunction. To complicate matters further, Senator [See Albany Report on page 3] By Rachel A. Fernbach, Esq. he New York State Psychiatric the jurisdiction of the Council on Association held its annual Spring Communications. Dr. Cross hopes for NYSPA Legislative Day T Area II Council Meeting on an increased focus on public affairs Saturday, March 28, 2009, at the activities at the state and local level. By Rachel A. Fernbach, Esq. LaGuardia Marriott Hotel in East Finally, she provided an update on vari- n March 11, 2009, members of for the mental health system. Elmhurst, New York. C. Deborah Cross, ous district branch public affairs activi- the NYSPA Executive Committee M.D., NYSPA President, called the meet- ties and efforts. • Sex Offender Management and traveled to Albany for a day of Treatment Act (SOMTA): NYSPA is ing to order and welcomed Council O NYSPA Vice-President, Glenn Martin, lobbying meetings with various state advocating for changes to SOMTA, guests. M.D., provided an update on the NYS legislators and representatives from the including the adoption of an outpa- After introductions, members of the Medicaid Pharmacy Preferred Drug Governor's office. Also present were tient treatment model to relieve bur- Executive Committee provided reports. Program and the NYS Legislature's Richard Gallo, NYSPA Government dens currently placed on the mental In her President's Report, Dr. Cross pro- request to add antidepressants to the Relations Advocate, Seth P. Stein, Esq., health system. vided an update on public affairs activi- preferred drug list. Dr. Martin reported NYSPA Executive Director and General • E & M Claims: NYSPA raised con- ties. She announced that the APA Board that starting in 2011, Medicare providers Counsel, and Rachel A. Fernbach, Esq., cerns regarding the refusal of private has decided to sunset the APA Public NYSPA Staff Attorney. insurance carriers to process claims Affairs Committee and place it under [See Area II Council on page 5] NYSPA distributed and discussed the from psychiatrists for outpatient following list of key issues for the 2009 evaluation & management services. Legislative Session: In its first meeting, the NYSPA delega- • Timothy's Law: The law is scheduled tion met with staff members from the to sunset at the end of 2009 and office of Assemblyman Richard must be reauthorized by the Gottfried (D-Manhattan), Chair of the Legislature. NYSPA advocates that Assembly Health Committee. The staff the Legislature remove the sunset members expressed Mr. Gottfried’s sup- provision and make Timothy’s Law port for a permanent Timothy's Law and permanent. the support of NYSPA’s position on • State Budget Proposal: NYSPA raised many other issues currently affecting concerns about certain provisions in psychiatrists. In addition, they agreed to the state budget proposal affecting follow-up with the New York State the NYS Medicaid Preferred Drug Department of Insurance regarding the List, pharmacy benefit managers, and processing of E & M claims by private the influence of drug manufacturers insurance carriers. on prescribing practices. NYSPA is Next, the NYSPA delegation met with also concerned about proposed Kristin Sinclair, Committee Director, in budget cuts to Article 28 hospitals C. Deborah Cross, M.D., Richard Altesman, M.D.,Abraham Halpern, M.D., and Aaron Satloff, M.D. and resulting adverse consequences [See Legislative Day on page 2] THE BULLETIN FROM THE EDITOR’S DESK... By Jeffrey Borenstein, MD NEW YORK STATE his edition of the Paterson the next day. Council Meeting. We have a report PSYCHIATRIC Bulletin provides an The President’s Report about serious mental illness and ASSOCIATION T update on NYS leg- focuses on the relation- increased cardio metabolic risk and a islative issues including the ship between psychia- report on the Medicare RAC Audit Albany Report and the trists and the pharmaceu- Editorial Board Program. I am also pleased to have a NYSPA Legislative Day. tical industry. The Area II Jeffrey Borenstein, MD report about a Mental Health Editor-in-Chief The State Senate unani- Trustee Report focuses on Holliswood Hospital mously passed the the challenges our organ- Community Education event spon- 87-37 Palermo Street Timothy’s Law Perma- ization is facing on the sored by the American Psychiatric Queens, NY 11423 nency Bill, and it was national level. We also Foundation, which was hosted by Tel: (718) 776-8181 ext. 321 signed by Governor Jeffrey Borenstein, MD report on the Area II Holliswood Hospital. ■ Fax: (718) 776-8551 e-mail: [email protected] http://www.nyspsych.org/web- pages/bulletin.asp President’s Message continued from page 1 Manoj Shah, MD Ann Sullivan, MD patient care and should not accept tionships with industry. APA needed to take on this issue, par- samples for themselves or their ticularly in light of the current climate Rachel A. Fernbach, Esq. The report then lists a number of rec- families. and the recent Institute of Medicine Assistant Editor ommendations relevant to psychiatrists 4) Attendance at industry-supported who conduct research on pharmaceuti- report released in April 2009 (which Robert J. Campbell III, MD educational programs: The recom- cals and devices which I will not list contained many of the same recom- Editor-in-Chief Emeritus mendation is that psychiatrists only here, but urge you to read if these are mendations as the Work Group report). Leslie Citrome, MD, M.P.H. participate in educational sessions pertinent to you and your work. Some Assembly members who Editor-in-Chief Emeritus that are ACCME-accredited or oth- The report closes with a final paragraph expressed the view that the report did erwise have procedures which which is worth quoting in its entirety: not go far enough and that the recom- PLEASE NOTE: NEW ADDRESS ensure that speakers are fully “These recommendations are intended mendations should, in fact, be man- New York State Psychiatric responsible for the content. Any as a ‘living document’, subject to dates on all members. However, Association payment for travel and lodging to this view was, in my opinion, in the 400 Garden City Plaza, Suite 202 amendment as additional issues require Garden City, NY 11530 attend CME programs should be attention and as new approaches are minority. (516) 542-0077; Fax: (516) 542-0094 declined as gifts. developed to the subjects addressed Dr. Appelbaum stated that our culture e-mail: [email protected] 5) Planning and presenting at indus- here. It is hoped that they will stimu- has changed and is continuing to http://www.nyspsych.org try-supported educational pro- late reflection and discussion among change and that what was seen as total- grams: The recommendation is psychiatrists, and will contribute to ly acceptable behavior in the past is Executive Committee 2008-2010 that psychiatrists other than heightened awareness of concerns stem- now viewed by many as suspicious and C. Deborah Cross, MD, President salaried employees of pharmaceuti- ming from relationships with industry.” presenting conflicts of interest in our Glenn Martin, MD, Vice President cal and device companies not par- The Reference Committee did not role as physicians. It is certainly true Seeth Vivek, MD, Secretary ticipate as presenters in industry- report its discussions about the Report that our profession, over time, has Darvin Varon, MD, Treasurer sponsored speakers’ bureaus or to the entire Assembly, since they were changed its view as to what is accept- James Nininger, MD, Area II Trustee similar activities. Any involvement given instructions that the assignment able behavior. We need only look a Seth Stein, Esq., Executive Director as a speaker should be limited to of the Report to the Reference few years back when there was great Barry Perlman, MD, Past President programs that are ACCME-accredit- Committee was for the purpose of hear- controversy as to whether it was accept- ed. ing debate. Rather, on Sunday morn- able to have personal romantic rela- Information for Contributors 6) Consulting arrangements: The rec- ing, Dr. Appelbaum came before the tionships with out patients to under- The Bulletin welcomes articles and ommendation is that psychiatrists entire Assembly and discussed the stand that time does change the way we letters that NYSPA members will avoid participation in consulting report and answered questions. Again view what is acceptable professional find timely, relevant, and compel- arrangements in which “they are there was no Assembly vote on the behavior. ling. Articles should be between unlikely to make substantive con- Report, since the Assembly was told The APA as a body, and specifically the 750 and 1500 words (three to five tributions.” that the purpose of the discussion was leadership and high profile members, double-spaced manuscript pages) 7) Contact with pharmaceutical and for feedback to the Board. have been under attack by the govern- and letters no more than 750 device representatives: The recom- Personally, it appeared to me that there ment (e.g., Senator Grassley), the press words. All submissions must be mendation basically states that in was considerable controversy about a and other entities for real and perceived made electronically, preferably by any contact with such representa- number of the recommendations. conflicts of interest and secrecy regard- email to the editor. All authors are tives, psychiatrists should be aware Without going into detail about the ing our relationships with Pharma. The encouraged to also provide a pho- that the role of such representatives specific recommendations, one of the Board has taken the position that our tograph of themselves which will is to market their products and major general concerns voiced by many profession needs to police itself and be printed alongside their article. “seriously consider the issues present was the fear that what was pre- this Report is a first step. Whether it is described above and the implica- sented as “recommendations” could adopted in its current form as “policy” Information for Advertisers tions for patient care before decid- quickly morph into “requirements” and of the APA or whether there are minor The Bulletin welcomes advertise- ing whether to interact with them.” that a psychiatrist who did not follow or significant changes to the Report is ments from both NYSPA members 8) Disclosure of relationships with the “recommendations” could be found really up to the membership. The rank and commercial enterprises. Total pharmaceutical and device compa- “unethical” by APA standards. and file of the APA needs to acquaint circulation averages 5,500 copies nies: The recommendation states Additionally, many expressed the con- themselves with the Task Force Report, per issue. The Bulletin is received by that the APA encourages develop- cern that the APA was not sensitive to discuss it at your District Branch meet- members of the American ment and adoption of uniform and the concerns of its many diverse mem- ings, ask questions of your leadership Psychiatric Association who belong accessible formats for disclosures bers and their day-to-day issues (in and each other and then let your opin- to a district branch in New York required by academic institutions, other words, this was seen by many as a ions be known—to the Board of State. The Bulletin is also sent to the funding agencies, journals, and “top down” edict which was at odds Trustees of the APA, your Area 2 Trustee leadership of other district branch- other entities. with most people’s current professional on the Board, Jim Nininger, to me, your es across the United States and to 9) Ethics Education: The recommen- lives). Representative to the APA Assembly New York State legislators, medical dation is that psychiatrists and A number of Assembly members and other leadership of the APA. libraries, and science writers. The trainees engage in on-going educa- praised the report for its balanced and Contact me at [email protected]. I Bulletin is published quarterly. tion on ethics issues about rela- thoughtful language and felt that the look forward to hearing from you. ■ Both classified advertisements and display advertisements are avail- able. Please contact the editor for current rates and media require- Legislative Day continued from page 1 ments. NYSPA members receive a the office of Senator Shirley Huntley Services, both in the Office of the Disabilities. Assemblyman Rivera discount of 50% off the basic clas- (D-Queens), Chair of the Senate Mental Governor. Issues discussed included expressed his support and concern for sified ad rate. Health and Developmental Disabilities Timothy's Law, possible hospital clos- all of NYSPA's legislative priorities and The opinions expressed in the arti- Committee. The group conveyed its ings, possible improvements to SOMTA, other issues facing psychiatry. He stated cles or letters are the sole responsi- appreciation for the Senator’s sponsor- and the proposed changes to the that he is actively working to ensure the bility of the individual authors, ship of a permanent Timothy’s Law bill Medicaid program. Mr. Baker also reauthorization of Timothy's Law prior and may not necessarily represent and discussed SOMTA and its use of the agreed to speak with a contact at the to its sunset at the end of the year. the views of NYSPA, its members, mental health system, proposed cuts to Department of Insurance regarding the "The day was very successful because it or its officers. Article 28 hospitals, and concerns processing of E & M claims submitted gave NYSPA representatives the oppor- regarding the activities of pharmacy by psychiatrists to private insurers. tunity to sit down at the table with key Graphic Design & Production benefit managers. Finally, NYSPA representatives met with policy-makers in Albany and to outline Lydia Dmitrieff The third meeting was with Joe Baker, Assemblyman Peter Rivera (D-Bronx), vital issues affecting our members, our A to Z Design Group Deputy Secretary for Health and Chair of the Assembly Standing patients and the mental health commu-
Page 2 New York State Psychiatric Association • THE BULLETIN Summer 2009 American Psychiatric Foundation, New York Psychiatrists Bring Mental Health Education to the Community By Rhondalee Dean-Royce ne in five people has a diagnos- Psychiatric Association; James Nininger, able mental disorder, but fear M.D., Clinical Associate Professor of O and shame can prevent them Psychiatry of Cornell University from seeking help. That message rang Medical College and Janet Susin, through the halls of Holliswood President of the National Alliance for Hospital in Queens, New York on June the Mentally Ill for Queens/Nassau of 16 during an event appropriately New York. named Community Connections: Let’s The event featured a wide range of top- Talk Depression. ics surrounding depression, from its The event, the last in a year-long series general warning signs and the treatment of community-based educational pro- of depression to the impact on cultural- grams, sponsored by the American ly diverse populations to its impact on Psychiatric Foundation, provided audi- the elderly. ence members with real information According to Dr. Bernstein, who intro- and resources about depression and duced the program, major depression other mental illnesses along with the can and does affect about 8 – 10 per- ability to ask questions about treatment cent of the population and tends to run options available in their communities. in families. Depression; however, is Left to right: Glenn Martin, M.D., Paul Burke, James Nininger, M. D.,Annelle Primm, M.D., MPH, These events help remove the stigma of treatable with medication, psychothera- Janet Sussin, C. Deborah Cross, M.D., Carol Bernstein, M.D., and Jeffrey Borenstein, M.D. mental illness and demonstrate that for py and other treatments, resulting in 80 people living with a mental illness to 90 percent of those individuals even- on the impact the illness has on the He added, “If you learn how to spot the there is help, there is treatment and as tually responding well and almost all older adult community. Dr. Nininger signs of depression and seek treatment, Dr. Jeffrey Borenstein, who hosted the gaining some relief from their symp- shed some light on the issue of depres- the golden years can certainly be happy event in New York stated, there is hope. toms. sion taking a heavy toll on older adults and vibrant.” The speakers consisted of the top men- Dr. Primm, who discussed disparities in if left alone. “Increasing community members’ abili- tal health experts across New York and mental health care for diverse cultures, According to Dr. Nininger, depression ty to identify depression in common the country including Jeffrey stated the disparities are often based on in the elderly is a common problem; settings such as school, work and Borenstein, M.D. Chief Executive factors of economics and cultural expe- however, only a small percentage gets home, and to tell them where to seek Officer/Medical Director, The riences. “African Americans carry a the help they need. The reason is the help in their community is an incredi- Holliswood Hospital; Carol Ann heavy burden when it comes to depres- disease is often overlooked. The elderly ble tool we offer with this educational Bernstein, M.D., DIO and Associate sion because they are less likely than face such issues as a death of a spouse program,” said Dr. Borenstein. Dean for Graduate Medical Education, Caucasians to seek mental health servic- or ongoing medical problems, or social “Providing communities with an Bellevue Hospital Center and President- es or to receive proper diagnosis and exclusion. “Some assume seniors have increased understanding of the impor- Elect of the American Psychiatric treatment. They are also more likely to good reason to be down or that depres- tance of early recognition and treat- Association; Annelle B. Primm, M.D., have depression for longer periods, sion is just part of aging. This can lead ment of depression will result in overall MPH, Director, Office of Minority and resulting in greater disability,” she said. to depression, especially for those with community health and well-being.” ■ National Affairs of the American Discussions on depression also focused no support system in place,” he said.
Albany Report continued from page 1 partners was full funding, $99,200,000 Law Campaign. Governor Paterson requirement. licensure) from entities that were not to be exact, to continue the small busi- introduced legislation on May 5, 2009, • Prohibits insurers and HMOs from authorized under law to provide such ness subsidy provided for in the origi- to make Timothy’s Law permanent on treating a “participating provider as clinical services. nal Timothy’s Law. what would have been Timothy a non-participating provider.” However, we strongly oppose the pro- The budget did not expand the New O’Clair’s 21st birthday. In the Assembly, visions of the bill that propose to Scope of Practice/Licensure Issues York State Medicaid preferred drug list the Governor’s bill, A8611, introduced solve the narrow licensing problem by Assemblyman Morelle (D-Rochester) Late in the session, NYSPA worked to include anti-depressants, as was pro- by an unprecedented and dramatic posed by the Governor and supported and others, passed unanimously, 148-0. feverishly to prevent the passage of a by NYSPA. By the same token, a provi- The Senate companion bill, S5672, State Education Department (SED) pro- expansion of the long-standing sion that sought to give pharmacy ben- introduced by Senator Huntley (D- gram bill, which would have suspended restrictions on the corporate practice efit managers (PBM) the authority to Queens) and others, is currently on the corporate practice of a profession of a profession. This bill would estab- switch patients from a prescribed medi- third reading. Although there is a great doctrine to accommodate certain licens- lish a mechanism to permit both not- ation to an alternative medication and deal of uncertainty surrounding the ing problems at the SED. For over a for-profit agencies and for-profit a proposal eliminating “physician over- Senate these days, the bill is expected to year, SED has been rejecting license business (including publicly owned ride” of the PDL formulary, both pass once some semblance of normalcy applications of psychologists, clinical corporations) both those that have opposed by NYSPA, were not adopted resumes. social workers, mental health coun- provided and those that have never leaving physicians prescribing authority Unfortunately, a bill that would require selors, marriage and family therapists, provided such clinical services to reg- intact. Also, the $400 increase in the the Healthy NY program, which insures and creative arts therapists, who ister with the Education Department physician biennial registration fee was 153,000 New Yorkers, to provide cover- received their post-graduate clinical and thereby become authorized to not adopted. age for biologically-based mental ill- experience in a program or agency that provide such professional clinical nesses enumerated in Chapter 748 of lacked an appropriate state agency The final budget did not include all of services including psychotherapy and the changes Governor Paterson pro- the laws of 2006 is not expected to operating certificate or whose organiz- counseling services. This last step is posed for the New York State Sex progress at this time. In addition, a bill ing documents expressly prohibit the Offender Management and Treatment that would expand the list of biologi- provision of Title VIII professional serv- both unacceptable and unnecessary.” Act (SOMTA) that would have cally-based mental illnesses covered ices. The below excerpt from NYSPA’s The bill died in the Assembly and is not addressed some of NYSPA’s concerns under Timothy’s Law to include post- Memorandum of Opposition indicates expected to pass in the Senate. with the program. However, the traumatic stress disorder faces uncer- our concerns about the bill: Other Matters of Interest tainty even though it sits on third read- changes that were enacted included: “We strongly support the provisions The Assembly passed a bill creating a ing in the Senate. of the bill to extend for an additional • Certain respondents will be Child Psychiatry Access Project that allowed to remain on parole or in two years the exemption from the Managed Care Reform would ensure primary care providers the custody of the Department of The fate of Governor Paterson’s propos- psychology, social workers and men- Correction pending their civil con- tal health practice acts for individuals obtain “timely” access to child psychia- al for managed care reform remains try consultations. finement trials resulting in a sav- unclear even though the Assembly employed by programs operated, reg- Whether it’s the bill that would prohib- ings of $15.2 million. unanimously approved it before ulated, funded, or approved by a New • Planned staff will be reduced by adjourning. Provisions of the proposed York state or federal agency, political it a health care provider’s participation 217 jobs saving $11.7 million. legislation, as drafted, include: subdivision, municipal corporation in torture, regulate the use of electro- • Giving a provider 90-day notifica- or local government agency or unit. convulsive therapy, or permit certain • The Office of Mental Health will This extension is necessary to ensure specialties to establish certain profes- adapt its treatment of sex offenders tion of an “adverse reimbursement the continuity of care and services sional services corporations, we will from an inpatient to an outpatient change” and subsequent opportu- nity to cancel the contract. provided by such entities. continue to track and monitor the legis- model that is comparable to other We also strongly support efforts to states and more cost efficient. • Requiring insurers and HMOs to lation as it progresses juxtaposed to resolve the problem of individuals NYSPA’s interests. Timothy’s Law/Insurance Parity pay an electronic claim within 30 pursuing licensure pursuant to New York is as close as it has ever been days. Education Law Articles 153 (psychol- Finally, we continue to pursue clarifica- to prohibiting mental health insurance • Codifying an insurers and HMOs ogy,) 154 (social worker), and 163 tion from the New York State Insurance discrimination thanks in part to culpability to locate and pay for- (mental health practitioners) who Department regarding the use of evalu- NYSPA’s tireless work and relentless mer policy holders dividends if obtained supervised clinical experi- ation and management codes by psy- advocacy by members of the Timothy’s they fail to meet a certain loss-ratio ence (necessary in order to secure chiatrists. ■
Summer 2009 New York State Psychiatric Association • THE BULLETIN Page 3 AREA II TRUSTEE’S REPORT By James Nininger, MD
Committee, and Work Groups developing Governance, chaired by Dr. Alan Council on Communications DSM-V and Practice Guidelines. At the Shatzberg, the Board of Trustees voted in Council on Advocacy and Government March Board meeting, Work Group reports March to approve a major restructuring of Relations were received on topics such as the its governance functions. The following Council on Healthcare Systems and Integration of Psychiatry and Primary changes were implemented immediately Financing Care, and the Relationships Between after the end of the APA Annual Meeting. Council on Minority Mental Health and Psychiatry and the Pharmaceutical and The current 14 councils have been consoli- Health Disparities Medical Service Industries. dated into nine councils, most committees Council on Psychiatry and Law This past year those of you with email (a total of 68) under these councils were Council on Medical Education and addresses on file with NYSPA received a sunset, and many of the functions of those Lifelong Learning James Nininger, MD short survey to tap your views on a num- committees are being rolled into the Council on Research and Quality Care ber of related issues that were coming appropriate councils. The councils will The Assembly budget was reduced by 20% before the Board in March. meet twice a year, once at the annual for the year 2010. (The original recom- he APA is facing the challenge of Approximately 300 members responded meeting and once in September. mendation from the work group on gover- how to best use our resources in a and the results were published in my New Task Forces, as needed, will be used nance had been 40%.) The Board of T time of general economic hardship. report in the last NYSPA Bulletin. I would to address specific issues in a time-limited Trustees eliminated three voting members We are re-examining our relationship with like to periodically use this mechanism to fashion to offset the loss of some commit- and one non-voting member and reduced industry and attempting to be more forth- get members’ feedback on a number of tees’ functions. meetings to three per year. The Joint coming and transparent in disclosing pos- important issues facing us as psychiatrists The following nine councils were created Reference Committee budget was reduced sible conflicts of interest especially if serv- and facing our Association. or retained to work on new priorities: by 70%. These actions will hopefully ing on professional groups that set policy The APA previously had over 90 commit- enable the APA to maintain its financial or exert considerable influence such as the Council on Adult Psychiatry tees and councils. On the basis of the rec- reserves and operate within a balanced Board of Trustees, Assembly Executive Council on Children, Adolescents and ommendations of the Work Group on Their Families [See Trustee's Report on last page)
Serious Mental Illness and Increased Cardiometabolic Risk: What the Research Says By Veronica Hackethal MD, MSC
he landscape of psychopharma- same time implicating atypical antipsy- recommendations draw attention to University a national Scientific Advisory cology has changed, especially chotics with cardiometabolic problems. screening and monitoring for metabolic Committee was established to support T concerning antipsychotics and Further studies have confirmed the rela- syndrome, a group of risk factors that development of quality indicators, clin- their associated risk of cardiometabolic tionship between second generation increases a person’s chances of develop- ical recommendations, and educational adverse effects. Increased cardiometa- antipsychotics and increased car- ing heart disease, adult onset (type 2) materials. The Scientific Advisory bolic risk may help explain why people diometabolic risk.456 diabetes, and stroke. Committee, Chaired by Jeff Lieberman, with serious mental illness have a life CATIE also brought attention to the dif- From a preventative medicine stand- MD, identified four antipsychotics as expectancy which is 20% shorter than ferential cardiometabolic risk of certain point, garnering awareness about the high risk for metabolic disturbance: the general U.S. population. The pri- second generation antipsychotics.7 The metabolic syndrome may be an impor- Chlorpromazine (Thorazine), mary cause of this premature mortality CATIE study showed that olanzapine tant way to forestall more serious med- 1 Olanzapine (Zyprexa), Quetiapine is heart disease. People with serious was associated with the greatest weight ical problems down the road. In peo- mental illness also suffer from diabetes gain and greatest increases in measures ple who are taking psychotropic med- (Seroquel), Thioridazine (Mellaril). at higher rates than the general popula- of glucose and lipid metabolism. ications that can increase cardiometa- Through these initiatives, web-based 2 tion. Moreover, studies have shown Further analysis of the CATIE results8 bolic risk—especially in those who CME courses are being developed. To that those with serious mental illness showed that after three months of treat- already have high cardiometabolic risk date, three courses are available on line also develop metabolic syndrome at ment, prevalence of metabolic syn- and are taking such medications—the at the PSYCKES Medicaid and the NYS very high rates. In the Clinical drome increased for olanzapine (from recommendations generally advise peri- DOH websites. A number of nationally Antipsychotic Trials of Intervention 34.8% to 43.9%), but decreased for odic monitoring of fasting blood glu- prominent psychiatrists have been Effectiveness (CATIE) study, even when ziprasidone (from 37.7% to 29.9%) cose, triglyceride and HDL cholesterol engaged in this effort including Dr. age, race, ethnicity, and body mass (p=.001). Moreover, a recent, independ- levels, as well as regular measurement Robert Findling of Case Western Reserve index (BMI) were controlled, men were ent literature review9 has shown that of weight/BMI/waist circumference and 85% more likely and women were olanzapine and clozapine carry the blood pressure. These recommenda- University, Dr. Christopher Correll of 137% more likely to have metabolic highest risk for cardiometabolic prob- tions also stress the importance of fami- Albert Einstein Medical College, and Dr. syndrome when compared to their lems. Another recent analysis using the ly history, past medical history, and eth- Alex Miller of the University of Texas counterparts without mental illness in a FDA adverse event data base found that nicity, which may all contribute to the Health Sciences Center, with introduc- representative sample of the general olanzapine, risperidone, clozapine, and tendency to develop metabolic syn- tions by Dr. Leiberman and Dr. Sederer. 3 U.S. population. quetiapine had higher associations of drome and related medical problems. In addition, quality indicators have 10 The underlying causes for this excess diabetes-related adverse events. In New York State, the Office of Mental been developed that look at the use of morbidity and mortality are multifacto- The APA has taken a leadership role in Health (OMH) is working collabora- high/moderate risk agents in the con- rial. They may stem from lifestyle fac- increasing awareness of the metabolic tively with the Department of Health text of co-morbid hypertension, tors, underlying disease mechanisms, as risks of antipsychotics, even before the (DOH) to increase physician awareness ischemic vascular disease, hyperlipi- well as limitations on access to and uti- CATIE study released its findings. In of the differences in risk profiles for demia, diabetes/pre-diabetes, and obe- lization of preventative healthcare. 2004, a joint effort between the APA, antipsychotics. They are working sity among consumers who are taking However, in recent years second genera- the American Diabetes Association together on a number of initiatives antipsychotic medications. NYSPA has tion antipsychotics have been increas- (ADA), the American Association of including a Continuous Quality been involved in these efforts, and has ingly associated with raised cardiometa- Clinical Endocrinologists, and the Improvement project in community bolic risk. The CATIE study brought North American Association for the mental health clinics, a prescriber edu- two representatives on the Stakeholder this issue to the forefront. The CATIE Study of Obesity developed consensus cation program for primary care physi- Advisory Committee. For more infor- results called into question the pre- recommendations for monitoring med- cians, and drug utilization review. mation and to access the CMEs sumed superior efficacy of second gen- ical abnormalities related to psy- Through collaboration with the New please visit: eration antipsychotics, while at the chotropic medication use.11 These York State Psychiatric Center/ Columbia https://psyckesmedicaid.omh.state.ny.us ■
1 Hennekens CH et al: Schizophrenia and increased risk of cardiovascular disease. American Heart Journal 50:1115-21, 2005. 2 Citrome et al: Incidence, prevalence, and surveillance for diabetes in New York State psychiatric hospitals 1997-2004. Psychiatric Services 57:1132-1139. 3 McEvoy JP et al: prevention of the metabolic syndrome in patients with schizophrenia: baseline results from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial and comparison with national estimates from NHANES II. Schizophrenia Research 80:19-32, 2005 4 Correll CU et al: Equally increased risk for metabolic syndrome in patients with bipolar disorder and schizophrenia treated with second-generation antipsychotics. Bipolar Disorders 10:788-797, 2008. 5 Ray WA et al: Atypical antipsychotic drugs and the risk of sudden cardiac death. New England Journal of Medicine 360 (3):225-235, 2009. 6 Daumit et al: Antipsychotic effects on estimated 10-year coronary heart disease risk in the CATIE schizophrenia study. Schizophrenia Research 105:175-187, 2008. 7 Lieberman JA et al: Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. The New England Journal of Medicine 353(12):1209-23, 2005. 8 Meyer JM, Davis VG, Goff DC, et al: Change in metabolic syndrome parameters with antipsychotic treatment in the CATIE schizophrenia trial: prospective data from phase 1. Schizophrenia Research 101:273-86, 2008. 9 Stahl SM, Mignon L, Meyer JM: Which comes first: atypical antipsychotic treatment or cardiometabolic risk? Acta Psychiatric Scandinavica 119:171-179, 2009. 10 Baker RA et al: Atypical antipsychotic drugs and diabetes in the US food and drug administration adverse event database: a systematic Bayesian signal detection analysis. Psychopharmacology Bulletin 42(1):11-31,2009. 11 American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 27:596-601, 2004.
Page 4 New York State Psychiatric Association • THE BULLETIN Summer 2009 AREA II TRUSTEE’S REPORT By James Nininger, MD
Area II Council continued from page 1
who adopt electronic health records Dr. Nininger also reported on the recent software will receive a subsidy in con- NYSPA survey sent via email soliciting nection with software costs. Finally, he member opinion on APA governance reported on various changes to the issues and the relationship between HIPAA privacy and security rules APA and the pharmaceutical industry. required by the American Recovery & NYSPA received a response from Reinvestment Act of 2009 that will be approximately 300 members, which phased in over the next 12-18 months. provided valuable feedback on impor- Darvin Varon, M.D., NYSPA Treasurer, tant issues. Dr. Nininger hopes that presented the financial statements for NYSPA will continue surveying mem- bers in the future. APA Update Carol Bernstein, M.D., APA President-Elect, provided an update on Board activities. The Executive Committee members at the Dais Board is currently working on a plan to reorganize APA councils, psychiatrists. To date, the NYS for her paper entitled "Suicide components and committees as a Insurance Department has not respond- Prevention: The suicide risk assessment way to save costs and preserve ed to NYSPA's request for guidance on and inpatient psychiatric hospitaliza- resources. Dr. Bernstein also this issue. tion." Dr. Hamilton presented a sum- reported that the Board would Executive Director's Report mary of her paper to the Council. like increase involvement Seth Stein, Esq., NYSPA Executive Second Place went to Abigail Dahan, between the APA and its allied Director, provided an update on M.D. for her paper entitled "A Proposed organizations and promote the NYSPA's lawsuit against the NYS Role for the Psychiatrist in the role of the APA as an umbrella Department of Health seeking to Treatment of Adolescents with Type 1 organization for all of organized enforce the provisions of a 2006 Diabetes." Third place was awarded to psychiatry. amendment to the New York Social Sophia Wang, M.D. for her paper enti- Bruce Hershfield, M.D., Services Law mandating that psychia- tled "Cardiovascular Risk & Memory in Assembly Recorder, provided Non-Demented Elderly Women." Dr. highlights from the recent Board meeting and reported on "The Lloyd Sederer, M.D. Action Paper," a new email newsletter written by and for 2008, 2007 and 2006 and January- members of the Assembly. March 2009, along with a comparison for the same time period for 2008 and Warren Williams Award 2007. Dr. Varon stated that dues rev- Aaron Satloff, M.D., and Richard enue is currently lower than it was at Altesman, M.D., presented the Warren this time last year due primarily to the Williams Award for Area II to Abraham timing of the dues mailing. Other fac- Halpern, M.D., a member of the tors for decreased revenues include a Westchester District Branch. Dr. decrease in the number of members Altesman recognized Dr. Halpern, a and an increase in the number of Life forensic psychiatrist, for his many con- Members, who no longer pay dues. tributions to organized psychiatry and the APA, his extensive publications in OMH Report the field, and for his participation in Lloyd Sederer, M.D., OMH Medical humanitarian and civil rights efforts. Director, provided an update on OMH Dr. Halpern thanked the Council for activities and initiatives. He discussed the honor and recognition. proposed budgets cuts to Article 28 hospitals and its potential effect on Legislative Committee mental health services, proposed sim- Barry Perlman, M.D., Chair of the plifications to the hospital survey NYSPA Legislative Committee, provided an update on NYSPA's lobbying efforts process and implementation of new Debby Standard and David Ho from Fountain Gallery clinic standards of care. in connection with the proposed New York State budget for 2009-2010. Area II Trustee’s Report trists receive 100% payment of the NYSPA has made several suggestions in Medicaid share of the Medicare copay- Dahan and Dr. Wang each received a James Nininger, M.D., Area II Trustee to connection with proposed changes ment for patients who are covered by plaque. the APA Board of Trustees reported that affecting pharmacy benefit managers, both Medicare and Medicaid. The Fountain Gallery the Board has been re-evaluating its including restrictions on medication court dismissed the lawsuit on proce- Dr. Perlman introduced Debby relationship with the pharmaceutical switches, physician override of Medicaid dural grounds and the Executive Standard and David Ho from Fountain industry and may phase out pharma- prescribing restrictions, and influence of Committee has voted to appeal the dis- Gallery, an art gallery sponsored by drug manufacturers on physi- missal. Fountain House that exhibits and sells cians. In addition, NYSPA is artwork by individuals with serious advocating that the sex offender Second, Mr. Stein reported that psychia- mental illness. NYSPA was pleased to civil confinement program be trists are encouraged to submit E & M display various works of art from the restructured with a focus on out- codes for psychiatric services billed Fountain Gallery Annual Outsider Art patient treatment in order to alle- under Medicaid, in addition to Exhibit during its luncheon. viate burdens currently placed on Medicare. The use of E & M codes the mental health system. when billing private insurance carriers, Dr. Cross announced that the winner of NYSPA is also concerned with however, is still unresolved. Finally, Mr. the MIT Deputy Representative Election the affect that proposed cuts to Stein provided an update on the OMH is Louise Mullan, M.D., a resident at St. Article 28 hospitals will have on restructuring of the COPS reimburse- Vincent's Hospital. In addition, community and local mental ment methodology. The first phase of Norma Panahon, M.D., reminded health services. the new reimbursement system will members that the Western New York begin January 1, 2010. NYSPA has pro- District Branch is hosting is 5th Annual Dr. Perlman reported that posed eliminating the current require- Comprehensive Review of Psychiatry, a Timothy's Law, New York's men- ment that only a psychiatrist can sign three day event featuring speakers and tal health mandate, sunsets at the off on all treatment plans as a way to programs, to be held on July 10, 11 and end of 2009 and must be extend- better reallocate the time and expertise 12, 2009 in Buffalo, New York. ed, especially in light of the new of psychiatrists. Carol Bernstein, M.D. federal parity law, which is The meeting was concluded with expected to work with Timothy's NYSPA MIT Scientific Paper Contest reports from the following NYSPA com- ceutical-sponsored symposia. He Law to provide full parity for mental Glenn Martin, M.D., announced the mittees: Addiction Psychiatry, Public announced that reports from the Work health and substance use disorder bene- winners of the second annual NYSPA Psychiatry, Children and Adolescents, Group on Integration of Psychiatry and fits in New York State. Lastly, he pro- MIT Scientific Paper Contest. This year, Psychiatry and the Law, Membership, Primary Care and the Work Group on ■ vided an update on NYSPA's efforts to 21 papers were submitted for considera- Economics Affairs, MITs and ECPs. Relationships Between Psychiatry and ensure that private insurance carriers tion. First Place and a $500 cash prize the Pharmaceutical and Medical Service pay claims for E & M services billed by was awarded to Celine Hamilton, M.D. Industries are now available for review.
Summer 2009 New York State Psychiatric Association • THE BULLETIN Page 5 Permanent Medicare RAC Audit Program Now in Effect Albany continued By Rachel A. Fernbach, Esq. ffective March 1, 2009, the Centers chiatrists should be careful to respond protection for psychotherapy notes by review in Federal District Court. In for Medicare and Medicaid promptly to any request for records and requiring written patient authorization addition to an appeal based on the mer- E Services ("CMS") began imple- file appeals where appropriate. prior to use or disclosure, with some its of a disallowance, providers may also mentation of a permanent Medicare In order to identify potential underpay- exceptions. In order to be eligible for dispute whether the extrapolation audit program utilizing third-party ments and overpayments, RACs may use the heightened privacy protection, the methodology used by the RAC was sta- recovery audit contractors ("RACs"). two types of review: (i) automated psychotherapy notes must be main- tistically sound. The RAC will be RAC audits were originally authorized by reviews, using data mining techniques to tained separately from the rest of the required to return any contingency fees the Medicare Prescription Drug, identify obvious payment errors and (ii) medical record.) earned on an overpayment determina- Improvement, and Modernization Act of complex reviews, using data analysis and Providers who do not agree with an tion that is ultimately overturned on 2003, to assess the use of recovery audit review of records to determine whether overpayment determination may appeal appeal. contractors in identifying Medicare an overpayment or underpayment the decision. Generally, the RAC appeals Any NYSPA member who needs assis- underpayments and overpayments and occurred. process is similar to the five-level tance in complying with a RAC records recouping overpayments. A three-year Under the permanent program, RACs Medicare appeals process: request should contact NYSPA Central demonstration project in five states, can only review claims paid on or after (i) redetermination; (ii) reconsideration; Office at 516-542-0077. For more infor- including New York, ended in March, October 1, 2007, and in the case of a (iii) review by an ALJ; (iv) review by the mation about RAC audits, visit 2008. In later legislation, Congress request for records, the initial request Medicare Appeals Council; and (v) www.cms.hhs.gov/RAC. ■ required CMS to include the RAC must be sent within three years of the demonstration project as a permanent date the claim was initially paid. In part of the Medicare program. The con- addition, there are limitations on the tractor currently assigned to New York number of records that a RAC may Trustee’s Report continued from page 4 (and five other states) is Diversified request from a provider. For 2009, for a Collection Services, Inc. sole practitioner, a RAC may request no budget. mendations from this report to elicit your The RAC audit program is unique more than 10 records within a 45-day The central APA staff has been serving us responses and opinions. because it is the only CMS audit pro- period. For a group of between two and well in spite of hiring and promotion The desired outcome is that the APA will gram that compensates contractors on a five providers, the limit is 20 records freezes, loss of FTE positions, decrease in become less unwieldy and more lean, contingency fee basis. In other words, within a 45-day period. the merit pool, etc., and has maintained focused and efficient. It remains to be the RAC will receive a portion of all Providers being audited must respond to good morale under the leadership of Jay decided whether the governance structure Medicare overpayments that it correctly a request for records within 45 days of Scully, our Medical Director. will undergo any further fundamental identifies. Further, RACs are permitted the request, although the provider may At the March Area Council meeting, I changes and, as you know, an Action Paper to use extrapolation methodology and request an extension prior to the original reported on, and made available, a Report arising from Area II proposed a scaling can receive their full contingency fee on deadline. Psychiatrists who are subject of the Workgroup on Relationships down of the Assembly, but only if that is extrapolated claims. This has the poten- to HIPAA and who receive requests for Between Psychiatrists and Pharmaceutical coupled with a new unicameral gover- tial to turn a relatively small overpay- clinical records that include psychothera- and Medical Device Industries. The nance structure. The task is how to deter- ment into a very large overpayment, py notes must ensure that the patient Assembly did not support the Report as mine and advance our priorities, maximize which will also result in a very large fee has signed a HIPAA authorization before currently written, but many of the suggest- two-way communication between our for the RAC. This financial incentive releasing such psychotherapy notes. ed items can serve as an important stimu- elected representatives and our members, suggests that RACs may utilize extrapola- (Note: The HIPAA "psychotherapy notes lus for discussion. I plan to send out and how to best serve our patients and tion whenever possible. As a result, psy- exception" provides heightened privacy another “e-survey” on the suggested recom- profession. ■ New York State Psychiatric Association State Psychiatric York New Association American Psychiatric Area II Council - 400 Garden City Plaza Suite 202 Garden City, NY 11530
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