AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES
Resolution: 702
(I-00)
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Introduced by:
Minnesota Delegation
Subject:
Elimination of Mental Health and Chemical Dependency Carve-Outs
Referred to:
Reference Committee G
(Patricia G. Klein, MD, Chair)
Whereas, Current American Medical Association policy supports integrated and concurrent
medical, surgical, and psychiatric care regardless of the clinical setting (H-345.983); and
Whereas, Coordinating physical and mental health care can be complex whether programs are
integrated or carved out; and
Whereas, Coordination is more problematic when there is a carve-out because benefit
packages, provider networks, payment systems, and program administration are separate for
the mental health carve-out and the general medical program; and
Whereas, Mental health carveouts reinforce the stigmatization of psychiatric illness, isolate
psychiatrists from medical care systems, and promote "cost shifting" at the expense of quality
patient care; and
Whereas, There has been a fair amount of new research on the impact of carve-outs, such as
work that showed poorer improvement in health status for Utah Medicaid enrollees with
schizophrenia who were enrolled in a carve-out, than for those in traditional Medicaid (Manning,
Liu et al); and
Whereas, The carve-out phenomenon has resulted in a disproportionate reduction in resources
allocated for mental health and chemical dependency treatment; therefore be it
RESOLVED, That our American Medical Association work to encourage payors to eliminate
mental health and chemical dependency carve-outs so that benefits for mental health and
chemical dependency are managed and administered like other health care services.
Fiscal Note: No Significant Fiscal Impact
Received: 10/26/00
Resolution: 702 (I-00)
Page 2
RELEVANT AMA POLICY
H-285.956 Mental Health "Carve-Outs"
The AMA advocate that all managed care plans that provide or arrange for behavioral health care adhere
to the following principles, and that any public or private entities that evaluate such plans for purposes of
certification or accreditation utilize these principles in conducting their evaluations:
(1) Plans should assist participating primary care physicians to recognize and diagnose the behavioral
disorders commonly seen in primary care practice.
(2) Plans should reimburse qualified participating physicians in primary care and other non-psychiatric
physician specialties for the behavioral health services provided to plan enrollees.
(3) Plans should utilize practice guidelines developed by physicians in the appropriate specialties, with
local adaptation by plan physicians as appropriate, to identify the clinical circumstances under which
treatment by the primary care physician, direct referral to psychiatrists or other addiction medicine
physicians, and referral back to the primary care physician for care of behavioral disorders is indicated,
and should pay for all physician care provided in conformance with such guidelines. In the absence of
such guidelines, direct referral by the primary care physician to the psychiatrist or other addiction
medicine physician should be allowed when deemed necessary by the referring physician.
(4) Plans should foster continuing and timely collaboration and communication between primary care
physicians and psychiatrists in the care of patients with medical and psychiatric comorbidities.
(5) Plans should encourage a disease management approach to care of behavioral health problems.
(6) Participating health professionals should be able to appeal plan-imposed treatment restrictions on
behalf of individual enrollees receiving behavioral health services, and should be afforded full due
process in any resulting plan attempts at termination or restriction of contractual arrangements.
(7) Plans using case managers and screeners to authorize access to behavioral health benefits should
restrict performance of this function to appropriately trained and supervised health professionals who
have the relevant and age group specific psychiatric or addiction medicine training, and not to lay
individuals, and in order to protect the patient's privacy and confidentiality of patient medical records
should elicit only the patient information necessary to confirm the need for behavioral health care.
(8) Plans assuming risk for behavioral health care should consider "soft" capitation or other risk/rewardsharing mechanisms so as to reduce financial incentives for undertreatment.
(9) Plans should conduct ongoing assessment of patient outcomes and satisfaction, and should utilize
findings to both modify and improve plan policies when indicated and improve practitioner performance
through educational feedback. (CMS Rep. 2, A-96)
H-345.983 Medical, Surgical, and Psychiatric Service Integration and Reimbursement
Our AMA advocates for: (1) health care policies that insure access to and reimbursement for integrated
and concurrent medical, surgical, and psychiatric care regardless of the clinical setting; and (2) standards
that encourage medically appropriate treatment of medical and surgical disorders in psychiatric patients
and of psychiatric disorders in medical and surgical patients. (Res. 135, A-99; Reaffirmation A-00)
H-345.992 Health Insurance Coverage of Psychiatric Illness
Our AMA (1) reaffirms its support for the provision of benefits for emotional and mental illness under all
governmental and private insurance programs which are equivalent in scope and duration to those
benefits provided for other illnesses; (2) reaffirms its support for the continued expansion and
improvement of peer review of the quality, necessity, and appropriateness of psychiatric services, and
encourages all third party payors to work with and to utilize the resources of appropriate medical specialty
groups in implementing such review; (3) supports development of model legislation for use by states to
require all insurance companies that offer either group or individual coverage of hospital, medical, and
surgical services to make available for purchase and affirmatively offer coverage of psychiatric services
comparable with the coverage provided for other illnesses in their standard group and individual policies;
and (4) supports legislation designed to expand psychiatric benefits provided under publicly financed
programs of health care to a level comparable with those provided for other illnesses. (CMS Rep. G, I-87;
Reaffirmation A-97; Reaffirmed: Sunset Report, I-97; Reaffirmed: CSA Rep. 7, I-97; Reaffirmation A-99;
Reaffirmation A-00)