AMA Opposes Mental Health Carveouts  

Barry Herman, MD

In an extraordinary demonstration of support for parity of mental health care, and the fight against discriminatory managed care practices, The AMA House of Delegates passed a Resolution proposed by the Minnesota Medical Association (MMA) to encourage payers to eliminate mental health and chemical dependency carveouts. The Resolution was approved at the Interim Meeting of the AMA’s House of Delegates in Orlando, FL, December 3-6, 2000. The phenomenon of carving out mental health care, that became more prevalent in the 1980’s as a response to increasing mental health care costs, has resulted in the proliferation of predatory, for-profit managed behavioral health care organizations (MBCO). Recent data reveal that more than one hundred and seventy million Americans currently have their mental health care managed by an MBCO. Patients and mental health care practitioners have long recognized the destructive impact on mental health treatment in a carveout system. 

The Resolution, shown below, has an interesting history. I have long been a strong and vocal advocate for the elimination of mental health care carveouts. In the spring, 2000 I was invited by the Washington, D.C. District Branch of the American Psychiatric Association (APA) to co-author an Action Paper calling for the APA to oppose mental health care carveouts. That Action Paper was presented to and passed by the APA’s Assembly last Spring. The Action Paper was referred to the APA’s Board of Trustees (BOT) for approval. However the APA BOT, for reasons that remain unclear, deferred voting on the proposal, and referred the Action Paper back to several of the organization’s Components for review and revision.

During this period of time, several Minnesota psychiatrists submitted a similar proposal that employed essentially the same language as that of the original APA Action Paper. That proposal was approved by the MMA, and ultimately proposed to the AMA’s House of Delegates last month. The APA Delegate Representatives to the AMA, under strong pressure, publicly supported the MMA’s Resolution. Several other state medical society have approved, or are in the process of approving, similar resolutions calling for the elimination of mental health and chemical dependency treatment carveouts. While it is unfortunate that the APA did not take the lead in this unequivocal condemnation of carveouts, the AMA Resolution is a huge step in the right direction in our struggle to end these discriminatory practices. The next battle should focus on efforts to convince health plans and purchasers of health care to integrate mental health care and chemical dependency treatment back into the body of the general medical care system.

The following is the AMA Resolution:    

American Medical Association House Of Delegates  

Resolution:  702 (I-00)  

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 payers 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.

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