AMA wants insurers to end mental health carve-outs

The House of Delegates resolves to get payers to stop using a payment system it says discriminates based on patient diagnosis and physician specialty.

By Cheryl Jackson, amednews staff. Dec. 25, 2000.

Orlando, Fla. -- In a move to stop the spread of medical carve-outs, the AMA House of Delegates resolved to encourage payers to get rid of those in the mental health and chemical dependency specialties.

Such carve-outs hinder the coordination of care, discriminate on the basis of patient diagnosis and physician specialty and result in fewer dollars being spent in those areas, opponents say.

Physicians fear that mental health carve-outs are a harbinger of the day when insurers will outsource all specialty care, causing confusion about how patients are covered. "In some ways, psychiatry is the canary in the mineshaft," said psychiatrist Thomas Allen, MD, of Towson, Md.

Physicians said funding for psychiatric care was inadequate even before the dominance of carve-out arrangements. Now, the moves have resulted in a disproportionate reduction in resources allocated for mental health and chemical dependency treatment, they said.

About a decade ago, mental health accounted for 7% to 8% of the health care dollar. Today, that's down to 3.5% to 4%, said Dr. Allen, an alternative delegate from Maryland.

About 72% of Americans with health insurance coverage were enrolled in managed behavioral health care organizations in 1999, the AMA Council on Medical Service reported.

Coordinating physical and mental health care can be complex whether programs are integrated or carved out, said the Minnesota delegation in one of two resolutions that addressed the issue.

Carve-outs make for more problems though, doctors say, because benefit packages, provider networks, payment systems and program administration are separate for the mental health carve-out and the general medical program.

Mental health carve-outs also reinforce the stigmatization of psychiatric illness, isolate psychiatrists from medical care systems and promote cost shifting at the expense of quality patient care, opponents say.

The Resident and Fellow Section also proposed a resolution for the AMA to encourage payers to eliminate the carve-outs so that those benefits are managed and administered like other health care services. Delegates adopted the Minnesota version.

Some doctors called for the resolution to be broadened to include all carve-outs, which the reference committee recommended. But after it was noted that there was not enough information on the impact of carve-outs in other specialties, the house adopted the stance on mental health and chemical dependency only.

The council report dealt only with mental health carve-outs, recommending steps to ensure patients protections with regard to quality, privacy and access, said council chair Joseph Heyman, MD.

"We have not looked at any other carve-outs, so I don't know how we can just decide that all carve-outs are bad," the West Newbury, Mass., obstetrician-gynecologist said.

Some physicians testified that the report was incompatible with the two elimination resolutions.

The council is preparing a report for the 2001 Annual Meeting addressing access to mental health services.