Scope of Practice

Congress plays name game to redefine “physician” under Medicare

Andis Robeznieks , Senior News Writer

What’s the news: The AMA, American Psychiatric Association (APA) and 86 other physician organizations are urging congressional leaders to oppose legislation that would change Medicare’s definition of “physician” to include clinical psychologists. Medicare statute requires physicians to diagnose patients, prescribe and manage medication, and supervise other medical staff.

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“This proposal jeopardizes the safety of patients in the Medicare program and would create silos in the delivery of appropriate mental and physical health care,” says the letter, written in opposition to the “Medicare Mental Health Access Act” (H.R. 884/S. 2772).

“This legislation runs counter to efforts to coordinate and integrate the delivery of care to patients with mental illnesses and co-occurring health conditions,” says the letter.

Why it’s important: The Centers for Medicare and Medicaid Services (CMS), in its Medicare Policy Benefit Manual, defines “physicians” as clinicians who medically diagnose patients, prescribe and manage medication, and supervise other medical staff.

The Policy Benefit Manual specifically states that clinical psychologists must consult with a patient’s attending or primary care physician during the course of providing psychological care. The proposed legislation, however, would change this policy.

Under the bill, clinical psychologists would be regarded as “physicians” and allowed to treat patients without doctor supervision throughout inpatient and partial-hospitalization settings. Partial hospitalization programs are designed for individuals with mental illnesses, specifically patients who may not meet the criteria for inpatient admissions but are too acutely ill to receive care in less intensive outpatient settings.

Although not required when clinical psychologists treat patients in an outpatient setting, physician supervision of a patient’s overall care is appropriate and necessary when it requires the intensive level of services provided as part of the Medicare inpatient or partial hospitalization benefit.

“Medicare patients in partial-hospital programs or inpatient settings with acute and serious mental illness often have multiple complex medical problems typically requiring several different medications to treat underlying illnesses,” the letter explains.

“Moreover, these patients often have chronic comorbidities ranging from severe depression to diabetes, hypertension, and cardiovascular disease,” the letter adds. “Psychologists are not trained to treat acute mental illness requiring medication management or co-occurring physical illnesses.”

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APA President Jeffrey Geller, MD, MPH, addressed this issue earlier this summer at a House Energy and Commerce Health Subcommittee hearing.

“Psychiatrists and the APA have a tremendous amount of respect for our psychologist colleagues and thank them for playing their important role in the delivery and provision of mental health care,” Dr. Geller added. “In many practices, psychiatrists and psychologists work together on a team with other providers such as nurses, physicians’ assistants, social workers and care managers.”

Dr. Geller noted the differences in training between physicians and psychologists, and these were also addressed in the letter. Physicians complete four years of medical school plus three to seven years of residency, including 10,000 to 16,000 hours of clinical training. Although they are an essential part of a physician-led care team, psychologists lack the requisite medical education, medication-management training, and clinical training that is critical in determining differential diagnosis.

“Given the complexity of this patient population, it is essential that we retain collaborative guardrails that require psychologists to consult physicians who have the education and training to effectively manage the entire treatment plan, including both physical and mental health services,” the letter explains.

The proposed legislation would not expand access to mental health and substance-use disorder services for Medicare beneficiaries because patients in inpatient or partial-hospital settings need care for acute mental and physical health conditions that require advanced medical training that psychologists do not have.

“If psychologists were allowed to manage these patients, they would not receive the full array of medically necessary services they require from an inpatient setting and, thus, access to the care that these patients truly need would be curtailed, not expanded,” the letter states.

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Legislation is unnecessary because Medicare already recognizes and allows psychologists to provide and bill for the services they are trained to perform, so the bill will not increase the “net number of mental health care providers in the community or the number of services that can be competently performed for patients,” notes the letter from the AMA and others.

Learn more: Patients deserve care led by physicians—the most highly educated, trained and skilled health care professionals. Through research, advocacy and education, the AMA vigorously defends the practice of medicine against scope-of-practice expansions that threaten patient safety.