AAGP California member Alex Threlfall, MD, took California’s Assembly Bill 48 (AB 48) seriously. The measure puts prescribers at risk of a misdemeanor charge if they prescribe psychotropics other than antidepressants to long-term care patients without obtaining written consent within 24 hours. “Long-term care patients may not be able to give informed consent for medication, ” Amita Patel, MD, said. “It can take weeks to contact families and guardians for medication consent for a patient with an acute need that, if ignored, will result in hospitalization,” Dr. Patel added.
Concerns that opposition to mental health treatment in nursing homes could spread to other states, Dr. Threlfall alerted the AAGP Board of Directors. Recognizing the national consequences of the California bill and the necessity of a collaborative effort to address the criminalization and access restriction, AAGP President (Dr. Helen Lavretsky) and President- Elect (Dr. Sandra Swantek) worked with Dr. Threlfall to craft communications opposing the California Assembly bill.
Efforts then turned to national physician organizations with added clout and resources. AAGP leadership and Dr. Threlfall were joined by our AAGP delegates to the AMA House of Delegates, Allan Anderson, MD, and Vanessa Stan, MD, to produce two resolutions, one for the Council of the American Psychiatric Association (APA) and a second for the American Medical Association (AMA) House of Delegates. The resolutions met submission deadlines with additional support from Tissy Greene, AAGP Interim Executive Director, APA staff, and a flurry of resolution revisions as the group wrote and rewrote the documents. After a period of lobbying other groups and additional edits, the two resolutions passed in the APA Council and the AMA House of Delegates, with AAGP leading the effort and with the backing of the California Medical Association, the American Medical Directors Association, and the physicians representing Geriatric, Internal Medicine, Family Medicine, Neurology, and Emergency Medicine.
The APA and the AMA resolved to work with key partners to advocate that CMS revise existing measures for psychotropic prescribing in nursing homes to ensure nursing home residents have access to all medically appropriate care.
The APA Council on Geriatric Psychiatry and Government Relations staff will work with the APA/AMA Delegation to take the steps necessary to ensure that medical decision-making and medical records documentation, exercised in good faith, do not become a violation of criminal law and that legislative or regulatory measures do not incentivize the discrimination of all those living with mental illness.
Prior resolutions put the AMA on record as opposing the criminalization of physicians providing medically proper care.
Helen Lavretsky, MD, MS – Editorial Comments
As an organization, the AAGP may be small but mighty, as when we work together, we get things done. The recent proof of our accomplishments is in two successful resolutions advocating for our patients and our peers is the work of many hands working quickly. We thank Drs. Alexander Threlfall, Vanessa Stan, Allan Anderson, Sandra Swantek, Gary Epstein-Lubow, and Melanie Scharrer for putting in late hours for this, and to our colleagues at the APA and AMA for the smooth and timely passing of the resolutions.
Restricting access to evidence-based treatment and criminalizing physicians caring for patients harms aging adults indiscriminately and deprives vulnerable nursing home residents of dignity and quality of life. The California legislation echoes laws limiting women’s access to health care in many states. Legislation criminalizing evidence-based care, medical decision making, and restricting access to treatment will harm patients wherever in the country it is proposed.
While the AAGP acknowledges cases of inappropriate diagnosis and prescribing, these cases demonstrate the need for greater oversight and training, not denying access to evidence-based treatment or criminalizing medical decision-making.
The Centers for Medicare and Medicaid (CMS) impose national quality measures in long-term care settings through quality measures limiting antipsychotic use in nursing homes to only three diagnoses—schizophrenia, Tourette’s syndrome, and Huntington’s disease and excludes evidence-based use of antipsychotic medications for other psychiatric conditions.
AAGP members report a pattern of inappropriate patient discharges from nursing homes to emergency departments after facility discontinuation of medically appropriate psychotropic medication for chronic mental illnesses such as bipolar disorder, treatment-resistant depression, or severe behavioral disturbances of dementia.
Criminalization of medical decision-making and restricting access to care threaten the very existence of long-term care facilities, which cannot effectively support their patient’s and workforce’s health and well-being.
We anticipate further collaboration with our peers and healthcare professional organizations and consumer advocacy to encourage change that ensures that older adults receive evidence-based psychiatric and medical treatment from physicians who do not fear criminal repercussions for giving appropriate evidence-based care.