by David Goodman, M.D.
[Spring/Summer 1998; Vol. 25 No. 1]
Jeffrey Janofsky, M.D., who assumed office as president of the Maryland Psychiatric Society in May, is a fourth generation Baltimorean. He met his wife Julie in the Pikesville High School marching band. She is an attorney specializing in employment law. They have two children, ages ten and eight.
Dr. Janofsky has been an educator and an active supporter of high-quality mental health services in Maryland for many years. He represents the American Academy of Psychiatry and the Law in the American Psychiatric Association, and he is a corresponding member on the APA's Council of Psychiatry and the Law.
Question: On what issues would you like to focus as president?
Dr. Janofsky: I believe the four principal areas are scope of practice issues for non-physician mental health practitioners, Medicaid and managed care issues, the ongoing issue of confidentiality and the Health Care Access and Cost Commission (HCACC) database, and regulations determining medical necessity decisions in managed care.
Question: Can you update us on the current state of prescription practice bills for non-physician mental health therapists?
Dr. Janofsky: The issue of psychologists seeking prescription privileges has been ongoing. Fortunately, we have successfully prevented this from occurring up to this point. The APA has been very instrumental in providing information and support for this issue nationally.
In Maryland, however, psychiatric nurse therapists have attempted to gain prescription privileges through bills introduced in the past two years. We have devoted considerable resources to defeating this bill. Until recently, however, nurse prescribing has been off the APA's radar screen. The MPS has successfully lobbied the APA to take a more active role in this issue.
Question: The Medicaid program has recently undergone significant changes under managed care. Can you explain the administrative structure and how the community mental health centers are suffering?
Dr. Janofsky: The recent change in the Medicaid program significantly affected the delivery of mental health services to the chronically mentally ill. Mental health services were carved out of the new system, and substance abuse treatment has been separated from mental health The Department of Health and Mental Hygiene devised a system to contract with an administrative service organization (ASO) to provide authorization and supervision for all psychiatric services. Maryland Health Partners, a new entity formed from a partnership between Greenspring Mental Health, Merit-Magellan and CMG, won the ASO contract. Significant startup problems have included slow payment, inconsistent authorizations, and an inadequate payment schedule.
Unfortunately, the fee structure has been set so low that it has jeopardized the financial stability of many community psychiatry programs. Several programs have already closed as a result. Psychiatric patients served by community programs often require broad services, yet many of these services are not reimbursable under the already inadequate fee schedule.
Question: Confidentiality for psychiatric patients in Maryland has been difficult to maintain, given the HCACC database. Does the HCACC program model exist anywhere else in the country?
Dr. Janofsky: No, the program for data collection is very intrusive into patient confidentiality and mental health treatment. HCACC receives from third party payers data on every single patient visit to a psychiatrist. This information is reported without the patient's knowledge or consent. We are working to secure modifications to this data collection process to protect patient confidentiality.
Question: Patients and mental health providers feel deep concern about managed care's medical necessity decisions when authorizing psychiatric treatment. How can the MPS make this process subject to independent review?
Dr. Janofsky: Deciding medical necessity for psychiatric treatment is a very difficult issue. With the many managed care companies, each following their own guidelines for deciding medical necessity, significant inconsistency in how these decisions are made results. Statewide guidelines for deciding all managed care psychiatric treatment issues would eliminate the inconsistency.
Question: Please tell us about your clinical responsibilities.
Dr. Janofsky: I have been an attending psychiatrist on an inpatient unit at Johns Hopkins Hospital for several years in a limited full time capacity. In addition, I maintain a small private outpatient practice. My teaching responsibilities include serving as director of the Psychiatry and Law Program at Johns Hopkins Hospital where I teach residents, co-director of the fellowship in forensic psychiatry courses in the department of psychiatry at University of Maryland, and teaching the ethics and forensic psychiatry courses in the department of psychiatry at Johns Hopkins Hospital. Given my patient care and teaching responsibilities, I have first hand experience with many of the issues concerning our society's membership.