[Main Page of Report | Contents of Report]
In this study, MPR identified several approaches to collecting personal health information under managed care, any of which could, if adopted more widely, reduce the amount of unnecessary personal health information that is shared by providers and MCOs. MPR does not endorse any of these specific approaches; we simply describe them in this chapter to further the discussion about how to reach a more privacy-sensitive state in managed care for mental health and substance abuse.
The Magellan Treatment Request Form, the Maryland Outpatient Treatment Plan Form, and the APA guidelines were each cited by at least one provider respondent as being privacy-sensitive approaches to collecting personal health information needed to manage care. Table IV.1 lists the information shared under each approach, by the type of information requested.
The Maryland Uniform Treatment Plan Form, which is reproduced in Appendix B, was mandated by the state legislature (Title 15, subtitle 10B of the Insurance Article and COMAR 31.10.21) in response to providers’ complaints about the administrative burden of having to complete many different forms for different MCOs. A committee comprising MCOs and provider representatives, led by the Maryland Department of Health and Mental Hygiene, developed the form, which was implemented in October 2000. A provider we spoke with in Maryland said the form has considerably reduced the amount of personal health information he must send to MCOs. This provider always talks with his patients about what information will be sent to their insurer and reports that he “has never had a patient tell him not to send the information, although some have been anxious about it. Now that the Maryland treatment form is in place, patients are much less concerned.” One respondent noted, however, that the form is not as sensitive to the information needs for substance abuse treatment as for mental health treatment. Some revisions might therefore be warranted if it were to be more widely adopted for both types of treatment.
| Type of Information | Magellan TRF | Maryland Uniform Treatment Plan Form | APA Guidelines |
|---|---|---|---|
| Patient Information | First name Date of birth Membership number Is patient on mental health or chemical dependency long-term or short-term disability? |
First name Date of birth Membership and group number Relationship to insured |
Name Date of birth Address Insurance information/ID number, Patient’s status (voluntary, involuntary) |
| Diagnosis | Dx code-Axis I and II Axis III: Does patient have a general medical condition potentially relevant to understanding or managing the Axis I or II conditions (yes/no)
Axis IV: Axis V: GAF score (highest past year, at first session, current) |
Dx code Axis I-IV
Axis V: GAF score (current, highest in past year) |
Axis I or “v” code
Axis II or III if relevant Axis IV or level of distress (none, mild, moderate, or severe) Axis V: GAF (current, highest in past year) or functional status (impairment: none, mild, moderate, or severe) |
| Previous Treatment | Number of times provider has seen the patient to date, by
CPT code
First date seen (this episode) |
Past two years:
Outpatient, partial hospital, residential treatment center, substance abuse intensive outpatient, other [all yes/no/unknown] Medical Hx Psychiatric meds (list, including name and dose) Compliance (yes/no) Side effects (yes/no) Comments Allergies Date first seen for current episode |
|
| Current Medications | Type, if any: anti-psychotic, hypnotic, anti-anxiety, etc. | List of psychiatric meds, with name and dose, in past two
years
Has patient been evaluated for medication (yes/no) Does patient follow medication regimen (yes/no) Comments (e.g., lab results, side effects) |
On psychiatric medications (yes/no) |
| Communicated with PCP or other relevant health care practitioners about treatment | Yes/no | Yes/no | |
| Symptoms/Risk Assessment | Rate the following symptoms as mild, moderate, or severe:
self-injurious behavior suicidal ideation homocidal ideation substance abuse problems |
Rate a list of symptoms that apply as mild, moderate, or
severe and indicate if it is a target or treatment; list of 56 symptoms in
the following categories:
social functioning/behavior cognitive/memory/attention mood/affect disturbance somatic disturbances anxiety perceptual disturbance substance use Risk assessment:
suicidality: ideation, plan, prior attempts (if known) other risk behavior comments Other assessment info (e.g., psych testing) Risk or relapse into chronic/acute symptoms: high, moderate, low, comments |
Level of distress (none, mild, moderate, or severe) or Axis IV rating |
| Other Services Client Receives | Other psychiatric, medical, or community
support services client receives
(type, e.g., group therapy, supportive housing) |
||
| Functional Assessment | Axis V: GAF score (highest past year, at first session, current) | Degree of illness-related impairment (none, mild, moderate,
severe) by category:
family relations job/school financial physical health legal friends/social |
Functional status (impairment: none, mild, moderate, severe) or Axis V (GAF: current, highest in past year) |
| Planned Treatment | Number of sessions requested, by CPT code
Duration for requested sessions |
Proposed treatment modality, with frequency and CPT code
for each:
individual group family medication conjoint other Estimated discharge date Expected number of visits Treatment plan discussed with patient, guardian, or other legal representative (if applicable) or parent of a minor (yes/no) Are additional health services required (yes/no, or referred to:) |
CPT codes, including recommended/expected frequency |
| Expected Treatment Outcomes | Check all that apply:
reduction in symptoms and discharge from active treatment return to highest GAF and discharge from active treatment transfer to self help/other supports and discharge from active treatment ongoing supportive counseling to maintain stabilization of symptoms ongoing medication management to maintain stabilization of symptoms |
Prognosis: the estimated minimum duration of treatment for
which authorization is sought
Estimated GAF at treatment’s completion |
|
| Additional Information | For first reviews, state additional information that may
help clarify the need for this outpatient treatment
For subsequent reviews, briefly state what progress has been made If no progress, indicate reasons and whether treatment plan is being revised to address targeted symptoms |
As shown in Table IV.1, the Maryland Outpatient Treatment Plan Form requests more information than the other two approaches, including previous treatment in the past two years, current medications, symptoms, functional assessment, and planned treatment.
Magellan’s Outpatient Treatment Request Form, reproduced with permission in Appendix C, was implemented in October 2001. The form, which replaces a request for a narrative description of the treatment plan, was developed partly in response to provider complaints about information requests but primarily because Magellan found it was not cost-effective to manage every case. One provider commented that “the Magellan form is back to the old style, where the MCO just required minimal information and trusted the clinician to make the right treatment decisions.”
The Magellan form requests more information than the APA guidelines, including current medications, the number of times the provider has seen the patient to date, and whether any of the following symptoms are mild, moderate, or severe: self-injurious behavior, suicidal ideation, homicidal ideation, and substance abuse problems. However, the form includes considerably less information than the Maryland Outpatient Treatment Plan Form on, for example, symptoms, planned treatment, and expected treatment outcomes.
The APA adopted Minimum Necessary Guidelines for Third-Party Payers for Psychiatric Treatment in December 2001 (reproduced in Appendix G). The guidelines “are based on the cumulative professional experience of APA members with respect to current practice and the necessity of privacy for effective psychiatric care.” The guidelines are also based on the principle that third-party payers should not ask for more information to approve psychiatric treatment than they would in order to approve treatment for physical health. Finally, the guidelines are founded on the current HCFA 1500 claim form and the protocol for disclosures to third-party payers as specified in the District of Columbia and state of New Jersey third-party mental-health privacy statutes (see Table IV.2).
The APA guidelines suggest restricting information sharing to a greater degree than either the Maryland or Magellan forms. For example, there would be no sharing of information on previous treatment or on whether treatment has been coordinated with a person’s primary care provider; and there would be only a yes/no question on whether the patient is on medications, for example.
While it is clear that the three approaches described above vary in how much information is shared, the context in which they are used or intended to be used must also be considered in order to understand the implications for consumers’ privacy. The Maryland Outpatient Treatment Plan Form is designed to provide all information that an MCO or other insurer needs to make a decision about approving or denying treatment. Although a denial can be appealed, this would require much more extensive information, probably the full medical record. One provider who was involved in the development of the Maryland form stated that, because only 0.5% of outpatient treatment requests are denied, appeals would be relatively rare.
| District of Columbia | New Jersey |
|---|---|
| “Information limited to:
Administrative information name, age, sex, address, identifying numbers, dates and character of sessions (individual or group) and fees Diagnostic information therapeutic characterization of the type found in the Diagnostic and Statistical Manual of Mental Disorder, or any comparable professionally recognized diagnostic manual The status of the client (voluntary or involuntary) The reason for admission or continuing treatment A prognosis limited to the estimated time during which treatment might continue If the 3rd-party payor questions the client’s entitlement to or the amount of payment benefits, they may, pursuant to a valid authorization, request an independent review of the client’s record of mental health information by a mental health professional or professionals. Mental health information disclosed for the purpose of review shall not be disclosed to the 3rd-party payor. Section 6-2017. District of Columbia Mental Health Information Act |
“Information limited to:
Administrative information Diagnostic information The status of the patient (voluntary or involuntary, inpatient or outpatient The reason for continuing psychological services, limited to an assessment of the patient’s current level of functioning and level of distress (both described by the terms mild, moderate, severe, or extreme. If the third-party payor has reasonable cause to believe that the psychological treatment in question may be neither usual, customary nor reasonable, the third-party payor may request, and compensate reasonably for, an independent review of the psychological treatment by an independent professional review committee. The State Board of Psychological Examiners shall, within 10 days of the notification, inform the treating psychologist of two or more members of the independent professional review committee who shall be known as “:reviewers” and who shall conduct the review. New Jersey Permanent Statutes: Title 45: Professions and Occupations Title 45:14-32. Disclosure to Third Party Payor |
On the other hand, the Magellan Treatment Request Form, which requests less information, is designed to provide all the information an MCO needs to approve most cases. All the study MCOs that use forms or interactive voice response systems follow up on some cases for more information, typically through calls from the case manager to the provider, before approving or denying payment for treatment. In Maryland, although payers are supposed to request only the information in the form, one provider told us that plans sometimes look for more but back down when reminded that this is not allowed. Providers can, however, submit additional information during the appeals process.
Under the APA guidelines, if an MCO or other insurer cannot make a decision based on the information allowed by the guidelines, then the case should be referred for review to a qualified psychiatrist who is independent of the insurer, whose cost will be borne by the insurer, and who would be given access to the clinical information necessary for assessing the need for treatment. This approach is similar to the provisions of the DC and New Jersey privacy laws (see Chapter I). We could not identify any information that would suggest either the benefits or costs of this approach based on the DC and New Jersey experiences.
The benefits of the DC and New Jersey laws—and by extension the APA guidelines—are unclear in part because the extent to which MCOs and providers know about and follow the laws is not clear. For instance, one Maryland provider noted that managed care firms based outside the state are particularly unfamiliar with the Maryland restrictions on information that can be shared. As a result, it is up to providers to inform the MCO when it makes a noncompliant request. One might suspect that the same could be the case in DC and New Jersey, but the laws there are substantially older than the Maryland requirement to use the Uniform Treatment Plan Form. One respondent suggested providers may routinely give MCOs what they ask for even if the request is noncompliant. Another provider believes that MCOs do back down if confronted with an objection based on the law.
The cost of the independent review process envisioned in the APA guidelines is also unclear. The corresponding provision in the New Jersey law was used for five years in the late 1980s and early 1990s, prior to managed care. However, those we interviewed did not know of readily available information on the cost of reviews during that time, and since then, the review process has largely not been used. In DC, the costs of reviews are borne by the MCOs; systematically tracking down whether any DC MCOs used the provision and how much it cost was beyond the scope of this study.
Thus far, we have described three approaches to collecting information viewed as minimally necessary for MCOs, but we have not discussed exactly how MCOs use the information to make decisions about the appropriateness of care or how they should do so. In fact, MCOs often have specific protocols or guidelines in place to assist case managers in making decisions about appropriateness, but the protocols are proprietary. One MCO in particular emphasized that “like its competitors, [it] has well-defined and empirically derived level-of-care guidelines for mental health and substance abuse. The guidelines are updated each year. Internal quality improvement committees are charged with an annual review of psychiatric literature and [the MCO] also conducts panels of experts.” If such guidelines are not publicly available, it is impossible for an outsider to understand why the various kinds of personal health information are needed.
With regard to level of care, there is more consensus in the field of substance abuse treatment than in the field of mental health. More specifically, the American Society of Addiction Medicine, which represents providers of addiction medicine, developed criteria for placing patients in various levels of care. While the criteria themselves do not pertain to privacy, they represent a provider consensus on appropriate care for addiction and are available to the public. As such, they provide a foundation for outlining what information is necessary for managing care. Indeed, one MCO we spoke with uses these criteria as the basis for its information requests and said that the American Managed Behavioral Health Association, which represents managed behavioral health care organizations, had endorsed the criteria (we could not confirm this). Please note that the most adamant of our provider representatives would probably argue that regardless of the extent to which MCOs use clinically sound criteria to justify their information requests, collecting personal health information beyond administrative data is inappropriate in that any information-sharing will inhibit effective treatment.