Most of the respondents who believe that some sharing with MCOs beyond basic administrative information is acceptable nevertheless feel that many MCOs request more information than they need. Certain items in particular are viewed as troublesome.
Past Substance Abuse. Many of the plans studied request information on past substance abuse, a controversial topic for some providers. For instance, a few said that successful treatment for a substance abuse disorder in the past may have no bearing on a current treatment request for mental health treatment. One clinician gave an example of a patient who had a problem with alcoholism that was successfully treated 20 years before. Although the provider believes this history has no relationship with the patient’s current situation, the information could follow the patient with every treatment request. This provider stated that she usually leaves the question blank in a case like this.
Physical and Sexual Abuse. Three plans request information on physical and sexual abuse. Two plans simply ask the provider to check a box in the symptom checklist indicating whether the patient was a physical or sexual abuse victim or perpetrator. The third plan asks the clinician to provide information on current physical or sexual abuse or neglect. There is a space on the plan’s form for details of the abuse, including whether it had been reported to authorities.
Many providers we spoke are strongly concerned about responding to these questions, particularly for sexual abuse. These providers do not believe that such information is relevant to the approval of care. One clinician said that plans sometimes want detailed information, such as the extent of the abuse and who the perpetrator was. Others mentioned that patients will often not want to disclose information on sexual abuse to the MCO, so the provider tries to complete an authorization request by simply saying, for example, that the patient had a traumatic experience that causing him or her to develop post-traumatic stress disorder.
Medications. Providers also disagreed with MCO requests for medication history and for the specific names of medications that have been prescribed. One respondent said that some plans ask for the patient’s entire history of medication use, which is burdensome for the provider. This provider does not feel it is necessary for the MCO to have the entire history in order to approve treatment. Another provider, objecting to requests for specific names of medications, stated that doctors other than mental health and substance abuse professionals are never asked for this information. For example, if a primary care physician is treating a patient for pneumonia, the plan does not ask for the specific name of the antibiotic being prescribed as a condition of authorizing treatment. Another provider pointed out that clinicians come to their treatment decisions after interacting with the patient and after years of training, and that there is no way an MCO could be given enough information to override this clinical judgment. However, one MCO representative said that the names of medications are needed to properly evaluate quality of care. As he stated, “You’d be shocked at how often the wrong medicine is prescribed. A person with depression should be prescribed an anti-depressant, but I have seen patients on anti-anxiety medications and anti-manic medications.” He feels that simply asking whether or not the patient is on any medication with requiring the specific names of the medications and dosages, is not sufficient to ensure that patients are receiving quality care.
Risk of Suicide. The providers we spoke with were in agreement that MCOs will approve treatment if the patient has an active risk of suicide. However, there is some disagreement among the providers we spoke with as to whether information on a patient’s risk of suicide is appropriate. Some respondents see the question as essential and do not have a problem with it. One Medicaid managed care plan representative said that his firm has not encountered any resistance from providers regarding this issue because suicide is a serious concern for their patients. However, a few providers stated that they believe that occasional wishes to die are common to most people and that this information may have nothing to do with the treatment. If the risk of suicide is low, it may not be necessary to share the information with third parties. One provider suggested that plans might instead ask if the provider has assessed the risk of suicide as moderate or above, thereby informing insurers as to a patient’s active risk of suicide without stigmatizing persons with a low risk of suicide.
Diagnosis. All of the plans we studied asked for information on the diagnosis. Even under fee-for-service, most plans did not pay a claim until the provider submitted the diagnosis. Several clinicians believe that many patients who choose to self-pay would not consent even to sharing the diagnosis with an insurance company. People who commonly choose to self-pay are typically well known professionals (for example, teachers, lawyers, or doctors) in the community whose careers could be jeopardized if anyone knew they were seeking mental health or substance abuse treatment. If these patients would not consent to sharing the diagnosis to begin with, then they would probably choose to self-pay under any insurance system. Thus, only a system in which payment was made without any information at all would satisfy their concerns.
"MHPrivacy.pdf" (pdf, 768.25Kb)
"appen-b.pdf" (pdf, 224.4Kb)