The MCOs we spoke with believe they collect only the personal health information they need to manage care. Those who commented directly on the APA guidelines do not believe that the guidelines provide for the sharing of enough information. The MCOs do not want to manage every outpatient case, but they do value the ability to flag outlier cases that might be problematic. They use the information both at the individual case level—to avoid treatment that is either not minimally necessary or inappropriate—and in some cases at the provider practice level as a profiling device, noting that problems are typically concentrated among certain providers. 4
One MCO explained that access to a considerable amount of clinical information is important to managing care in terms of both patient use and cost. That is, it is important to the plan to use medical necessity and quality criteria, but the plan also feels a need to protect itself against artificial cost increases. In the MCO’s words, “with the enactment of parity, we have seen ‘diagnosis drift,’ so someone with an adjustment disorder might be characterized as having depression or bipolar disorder [so the provider could obtain payment for the additional treatment expected for patients with bipolar disorder]. Clinicians tend to be influenced by their own financial needs as well as the patient’s needs.” The routine record audits described in Chapter II presumably help to protect against this tendency.
4 One MCO we spoke with currently uses provider profiling, while a second is working towards this ability.
"MHPrivacy.pdf" (pdf, 768.25Kb)
"appen-b.pdf" (pdf, 224.4Kb)