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.