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An APA member is raising an alarm that site visits by managed care companies pose dangers for psychiatrists and patients. The site visits, it appears, have become common. But what is the purpose of going through patient records and is that purpose adhered to?
In January Green Spring Health Services sent a notice to a handful of psychiatrists in the state of Maine announcing that it was going to visit their offices.
"It was a very blunt directive saying we want you to send three patient charts to headquarters, that we will review them and then do a site visit and evaluation of your services," said Jerome Collins, M.D., one of the five. The letter said the deadline was in February, and it did not address the issue of disguising names on the charts, said Collins.
Reluctant to allow outsiders to see his charts and alarmed at the prospect of revealing patient information, Collins consulted with several APA leaders. He then wrote to Green Spring and asked the company to place a moratorium on its request for records and site visits and to consult the National Committee for Quality Assurance (NCQA) with Collins.
"I wrote [that] the program is so intrusive and so provider and patient unfriendly that I thought it should be rethought. I suggested we go back to the drawing board," he said.
Collins received a letter from Green Spring saying it was trying to get accreditation from the NCQA and thus needed to do the site visits. Green Spring has since sent Collins three more letters asking him to set up an appointment for a site visit.
Collins and the other Maine psychiatrists were apparently chosen for site visits because they are "high-volume providers": they see 50 or more Green Spring patients in a two-year period. Green Spring, as well as an increasing number of other MCO's, conducts site visits to these providers' offices as part of a two-year recredentialing practice. MCO's are required to do site visits for initial credentialing and recreden-tialing of practitioners by the NCQA, the employer-sponsored nonprofit organization that began accrediting MCO's in 1991. (They do not review the medical records of nonmember patients.)
The NCQA guidelines specify that an MCO organization must conduct site visits at the offices of potential high-volume behavioral health care practitioners prior to acceptance to panels in order to verify credentials of these practitioners. In addition, MCO's will conduct site visits to the offices of high-volume practitioners at the time of recredentialing (every two years). The NCQA requires that MCO's "conduct a structured review of the site to ensure conformity with the organization's standards" and "document an evaluation of treatment record-keeping practices at each site to ensure conformity with the organization's standards."
The rationale for the recredentialing site visits, says the NCQA, is "to determine if there have been any changes in the facility, equipment, staffing, or treatment record-keeping practices that may affect the quality of care or service provided to the member of the organization. According to the 1998 Surveyor Guidelines for Managed Behavioral Healthcare Organizations, MBHO's are expected to set standards for treatment records, systematically review for conformity, and institute corrective actions when standards are not met."
The NCQA reviews a random sample of blinded treatment records of the MBHO's patients in the MBHO credentialing process. Its 1997 standards document says that the NCQA uses the following procedure in reviewing patient treatment records:
Though Collins and his colleagues in Maine had signed contracts saying that the MCO might do site visits, they thought that MCO's would be more likely to visit primary care physicians. Further, they also did not envision that MCO's would review records without patients' permission.
"When we sign on as providers," said Collins, "the contract says, 'We may have occasion to do site visits,' but it does not go into specifics. When they say they may need to do chart reviews, we assume they will get the patients' permission if they do that."
As more and more MCO's visit psychiatrists' offices, however, the issues raised by the visits will continue to reverberate. Managed behavioral health organizations are growing in numbers, and the NCQA has been adapting its standards during a period of rapid growth and change from four to 240 employees and several reorganizations in the last seven years.
APA continues to examine the subject of site visits in various committees, including the Managed Care, Confidentiality, Private Practice, and Ethics committees. The Committee for Management of the Litigation Fund is looking at the possibility of litigation on the matter.
Daniel Borenstein, M.D., APA's representative to the NCQA Practicing Physicians Advisory Council and an APA vice president, is concerned that there are not enough limits upon MCO's doing site visits. The NCQA has printed standards, but places no limits on what MCO's can do in evaluating their practitioners, he said. "There is not one limit that I can see. There are minimum requirements, but there is nothing to stop them from doing more."
The purpose of site visits, according to the NCQA, is to check the content of records to see if the right kinds of information are included, not to look at details about individuals, noted Borenstein. But at this point, he said, there is nothing to stop managed care organizations from gathering information about individuals and using it as they want. "The fly in the ointment is that the managed care organization can do whatever it feels is necessary to assure its quality of care."
Many APA members are concerned about the lack of confidentiality protection. As the situation stands, said Collins, providers who sign on with a managed care organization "offer fees and carte blanche to all medical information." Do patients, he asked, "have any idea that when they sign an authorization form, we could say they are signing a medical search warrant that lasts for the duration? Blue Cross/Blue Shield can contact anyone, anywhere to get information, disseminate it to anyone-an affiliate, a pharmacy benefit plan."
Michael Hughes, M.D., chair of APA's Committee on Private Practice, agreed. "I signed up with six or seven MCO's. I have no idea what I'm signing, and patients don't know what they are giving away when they sign an authorization." An added complication, he said, is the question of what it will mean if the doctor tells patients that MCO's may read their charts. Doctors may get fired, he said.
Yet "if patients knew what they were signing, they wouldn't sign it," said Richard Harding, M.D., APA's other vice president and a member of the national advisory committee charged with developing the Clinton Administration's legislation for medical record confidentiality. Harding said ideally patients should know exactly what they are signing when they fill out an authorization form because informed consent is a necessity for beneficial treatment.
"The chart is there for treatment of the patient, not for financial gain. It's there to make treatment the best possible, and anything in the way of that will get in the way of the best patient care that can be provided," he said. Without trust between patients and doctors, he added, patients will not get what they need.
Hughes observed that though MCO's say that the purpose of site visits is to ensure quality of care, in reviewing records these companies are trying to oversee what doctors do. "They want to control it. They have an agenda-we do things their way or get canned. It's awkward when we have business taking over education [and] defining how to take records, what to include."
In addition, he said, managed care claims that if it controls how charts are kept, better outcome studies will result. In fact, Harding said, MCO involvement may skew results because patients and practitioners fear loss of confidentiality and may distort information.
"MCO's need certain information to process claims, to show that a legitimate illness is being treated - just to let them mess around in records will lead to trouble," said Harding. Providers will begin to make charts look like they're supposed to look for managed care instead of reporting reality, and they will leave things out to protect patients, he said. In addition, patients will leave things out to protect their own privacy. "Then we will have garbage in our charts. We will start making projections and future plans based on garbage."
One avenue through which APA and other mental health care organizations can influence credentialing practices, said Borenstein, is through clinical representation. At present, he said, the NCQA has several psychiatrists working on its committees, but only a couple of them are practitioners. As APA's representative to the Practicing Physicians Advisory Council, Borenstein requested that the NCQA include practitioners on other components of the organization. The NCQA said that it would choose some APA representatives to do so.
Borenstein said he also had suggested to the NCQA that psychiatrists should be involved in evaluation of practitioners and office practices. The California Medical Association of which Borenstein is a member has appointed physicians to do site visits.
The AMA is also setting up a physician-controlled accreditation organization, the American Medical Accreditation Program (AMAP) that will begin to accredit physicians this year. AMA, in collaboration with specialty, state, and local medical societies, developed the AMAP to measure and evaluate physicians against national standards, criteria, and peer performance in five areas. These areas include credentials, personal qualifications, environment of care, clinical performance, and patient care results. The AMAP will conduct one office site review for each physician it accredits to evaluate safety, appearance and access to office, office systems, staffing and performance, and medical records. The extent to which the AMAP will supplant MCO credentialing is unknown.
Collins, who is chair of the Managed Care Committee for the Maine Psychiatric Association (MPA), said that the MPA has been discussing the legal implications of site visits with the Maine Civil Liberties Union. The MPA has also participated in a number of other efforts to raise public and mental health professional awareness about site visits. The Portland Press Herald is doing a five-part series on these site visits, and local television station WGME is doing a three-day series on managed behavioral care and site visits.