An Action Research Project

 Letter from Betsey A. Edwards and Nancy A. Hewitt:

 

                                                                        October 15, 2007

The Honorable Nonnie Burns

Commissioner

Massachusetts Division of Insurance

One South Station, 5^th Floor

Boston, MA 02110-2208

 

Dear Ms. Burns:

 

We are two of many Massachusetts mental health practitioners who strongly object to an initiative launched in May by Blue Cross and Blue Shield of Massachusetts.  This program purports to measure outcomes of psychotherapeutic treatment for thousands of our state’s most vulnerable patients.

 

We support the concept that a well-designed evaluation could be useful, and as professionals, we continually monitor our patients’ progress.  However, we are alarmed at several aspects of this particular outcome tool.  Other insurance companies for which we are providers have devised measurement devices that are less intrusive than the BC/BS TOP questionnaire and which do not create the potential conflict of interest that we detail below.  We believe that it is important for the Insurance Commission to be informed of clinicians’ perspectives, since our concern is that this questionnaire raises issues that are ethical, clinical, and potentially legal in nature.

 

We therefore respectfully request that you read this brief overview, and we would be very happy to meet with you to describe further the situation and accompanying issues.  Blue Cross and Blue Shield representatives have met with providers in group settings to discuss the use of the TOP tool, but we feel that our feedback about its use in the context of clinical treatment has not been adequately addressed.

 

We are attaching actual copies of the questionnaires that Blue Cross is asking that all practitioners use with most of their subscribers in our care.  While it is ostensibly voluntary for all parties, they have informed providers that our reimbursement rates will soon be contingent on our participation, and that of our patients.

 

Our concerns may be summarized as follows:

 

             1) Connecting therapist income with patient compliance places us in a dual relationship with our patients because it creates a potential conflict of interest between our needs and theirs.  Such relationships are prohibited in the ethics codes of all mental health disciplines.

 

              2)  The validity of the instrument itself is questionable.  Tying patient responsiveness to their therapist’s income will most likely distort any data gained, thus compromising any value to patient or therapist.  Furthermore, the questionnaire asks a number of extremely intrusive questions at a very early stage of treatment, thus potentially jeopardizing the safety and efficacy of the therapy relationship and having a potentially chilling effect on the ability and willingness of patients fully to engage in a therapeutic process.

 

               3)  Confidentiality is of the utmost concern to all of us, therapist and client

 alike.  While Blue Cross has attempted to build in safeguards, the data collected

 is highly sensitive, (in some cases involving disclosure of potentially illegal activities), and both practitioner and patient have no control over such data once it is faxed to another destination.  We are concerned both about the implications under HIPAA laws, and of course, for the nature of essential privacy protection within a therapeutic relationship.

 

                4)  Massachusetts is a humane provider of parity between physical and psychological treatment benefits for our most compromised patients. We believe such parity should extend to the evaluation methods used in each instance.  To that end, for instance, how many orthopedic or oncological patients and their practitioners are being asked to complete a questionnaire such as that included with psychotherapeutic treatment?

 

We very much appreciate your time in reading our letter, and hope you will share enough of our concerns to meet with us to allow discussion of these issues in further detail.

 

                                                                                     Sincerely,

                                                                             

                                                                              Betsey A. Edwards, LICSW, BCD

                                                                                    

                                                                              Nancy A. Hewitt, LICSW, BCD

The validity of the instrument itself is questionable