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PacifiCare screening
tool, policies raise concerns
(April 2005
Issue)
By Phyllis Hanlon
In June 2004, Harvard Pilgrim Health Care signed a three-year deal
with PacifiCare Behavioral Health, Inc. (PBH) to assume management
of its mental health division beginning Jan. 1, 2005, replacing
ValueOptions. The not-for-profit Harvard Pilgrim serves approximately
800,000 members in Massachusetts, New Hampshire, Maine and Rhode
Island. PBH has approximately 4.1 million members in its nationwide
network. In spite of preliminary steps, the change-over has met
with some challenges.
According to Ed Jones, Ph.D., PacifiCare's vice president and chief
clinical officer, PacifiCare conducted dozens of two-hour training
sessions in New England, met with representatives of professional
associations in each state and distributed written material related
to PacifiCare's administrative and clinical processes prior to the
transition. He reports that the company will continue to 'over-communicate,'
noting another series of training sessions were scheduled in March
as New England Psychologist went to press.
The packet of training material contained a sample Life Status
Questionnaire (LSQ) form, which Jones explains is a "hallmark" of
PacifiCare's system. "We encourage its use to help detect risk factors
such as suicidal tendencies and substance abuse," he says. "We use
it to monitor changes during treatment and focus on sudden deterioration
in functionality and symptomotology."
PacifiCare recommends that the LSQ be administered at sessions
one, three and five and every fifth session thereafter. Jones emphasizes
that the forms are not mandatory, but that completing this step
will streamline the approval process and ensure timely payment.
He calls the patient forms "lab tests for behavioral health."
According to Elena Eisman, Ed.D., executive director of the Massachusetts
Psychological Association (MPA), this "confusing startup" has raised
several questions and caused significant uncertainty among providers.
Although she was not invited to the original training sessions,
she says that professional organizations are now being included
in those meetings. Eisman heard complaints from psychologists about
a lack of training materials at training sessions, which triggered
misunderstandings and left providers with unanswered questions.
To clarify the situation for providers, Eisman says that PacifiCare
sent detailed explanatory letters following the training sessions.
Psychologists in the Commonwealth are expressing considerable concern
about the length, effectiveness and frequent administration of PacifiCare's
30-item screening tool. Eisman says, "I have never seen such negative
reaction from providers. We're seeing some statements that may not
be accurate about the instrument. Our main issue is the way it [the
LSQ] gets implemented on the ground level." Having to spend additional
time administering the questionnaire cuts into therapy sessions
for the patient and adds to the provider's workload, she says. Eisman
also questions some of the items, which are regarded by some as
intrusive, particularly to adolescents. She says that such screening
tools should be administered in a scientifically appropriate manner.
"Otherwise distortions of the clinical decision making process can
happen," she says. "We want to make sure the instrument does what
it says it will do."
Eisman says that such measurement tools appear to be the wave of
the future. "Of five major mental health providers, four have some
kind of outcome measure in the works. All healthcare providers will
have to deal with these soon. We are helping our members negotiate
the system in the best possible way," she says.
Some Massachusetts' providers also reported a discrepancy regarding
a fax number listed in training materials. Jones explains that the
sample form within the training packet did have an outdated fax
number on it, although all other materials contained the correct
fax number. "If anyone attempted to fax material to the old fax
number, no information would be transmitted and so no confidential
information was ever breached," Jones says. "PBH sent notification
to all network practitioners that the sample form was not to be
used and the correct fax number was also included."
Although PacifiCare has stood firm on many of its policies, the
company has been open to discussion on some issues, states Eisman.
A case in point concerns the provider identification number. Eisman
says, "The provider ID, which was the social security number, was
printed on the back of authorization letters to patients. In this
era of theft identity, we asked them to remove that and PacifiCare
did."
Massachusetts psychologists are not alone in their disenchantment
with some of Pacificare's policies. Jennifer Harris, office manager,
University Associates in Psychology, a group private practice in
New Hampshire, reports a "varied" experience with Pacificare. "It
seems these behavioral health management companies are never up
to speed on individual state laws governing HMO authorizations and
their provider relations and claims processing staff get much of
their training through phone calls from frustrated providers who
have to walk them through problem resolution. PBH is no exception,"
she says.
Harris echoes the Massachusetts complaints regarding intrusive
and excessive paperwork. She questions the efficiency of a complex
system that automatically gives two to four additional authorized
sessions based on faxed forms or phone calls from the clinician.
"What is the point of all the staff and paperwork when sessions
are going to be automatically approved only on the basis of submitting
paperwork? All in all, their paperwork is complex, voluminous, intrusive
for patients and time consuming," she says. "PBH is only one of
the many managed care plans providers must deal with, and many of
these plans seem to presume that providers work only for them and
view their protocol as top priority."
Eisman admits that much more is expected of providers today. At
the same time, she expresses concern that patients still have access
to the same amount of clinical services as they did in the past
and that clinicians be reimbursed for any additional time spent
completing paperwork.
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