SD41 - Certain Practices Among Psychiatric Professionals
Executive Summary: The general climate surrounding the treatment of psychiatric and substance abuse has changed dramatically during recent years. No longer are the mentally ill kept hidden at home or sent away to an institution for a lifetime. The evolution in social mores has contributed to an enlightened general public and removed much of the stigma attached to receiving treatment. This, together with the development of better treatment methods has contributed to the increase in the number of affected persons who seek treatment. Many state governments, including Virginia's, have encouraged this change in climate by providing for or mandating insurance coverage to include treatment for mental disabilities and saying to the insurance industry that this treatment should be reimbursed no less favorably than treatment for any other physical illness. At the same time, the number of hospitals with psychiatric or substance abuse wards as well as freestanding facilities have increased dramatically. This increase can be attributed to a number of factors. Sheer population growth with the concurrent increase in the numbers of persons who may need treatment accounts for a large proportion of the increase of clients needing treatment. Insurance now covers inpatient, as well as some types of outpatient, treatment. Recent government cost-control measures and strict monitoring of the Medicaid and Medicare programs have freed up many hospital beds which have been converted into psychiatric beds. Advertising by psychiatric facilities is a relatively new phenomenon which performs a social function to identify the types of treatment available and where to find such treatment. Families today do not form the traditional nuclear unit that was once the norm, thereby diluting the family support structure that many see as necessary to a stable family unit. Drugs are more prevalent and easily obtained, and addiction has given rise to new and different treatments. In all, there is no one factor that explains the increase in the number of inpatient beds, but it is a phenomenon resulting instead from a myriad of factors. The joint subcommittee heard testimony about a variety of perceived problems which cover the entire scope of treatment from admission to reimbursement by third-party payors. The more prevalent issues discussed included methods of payment to clinicians or other hospital officials, advertising, plans for treatment after release from a facility, utilization review for treatment and third-party payor reimbursement, and the effects of the thirty-day insurance mandate on treatment decisions The joint subcommittee agreed that clear and specific policies are needed to delineate the state's position on treatment of clients who have psychiatric or substance abuse problems. The effect would be two-sided: it would make a positive statement about what the state feels is a proper role for all entities and individuals involved in the treatment process; and it would correct any isolated problems which might now exist. The joint subcommittee recommends that: • Advertising by facilities as defined in § 37.1-179 of the Code shall follow general guidelines with respect to truth and accuracy, fairness, use of clinical staff, depiction of patients and hospital setting, and the depiction of the need for services. Additional requirements for the disclosure of fees and payment for services shall also be included. The State Mental Health, Mental Retardation and Substance Abuse Services Board shall promulgate regulations to delineate and enforce these guidelines. • Entities which provide utilization review for treatment and reimbursement purposes shall be required to be certified by the Commissioner of Insurance. Certification would require (i) a review plan describing standards to be used in evaluating hospital care and provisions for appeal of decisions by the private review agent, (ii) minimum standards for the qualifications of personnel who will perform reviews, (iii) procedures ensuring availability of private review agents during normal business hours, (iv) procedures to protect confidentiality of medical records, (v) materials to inform patients and providers of requirements of the utilization review plan and those standards to be used to evaluate care, and (vi) a list of third-party payors for which the private review agent is performing utilization review. • Any form of remuneration to professionals involved in the treatment process shall not be based on numbers of admissions or any other form of payment which might provide incentive to admit. Remuneration includes, but is not limited to, kickbacks, bonuses, and preferential patient assignment. Such statute shall also prohibit the denial of admitting privileges based upon the criterion of number of patient admissions. The Board of Health and State Board of Mental Health, Mental Retardation, and Substance Abuse Services shall promulgate regulations to effect this change. The joint subcommittee supports, by resolution, the concept of insurance coverage for alternative levels of care which is being studied by several other committees. Insurance has traditionally covered only inpatient care for psychiatric and substance abuse services. The concept being developed recognizes other levels of care appropriate to treatment and would establish a conversion ratio whereby inpatient days of care could be converted and used to pay for the other designated levels. The ratio will be based on a cost formula which will attempt to guarantee that benefits are not decreased and treatment is maximized. |
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