APA task force addresses common ethical challenges

An upcoming report will suggest ways APA can support psychologists faced with ethical and legal dilemmas under managed care.

By Lisa Rabasca
Monitor staff

Is it ethical for a psychologist to work in a managed-care company?s utilization-review department?

What is a practitioner?s obligation to a patient whose managed-care company has denied him treatment?

Is it right for a psychologist to show a managed-care company patient records from a client who is not insured by that company as part of the practitioner?s application to become a member of the managed-care company?s panel?

These are some of the questions APA?s Committee for the Advancement of Professional Practice (CAPP) Task Force on Ethical Practice in Organized Systems of Care will address in its report to CAPP on ethical dilemmas facing practitioners in the changing health-care delivery system. CAPP charged the task force with reviewing issues of ethical service delivery in organized care settings and suggesting ways that CAPP could provide support for psychologists faced with ethical and legal dilemmas in these settings. The task force report is organized with a focus on four issues that commonly arise regarding ethics in managed care?patient confidentiality, informed consent, utilization review and patient abandonment?and it will provide practitioners grappling with these questions a model for making decisions. A draft document is expected to be available in a few months.

Members of the task force previewed their work at the Aug. 16 session, 'Ethics and managed care?oxymoron or professional challenge?'

'Very narrowly, what is unethical for psychology is what is prohibited by the APA?s Code of Ethics,' said Catherine Acuff, PhD, task force chair. To determine frequent areas of ethical concerns, the task force surveyed state psychological associations, licensing boards and APA?s divisions, she said.

Keeping records private

Informed consent?a patient?s voluntary agreement to accept treatment knowing the nature of the procedure, potential risks and benefits and any alternative treatments?was the number one area of concern, followed by maintaining patient confidentiality, said task force member Patricia Bricklin, PhD, a practitioner and professor of psychology at Widener University in Chester, Pa. These issues, she said, are intertwined because how practitioners manage confidentiality will govern how they obtain informed consent.

While practitioners have a professional responsibility to reveal nothing about their clients without their consent, managed-care companies have become more aggressive about asking for patient information. Ownership of patient records has become increasingly unclear. Traditionally, practitioners and clients believed they owned patient records, but some managed-care contracts state that the insurance company owns the records, she said.

The task force report will suggest that practitioners be cautious when responding to insurance companies? requests for patient information. 'When you get a request for information from a managed-care company, stop and think about what is being asked,' said Acuff, a practitioner for 18 years.

For example, if as part of the application process to become a panel member, a managed-care company requires a practitioner to provide sample patient records, the psychologist should try to negotiate with the company. Practition-ers can acknowledge that the company needs the information but explain that releasing nonmember patient records without the patient?s informed consent would be a violation of the APA Ethics Code, and possibly a violation of state or local law, she said.

Task force members suggested that practitioners may want to use a document that informs patients of their rights as well as the risks of seeking reimbursement from a managed-care company. Practitioners need to explain to their clients that insurance agreements require them to provide a clinical diagnosis and, sometimes, additional clinical information such as a treatment plan or summary, said task force member Bruce E. Bennett, PhD, executive director of APA Insurance Trust. An informed-consent document should point out that in some cases the insurance company may ask the practit-ioner to provide a copy of the patient?s entire record. This information will then become part of the insurance company files and, in all probability, some of it will be computerized.

Although the task force report will include a sample informed-consent document, Bennett urged practitioners to have an attorney review any informed-consent document they use to ensure it complies with local or state laws.

Potential conflict of interest

Utilization review also was identified as a frequent dilemma facing practitioners because it could present a conflict of interest when cost-containment practices are pitted against patient needs, said task force member Mathilda Canter, PhD, CAPP liaison. While the APA Ethics Code does not categorically prohibit psychologists from working in the utilization-review department of a managed-care company, there are some potential risks, including conflict of interest and practicing outside the boundaries of competency.

Before conducting such reviews, practitioners should carefully analyze the employment contract and the company?s utilization management policies, said Canter, who operates an independent practice. Make sure that you will be asked to perform reviews that are within your area of expertise, she said, and be cautious about entering into a contract with a company that places too much emphasis on cost-containment.

One of the most dangerous situations, Canter said, is when gifts, vacations and financial rewards are given to reviewers as incentives to curtailing services. In some contracts, the reviewer?s income is directly tied to the amount of care that is denied to those insured. And because overall bonuses or incentives may be distributed among the reviewers in the department, each reviewer may be subject to strong peer pressure to deny care.

When care is denied

Practitioners who provide treatment also have a responsibility to their patients under utilization review, according to the task force. When a managed-care company denies necessary care, the practitioner needs to help the patient obtain needed services, Canter said. This may mean writing to the reviewer to explore other options and possibly encouraging the patient to appeal the decision.

'If you are going to appeal the decision, make sure you have a clear clinical basis,' she said. 'It must be based on helping the client.'

When the patient needs more care but the managed-care company terminates treatment, practitioners often wonder if they are guilty of patient abandonment. Although psychologists have no obligation to see nonemergency clients on a pro-bono basis, prudent practitioners will offer patients other options, said task force member Samuel Knapp, PhD, director of professional affairs for the Pennsylvania Psychological Association.

For example, he said, you could refer them to a public mental health facility or a support group. Practitioners should also offer such patients the option of paying out-of-pocket, he said. However, Acuff warned, some managed-care contracts prohibit practitioners from seeing patients after the company terminates treatment even when the patient pays for services or the practi-tioner provides pro bono care.

The task force report will encourage practitioners to advocate for their patients? needs, Acuff said. Many models used in the report include ways to advocate for change, she said.

'Don?t be passive,' said task force member Stan Moldawsky, PhD, who operates an independent practice. 'Speak up. You are advocating for your patient so that the patient can get the best care. We believe it is an ethical activity for psychologists to fight and advocate on behalf of their patients,' he said.

For example, he said, practi-tioners could advocate for their patients by asking the managed-care company to reconsider its decision or calling the reviewer directly to discuss the treatment.

However, according to Russ Newman, PhD, JD, APA?s executive director for practice, the task force is mindful that individual advocacy efforts have the potential for retaliatory actions from managed-care companies, including termination from provider panels. Such actions, he said, point to the need for organized psychology as well to involvement in advocacy efforts.