Professional Standards in Mental Health Care - Essay Example

Running Head: PROFESSIONAL STANDARDS IN MENTAL HEALTH CARE Professional Standards in Mental Health Care [Name of the Writer] [Name of the Institution] Professional Standards in Mental Health Care Managed mental healthcare has considerably affected the counselling profession. Managed care guidelines determine whether and how counsellors deliver services and whether services are repayable. Counsellors are particularly challenged when insurance repayment is denied because managed care organisations (MCOs; Danzinger & Welfel, 2001, 137-151; Glosoff, 1998, 8-16) are not honouring codes in the British Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. Rappo (2002, 167-169) emphasised that it is health cost that is being managed versus health care. In this article, we provide an overview of the effectiveness of managed healthcare systems and their impact on mental health counsellors. We review ethical and legal dilemmas involving informed consent, confidentiality, client autonomy, competence, treatment plans, and termination that had not existed prior to the introduction of managed healthcare systems. We outline the relationship between the DSM and insurance repayment for delivery of services and examine how MCO regulations regarding certain diagnostic codes prompt intentional misdiagnosis of mental disorders for insurance repayment. We provide reasons why insurance repayment is denied based on certain DSM diagnostic codes. We examine violations of the British Counselling Association's (BCA; 1995) Code of Ethics and Standards of Practice and the British Mental Health Counsellors Association (BMHCA; 2000, 2-22) "Code of Ethics of the British Mental Health Counsellors Association" in relation to intentional misdiagnosis of mental disorders for receipt of insurance repayment, as well as legal consequences surrounding this issue. We consider implications for counsellors and offer suggestions for professional conduct regarding intentional misdiagnosis. During the 1980s, MCOs emerged as an approach to curb spiralling healthcare costs. Burgeoning expenditures involving healthcare maintenance captured the nation's attention to the extent that significant measures had to be taken to control healthcare spending. Despite efforts made during the 1980s to contain healthcare spending, the UK Department of Justice Healthcare Fraud Report Fiscal Years 1995 & 1996 (1997) indicated that health costs still exceed 1 trillion pounds each year. In general, managed healthcare involves consumers, medical and mental health professionals, hospitals and nursing homes, and mental health agencies that fall under mandates of MCOs such as health maintenance organisations, managed mental healthcare organisations, preferred provider organisations, independent practice associations, and Medicare and Medicaid. MCOs also define and determine access and delivery of healthcare services, as well as regulate distribution of insurance repayment. Effectiveness and Impact of Managed Care Varying viewpoints exist regarding the effectiveness of managed healthcare during the 1980s and 1990s. Some authors believed that managed care was a realistic method of controlling cost while maintaining quality healthcare (Cummings, Budman, & Thomas, 1998, 460-469). As costs in healthcare increased, so did the number of restrictions placed by insurers on repayment for mental health services. As a result, providers and consumers expressed concerns about diminishing access to needed services as healthcare service delivery moved from traditional fee-for-service providers (e.g., consumers purchased insurance from a commercial carrier, paid a deductible, and chose their physician separately to managed care providers (Huff, 2000, 441-457). Most mental health counsellors strive to meet MCO regulations (Danzinger & Welfel, 2001), but they do not agree that managed healthcare is effective. Regardless of the answer, results from studies indicated that the majority of mental health counsellors perceived MCO requirements as a negative influence on their practices (Danzinger & Welfel, 2001, 137-151). Ethical and Legal Dilemmas A continued movement toward managed healthcare systems and a departure from fee-for-service methods of care have altered how counsellors conducted business for many years (Cuffel et al., 1996, 109-124; Stern, 1993, 162-175). For example, now the staff model limits mental health benefits to 20 sessions; brief therapy limits benefits to 1 to 5 sessions; capitation sets outpatient mental health benefits at £1,500 to £2,500; and medical necessity and standards of practice use case review or case management of mental health to determine, respectively, whether services are granted and whether services are effective. At the same time, managed care systems have cultivated ethical and legal dilemmas that did not exist before the enforcement of managed health care. Counsellors struggle to find a balance between the demands of managed mental healthcare requirements and obligations to clients. Counsellors grapple with ethical and legal challenges involving the following: 1. Clients may not know or understand their mental health benefits. Clients may be unaware that counsellors can no longer ensure privacy of disclosure because MCOs may require client information for determining treatment and for insurance repayment (Danzinger & Welfel, 2001). 2. Client autonomy. Under managed mental health care, providers and the type of treatment are often determined by MCO policies and utilisation reviews (Wineburgh, 1998, 433-443). These restrictions diminish client and counsellor autonomy in making mental health decisions that are in clients' best interests (Danzinger & Welfel, 2001; Meyers, 1999, 382-388; Wineburgh, 1998). 3. Treatment plans. When certain DSM diagnoses are not covered benefits in insurance plans, counsellors may be tempted to intentionally misdiagnose mental disorders so that clients can receive services and counsellors can receive repayment (Danzinger & Welfel, 2001). This is especially true when clients cannot afford treatment without insurance repayment. The upcoming discussion reviews the relationship between the DSM and managed mental health care. DSM Codes and MCO Regulations: Insurance Repayment For more than 50 years, the DSM-I, DSM-II, DSM-III, DSM-III-R, DSM-IV, and DSM-IV-TR have been the sources of categories for mental disorders. Given the fact that the DSM is such a powerful, widely used system for classifying mental disorders in the United Kingdom (Mead et al., 1997, 383-402; Seligman, 1999, 383-402), MCOs have used its codes to determine whether, and to what extent, insurance repayment is granted for delivery of mental health services. The DSM and Today's Counsellors A primary reason why counsellors use the DSM system is because third party payers require its coding axes for insurance repayment (Danzinger & Welfel, 2001). Adherence to DSM criteria and diagnoses weighs heavily in mental healthcare because specific diagnoses dictate which services are reimbursed by MCOs. Counsellors who are preferred providers pay attention to MCO guidelines that regulate insurance repayment for mental health services because these rulings govern their financial survival. When counsellors are unable to receive repayment for services rendered because certain DSM diagnoses are not accepted by MCOs, clients may not receive needed treatment may be prematurely terminated, or may be abandoned (Danzinger & Welfel, 2001). Denial of Insurance Repayment DSM codes are denied for insurance repayment for different reasons (e.g., medical necessity could not be established; insurance benefits were exhausted). Managed mental healthcare plans often deny benefits and insurance repayment for adjustment disorders, for disorders typically requiring long-term counselling, and for diagnostic codes that bear exclusively Axis II status (Glosoff, 1998, 1-16). In general, Axis I disorders are accepted by MCOs for insurance repayment with the exception of problems identified as V Codes, although levels of distress associated with these problems may be as severe as or greater than distress experienced by Axis I disorders other than V Codes. For example, some MCOs do not reimburse for marital therapy, coded as V61. Managed mental healthcare often presents difficulty for family counsellors who operate from a family systems orientation that emphasises resources and strengths versus pathology. Family counsellors recognise that the family system is malfunctioning, not just one family member, and that symptoms and dysfunctional behaviours are manifestations of a faulty system, not the disequilibrium of forces within just one family member. For instance, Doherty and Simmons (1996, 9-25) found that in 35% of the cases submitted, family counsellors reported they did not use diagnostic codes because they believed diagnoses are "unsystemic" and harmful to their clients. Although some family counsellors believe that assigning diagnoses may not be in their client's best interest, they also know that in order to receive insurance repayment, utilisation reviews typically require DSM diagnoses of individuals rather than of relationships (Sank, 1997, 548-554). When repayment is denied, family counsellors may find themselves in a triple bind--striving to promote clients' welfare by helping them gain insurance repayment, aspiring to uphold professional associations' ethical obligations by making and assigning accurate diagnoses, and desiring to meet MCO regulations by providing services for only approved diagnoses. Counsellors may become confused about where their primary allegiance lies--with the client, with the professional association, or with the MCO. When conflict of interest occurs among the client's needs, counselling ethics, and MCO policies, counsellors should strive to clarify their commitments to all entities (Huber, 1995, 42-45). Intentional Misdiagnosis: Ethical Codes and Legal Statutes Ethical and legal dilemmas and behaviours involved in the process of managed mental healthcare are complex and multifaceted. When insurance repayment is denied because certain DSM codes are not MCO approved, mental health counsellors (Danzinger & Welfel, 2001), clinical counsellors (Mead et al., 1997), social workers (Kirk & Kutchins, 1988, 225-237), and psychologists (Murphy et al., 1998, 43-51) may intentionally misdiagnose mental disorders in order to receive insurance repayment for delivery of services. Although intentional misdiagnosis of mental disorders for insurance repayment may constitute unethical behaviour, it is unclear to what extent counsellors know and agree that such behaviour is unethical. Counsellors may need more explicit standards to direct their behaviour regarding this issue. Violation of BCA and BMHCA Codes of Ethics The BCA (1995) and the BMHCA (2000) codes of ethics establish principles that define members' ethical behaviour and that form the basis for processing ethical complaints. It appears that intentional misdiagnosis of mental disorders for insurance repayment is in violation of the following BCA and the BMHCA codes of ethics. Many counsellors may believe they have their clients' best interests at heart when they agree to intentionally misdiagnose mental status in order to receive insurance repayment. Yet, engaging in intentional misdiagnoses of mental disorders takes advantage of clients who may be unaware that certain diagnoses carry with them potential and unexpected repercussions. Being assigned certain mental diagnoses may result in denial, cancellation, or refusal to renew health, life, and/or automobile insurance, increased table class rates for life and/or automobile insurance, larger medical or mental health insurance co-payments and/or premiums (Meyers, 1999; Miller, 1996, 349-363), and lower lifetime policy limits and higher deductibles and co-payments for treating mental illnesses than for treating other physical illnesses. Intentional misdiagnosis of mental disorders not only puts the counsellor at risk for ethical reprimands, but it also puts the counsellor and client in jeopardy of legal consequences. Clients may lose respect for the counsellor and for the counselling profession. BMHCA's (2000) Principle 1, Item A.2, states that "Mental health counsellors are aware of their influential position" (p. 20). Clients often regard counsellors as experts who hold their best interest at heart, and they trust that counsellors will do so. Hence, clients may not question a counsellor's proposal for misdiagnosis for insurance repayment. However, when counsellors intentionally misdiagnose clients' mental statuses, they abuse their position of power and break clients' trust because intentional misdiagnosis involves deceptive behaviour. As a result, clients may feel a sense of being used for the counsellor's own gain. BCA's (1995) Section E: Evaluation, Assessment, and Interpretation, E.5 Proper Diagnosis of Mental Disorders, Item a, states that "Counsellors take special care to provide proper diagnosis of mental disorders" (p. 7). BMHCA's (2000) Principle 10, Moral and Legal Standards, Item 10.B states that "Providers of counselling services conform to the statutes relating to such services as established by their state and its regulating board(s)" (p. 16). Counsellors not only misuse mental health services and diagnoses, but they also violate state and federal statutes. In doing so, counsellors risk ethical reprimands and legal consequences. The counsellor loses credibility, and the counselling profession as a whole may be spurned. Violation of Legal Statutes Intentional misdiagnosis of mental disorders for insurance repayment is also considered healthcare fraud (Peterson, 2000, 69-89). Such fraudulent behaviour leads to legal censures (O'Leary, 1995, 211-224) and court actions (Peterson, 2000, 69-89) by local, state, and federal governments. False claim schemes involve obtaining undeserved payment for a claim or series of claims for financial gain and are the most common type of health insurance fraud. The high cost of fraudulent claims spurred the government to renew its commitment to combating insurance fraud. The government uses the Health Insurance Portability and Accountability Act of 1996 in its efforts to combat insurance fraud; this act established the Healthcare Fraud and Abuse Control Programme, which coordinates federal, state, and local law enforcement activities regarding healthcare fraud and abuse. It strengthened enforcement authority regarding criminal healthcare fraud. The act allows the government to investigate individuals (e.g., counsellors) with the requisite knowledge who (a) submit false claims, (b) "cause" such claims to be submitted, (c) make or use false statements to get false claims paid (e.g., intentional misdiagnosis of mental disorders), or (d) "cause" false statements to be made or used. Qui tam plaintiffs receive 25% of government judgments. Implications and Suggestions for Counsellors The following are suggestions for counsellors regarding ethical and legal considerations in relation to diagnosis of mental disorders: 1. Advocate for insurance reform so that all DSM diagnostic codes are accepted for insurance repayment, thereby eliminating the temptation for counsellors to intentionally misdiagnose mental disorders. Actively confront managed health care, a system that precipitates fraud via MCO cost containment policies that are inconsistent with ethical practice and client welfare. 2. At the beginning of professional relationships with clients, discuss the regulations and limitations of MCO's service provisions. Inform clients of limits to confidentiality, including use of electronic transmission of mental health information to insurance providers (D. Smith, 2003, 50-55) and possible repercussions from disclosure of personal information (Kremer & Gesten, 1998, 553-558). 3. Tell clients that certain services (e.g., partner or parent-child relational problems, Academic problems, substance abuse) may not be covered benefits under their insurance plan, that the insurance plan and utilisation review direct the type and length of treatment received, and that payment for treatment might be terminated before the client and/or the counsellor believe(s) the goals of therapy have been achieved. Regardless of your counselling role (e.g., counsellor, advocate, supervisor, expert witness), ask yourself how you can be the best counsellor possible. The National Committee for Quality Assurance (1996) requires providers of behavioural healthcare to document the quality of their work, client satisfaction, demonstration of clinical outcomes, and adherence to data-based triage and care guidelines. 4. Learn to provide quality care without compromising ethical and legal concerns. Know whether you are in compliance with ethical guidelines and state and federal statutes and antifraud laws regarding managed mental health care. 5. Refer to, and be familiar with, BCA's (1995) and BMHCA's (2000) codes of ethics regarding ethical dilemmas involving informed consent, confidentiality, termination and abandonment, utilisation review and limits to treatment, client and counsellor autonomy, diagnosis, and insurance repayment. 6. Do not falsify or misrepresent any information or facts regarding insurance claims and cost repayment (D. Smith, 2003), including but not limited to intentionally misdiagnosing mental disorders, upcoding, double billing, making claims for services not provided, and so on. 7. Know your risks for liability associated with diagnoses of mental disorders in relation to insurance repayment. Educate yourself about the ethical and legal requirements for insurance repayment. Maintain liability insurance. Counsellors struggle to find a balance between MCO demands and providing quality service to clients. A primary concern involves certain DSM codes that are not honoured by MCOs. When DSM codes are unaccepted, clients may not receive needed services and counsellors cannot receive insurance repayment, which is their livelihood. Hence, counsellors may be tempted to intentionally misdiagnosis mental disorders in order to receive insurance repayment. This behaviour violates BCA's and BMHCA's codes of ethics and constitutes fraud. Conclusion Counsellors struggle to find a balance between MCO demands and providing quality service to clients. A primary concern involves certain DSM codes that are not honoured by MCOs. When DSM codes are unaccepted, clients may not receive needed services and counsellors cannot receive insurance repayment, which is their livelihood. Hence, counsellors may be tempted to intentionally misdiagnosis mental disorders in order to receive insurance repayment. This behaviour violates BCA's and BMHCA's codes of ethics and constitutes fraud. It is assumed that counsellors who intentionally misdiagnose mental disorders for insurance repayment do so because they genuinely care about client welfare. For counsellors who refrain from intentionally misdiagnosing mental disorders for insurance repayment, is it because it simply is "not right" to do so, because they fear ethical and legal consequences, or because they know that doing so does not ultimately represent the best outcome for clients? How do counsellors reconcile their altruistic mission of serving clients with diagnostic exclusions that serve cost containment interests for MCOs? Counsellors are forced to choose between allegiance or compliance--providing needed services to clients or adhering to MCO standards that compromise these services. Research is needed to assess counsellors' frames of reference and motivation regarding intentional misdiagnosing of mental disorders. Intentional misdiagnosis of mental disorders results in inaccurate mental health statistics at state, national, and global levels. An example is intentional misdiagnosis using Major Depression or Generalised Anxiety Disorder Codes instead of actual V Code diagnosis. The question is, how reliable are WHO statistics when research indicated that counsellors, psychiatrists, social workers, marriage and family therapists, and psychologists intentionally misdiagnosed mental disorders? References British Counselling Association Office of Public Policy and Information. (n.d.). Effective advocacy and communication with legislators. Alexandria, VA: Author. British Counselling Association. (1995). BCA code of ethics and standards of practice (6th ed.). Alexandria, VA: Author. British Mental Health Counsellors Association. (2000). Code of ethics of the British Mental Health Counsellors Association. Journal of Mental Health Counselling, 23, 2-22. Cuffel, B. 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