Core Psychotherapy Values and the Erosion by Healthplan Practices

A Discussion Paper

Introduction

In recent years, the shift from fee-for-service to value-based payment contracts in healthcare has been touted as a solution to many systemic problems. However, this transition, particularly in mental and behavioral health services, has introduced new challenges and potential for fraud that undermine core values. This paper examines how Healthplans, exemplified by Moda Health, deviate from established guidelines and engage in practices that compromise the quality of care. It emphasizes the importance of robust oversight and legislation to protect the interests of providers and patients alike.

Core psychotherapy values such as confidentiality, trust, individualized care, and professional integrity are foundational to effective mental health treatment. Unfortunately, certain Healthplan practices are eroding these values, driven by financial considerations and competitive pressures. This paper will detail specific examples of how these values are being compromised, the challenges faced by providers in contesting these practices, and the critical need for legislative action to ensure ethical and effective healthcare delivery. The importance of having independent certified internal auditors, ethics point portals, and clearly written contracts is underscored as essential measures to safeguard against fraud and maintain the integrity of mental health services.

Core Psychotherapy Values

Core psychotherapy values serve as foundational principles that guide therapists in their practice to ensure ethical, effective, and compassionate care for their clients. These values emphasize individualized care, empathy, trust, and integrity, which are essential for providing high-quality mental health services.

• Empathy: Understanding and sharing the feelings of clients, providing supportive and effective therapy.

• Compassion: Offering care and understanding, especially in times of need and distress.

• Beneficence: Acting in the best interest of the client to promote their well-being.

• Non-maleficence: Avoiding harm through therapeutic practices.

• Respect for Autonomy: Honoring clients' rights to make informed decisions about their care.

• Competence: Ensuring high-quality care through continual learning and professional development.

• Confidentiality: Maintaining privacy and trust in the therapeutic relationship.

• Integrity: Adhering to ethical principles and honesty in all professional interactions.

Healthplan Practices Undermining Core Values

Healthplans and managed care practices often undermine these core values through policies and procedures that prioritize financial considerations, or profiteering, over patient care. The transition toward value-based payment contracts, driven by competition among Healthplans, has further eroded these foundational principles.

Healthplans limit the number of therapy sessions, forcing therapists to rush treatment and potentially compromise care quality for those patients who requires more resources and have significant social determinants of heath. For instance, a client diagnosed with severe depression may be limited to an average 12csessions, which may be is insufficient for effective treatment if they have co-morbid social determinants of health. Another example is a child with autism who is granted minimal sessions, limiting progress in social and communication skills and resulting in regression.

Pre-authorization requirements also cause significant delays in treatment, exacerbating clients' conditions. A client experiencing acute anxiety may wait weeks for therapy due to pre-authorization delays, worsening their mental health. An adolescent with suicidal ideation might face dangerous delays in receiving necessary inpatient care due to pre-authorization hurdles.

Inadequate reimbursement rates lead therapists to shorten sessions or see more clients, reducing the quality of care. For example, a therapist might cut session times to 45 minutes to maintain financial viability, compromising the depth of therapy. Additionally, a counselor may decide to leave private practice or cancel a contract due to unsustainable reimbursement rates, reducing access to care for many clients.

Strict documentation and reporting requirements impose excessive administrative burdens, reducing the time available for client care and leading to therapist burnout. A therapist spending significant time on paperwork may have reduced availability and emotional presence for clients. A clinician's focus may shift from client interaction to meeting documentation standards, resulting in decreased therapeutic engagement.

Frequent audits and utilization reviews pressure therapists to conform to rigid protocols rather than individualized care. For example, a therapist might be forced to follow strict guidelines that do not align with the client's needs, impacting treatment outcomes. A mental health provider may be penalized for deviating from standardized care plans, even when doing so benefits the client's unique situation.

Confidentiality breaches occur when Healthplans require detailed treatment notes to be shared with non-clinical staff. This breaches client confidentiality and trust. A client's sensitive information may be accessed by several administrative personnel, leading to a loss of trust. Another example is a client's therapy progress and personal details being shared with insurance adjusters, compromising their privacy and therapeutic alliance.

Transition to Value-Based Payment Contracts

In a mad rush to transition from fee-for-service to value-based payment contracts, these issues have been exacerbated. These contracts, driven by financial considerations and competition among Healthplans, often undermine the core values of mental health services. Group contracts focused on financial metrics rather than individual patient needs create a one-size-fits-all approach to care. The focus on metrics and financial targets can reduce the quality of individualized care, as providers are compelled to meet specific benchmarks rather than address unique client needs. Providers may engage in gaming behavior, such as avoiding complex cases to meet performance metrics, or Healthplans may manipulate data to enhance financial outcomes. Therapists are pressured to prioritize efficiency over effectiveness, potentially harming clients. The lack of individualized care can lead to poorer outcomes for clients with complex needs.

Clients with serious and chronic health problems often require long-term support that, in fact, costs less than medications that do not cure the patient and may simply create side effects without improving mental health and well-being. These conditions include PTSD, developmental trauma, obsessive-compulsive disorder, severe and chronic anxiety, and other mental health issues that cannot be cured any more than chronic medical problems can. For example, a veteran with PTSD requires consistent, long-term therapy to manage symptoms, but limited session approvals and pre-authorization delays hinder progress. Another example is a client with severe OCD who benefits from intensive therapy, but inadequate reimbursement rates and administrative burdens lead to reduced therapy availability, resulting in increased medication reliance with significant side effects.

Healthplans often market value-based care as individualized, but in practice, they promote a one-size-fits-all model. This approach fails to account for the unique needs of each client, compelling providers to focus on meeting metrics rather than providing tailored care. Providers may manipulate reporting or avoid high-risk patients to meet performance targets, while Healthplans may set unrealistic benchmarks or selectively report data to maximize their financial benefits, undermining fair compensation for providers.

Challenges for Single Providers and Group Practices

Single providers and group practices face significant challenges in effectively challenging Healthplan practices and preventing the misuse of value-based payment contracts. The cost of litigation is prohibitive, and it can take years to litigate a single case. This lengthy and expensive process deters providers from pursuing legal action against unethical practices, allowing Healthplans to continue undermining core values without accountability.

Legislation for Value-Based Payment Contracts

Moda Health’s contracts deviate from state, federal, and industry guidelines and best practices. Based on an evaluation provided, this deviation has a probable to almost certain moderate or catastrophic impact on public employees under the Oregon Education Benefits Board (OEBB) and Public Employee Benefit Board (PEBB)​​. The Moda contract is an uncontrolled experiment at best. The fraud perpetrated thus far is enough evidence to justify independent oversight of experimental measurement and value-based contracts. Independent oversight is already an industry standard of practice in Healthcare systems, but not yet Healthplans which are controlling those systems.

Moda Case Example

Moda Health’s contracts deviate from state, federal, and industry guidelines and best practices. Based on an evaluation provided, this deviation has a probable to almost certain moderate or catastrophic impact on public employees under the Oregon Education Benefits Board (OEBB) and Public Employee Benefit Board (PEBB)​​. The Moda contract is an uncontrolled experiment at best. The fraud perpetrated thus far is enough evidence to justify independent oversight of experimental measurement and value-based contracts. Independent oversight is already an industry standard of practice in Healthcare systems, but not yet in Healthplans which are increasingly controlling those systems.

Healthy Contracts Legislation

The Healthy Contracts legislation is crucial to addressing these issues. This legislation will require Healthplans to implement three essential requirements to protect the integrity of mental health services:

1. Independent Certified Internal Auditors (CIAs): CIAs will monitor Healthplan practices, stopping practices that undermine service quality, access, and length of care. CIAs must not report to Healthplan management to ensure their independence and effectiveness.

2. Ethics Point Portal: An ethics point portal will allow stakeholders to report unethical behavior and compliance issues anonymously, encouraging transparency and accountability.

3. Contracts and Policies Written in Plain Understandable Language: Clear and understandable contracts and policies will ensure that providers and Healthplans can meet required standards without misinterpretation.

Essential Requirements

The Healthy Contracts legislation will require Healthplans to implement these three essential requirements:

1. Independent Certified Internal Auditors (CIAs): To monitor and stop practices that undermine service quality and access.

2. Ethics Point Portal: To allow anonymous reporting of unethical behavior and compliance issues.

3. Contracts and Policies Written in Plain Understandable Language: To ensure clear communication and prevent misinterpretation of contract terms.

This legislative action is crucial for ensuring that value-based payment contracts uphold the core values of mental health services, rather than being driven solely by financial considerations.