Informed Consent Motivates Patients to Game Outcome Measures
A Discussion Paper
Summary
Psychotherapy outcomes include symptom burden, social and functional skills, pain experience, physical and social activity, and the patient’s experience.
The bedrock of psychotherapy outcome prediction, established over the past 40 years, is the psychotherapist-patient alliance.
When outcome measures are used by Healthplans to govern psychotherapy treatment decisions, the measures are subverted and are corrupted by patients who have received ethical informed consent.
The validity and value of patient reported outcome measures (PROM) depends more upon the purposes for which questionnaires are offered than any statistical evidence from the questionnaires. Psychotherapists use questionnaires based on their purposes. When a patient and therapist invest time and effort in questionnaires, they expect a “return” on that investment. When the purpose is to gather information to facilitate or improve the therapy process, both receive benefit. Diagnosis and treatment are supported by questionnaires which gather symptoms, problems, relevant history and questions which address changes in symptoms, problems, behavior and patients’ experience including the therapeutic alliance. The bedrock of outcome prediction, established over the past 40 years, is the psychotherapist-patient alliance.
The purpose of some questionnaires is a hidden threat to their utility and validity. Informed consent about the purpose of questionnaires is clinically and ethically essential. Ethical informed consent motivates patients to “game” payer-required outcome measures.
Psychotherapists are ethically required to inform their patients of the purpose of any questionnaire and the purposes for which the information will be used. It is insufficient for a therapist to advise that information is gathered to “support healthcare operations.” There are many concerns for which such justifications are not valid. Many Healthplans define themselves as part of healthcare operations and assert governance over healthcare decisions and treatment. Evidence of such governance can be seen in (1) utilization reviews, (2) recovery audits, (3) coding advisor programs, (4) pre-authorization requirements, (5) evidence of medical necessity, and (6) charting requirements. These restrictions are not clinically useful and provide no incremental improvement in psychotherapy outcomes.
Assessment and outcome measures are interventions
Administering questionnaires, gathering the results, analysis of, and reports about that data to patients are clinical interventions. The information is conveyed, interpreted, and integrated into future treatment. Patients are entitled to know, and psychotherapists are required to tell patients for what purpose the data is intended, who will benefit, who may profit, and any risks of responding. Psychotherapists are the gatekeepers concerning what information is necessary and appropriate to be entered into their patients’ medical records. The psychotherapist-patient alliance and patients themselves are harmed when Healthplans attempt to govern psychotherapy treatment decisions and the information entered into a patient’s record. When outcome measures are selected, and used by patients and psychotherapists to inform treatment, the resulting measures of incremental improvement and change are valid and useful.
Patients and psychotherapists circumvent Healthplan measures
Campbell's Law is an adage developed by Donald T. Campbell, a psychologist and social scientist who wrote about research methodology. Campbell’s Law states that “the more any quantitative social indicator is used for social decision-making, the more subject it will be to corruption pressures and the more apt that indicator will be to distort and corrupt the social processes it is intended to monitor.”
Goodhart's Law is an adage honoring British economist Charles Goodhart, who advanced an idea in a 1975 article on monetary policy in the United Kingdom “that any observed statistical regularity will tend to collapse once pressure is placed upon it for control purposes.”
Anthropologist Marilyn Strathern Generalized Goodhart's law beyond statistics and control to evaluation more broadly. The phrase most cited as Goodhart's law: “When a measure becomes a target, it ceases to be a good measure” appeared in a Strathern paper. “Target” is another word for requirement or benchmark.
Healthplans want psychotherapists to use outcome measures administered via online software. Healthplan approved software uses patients’ and psychotherapists’ scores to compare psychotherapists’ performance to one another. When Healthplans have access to those comparisons, therapists can be identified, contacted, and told that their performance deviates from the norm and may be wasteful. Such comparisons are insufficiently informed and have a negative impact on patients and psychotherapists.
When a measurement process supports incremental improvement in outcomes it is useful for psychotherapy. When a measurement process is used by Healthplans to govern treatment decisions, the process is subverted by patients and psychotherapists and the measure is corrupted. When outcome measures are used by psychotherapists and patients to inform treatment, the resulting measures of incremental improvement or change are valid and useful. Gathering information about about symptoms burden, functional problems, well-being, and social circumstances should be used to inform treatment decisions and to support the patient-therapist alliance.
When a patient is told that a Healthplan requires specific measures be administered using an approved online software in order to compare patients and psychotherapists to large populations to justify and/or restrict care, it is inevitable that patients will protect themselves by using answers which endorse less improvement and/or greater distress.
Psychotherapists are expert at persuasion using words, voice tone, and body language. Following are examples of how psychotherapists can subvert the results of payer-mandated questionnaires by professionally and ethically forthright statements:
Here is a questionnaire your Healthplan requires. You can complete if you think it would be helpful.
Here is a questionnaire. If you complete the questionnaire, it will help determine how long I can see you.
Here is a questionnaire. You are not required to complete this to see me.
As part of my contract, I am required to offer you this questionnaire to complete. I don’t find this questionnaire very useful. There are better questionnaires which I believe are more appropriate to evaluate your situation and progress.
The purpose of a questionnaire defines the level of ethical informed consent required:
When the purpose is to inform treatment, the questionnaire should be selected by the therapist and its purpose explained to the patient.
I use this questionnaire to help me understand you and the issues that are concerns for you. As we look at your responses it will help us to make decisions about your care. The best answers are the answers that are true for you.
If the purpose may be to restrict or limit care, the psychotherapist has a responsibility to discuss that possibility.
If the purpose is to save the payer money, the psychotherapist has an ethical responsibility to discuss that purpose.
If the purpose is to support panel participation or removal of psychotherapists from a panel, the psychotherapist has an ethical responsibility to discuss that purpose. (i.e., outlier therapists offer very brief or quite extended patterns of care).
If the purpose is to reduce premature termination, the psychotherapist has an ethical responsibility to discuss that purpose.
If the purpose is to determine whether treatment is on-track or off-track, a psychotherapist has an ethical responsibility to discuss that purpose.
If the principal purpose is to financially reward psychotherapists, the provider has an ethical responsibility to discuss this with patients (and should discuss their business decision with their attorney).
If the purpose is to increase Healthplan profits, then the psychotherapist has a responsibility to discuss that influence.
If the purpose may restrict services to patients who are part of populations with significant chronic problems and symptoms, that requires discussion.
The only way a psychotherapist may justifiably not inform a patient of the purpose of a questionnaire is when the questionnaire is part of a research study that has been approved by an institutional review board.
Healthplans that support use of clinically-focused outcome measures will benefit their enrollees with care that is better focused
Psychotherapists trained to offer clinical measures that improve information gathering choose questionnaires that have the greatest diagnostic and treatment value for individual patients. Psychotherapists need access to a range of screening, health status, progress, adherence and outcome measurement options. Measures of symptom burden, social and functional skills, pain experience, physical and social activity, and the patient’s experience must be appropriate both clinically and culturally.
References
The Role of Patient Reported Outcome Measures in Mental Health?
https://www.mentorresearch.org/the-role-of-patient-reported-outcome-measuress-in-mental-health
What is the Value of Charting in Psychotherapy Practice?
https://www.mentorresearch.org/value-psychotherapy-charting
Ethical Principles for Practice and Business Operation of Collaborative Mental Health Services.
https://www.mentorresearch.org/s/Ethical-Principles-for-Practice-and-Business-Operation-of-Collaborative-Mental-Health-Services-ky9m.pdf
MODA - Clinical Guideline Using Outcomes in Outpatient Psychotherapy
https://www.mentorresearch.org/s/Clinical-Guideline-Using-Outcomes-in-Outpatient-Psychotherapy.pdf