AACP Newsletter, Volume 14,
Number 1, Winter 2000
Editorial Column: Partials Burdened With Inconsistent Regulations
This sad dilemma arose from my colleague's excellent work in one of the five PHPs associated with my CMHC. His call was a poignant interruption of my work with the APA's Work Group on Partial Hospitalization Guidelines, chaired by Lloyd I. Sederer, MD. This group is studying the byzantine and internally inconsistent policies administered by regional fiscal intermediaries. In the spring of 1999, a coalition of organizations, including the AACP, the APA, and the national organization of PHPs, was successful in pushing back a set of highly restrictive HCFA guidelines. Knowing that the victory would be short lived, the APA had invited the AACP to participate again, this time with the goal of producing a set of recommendations from which to draft PHP Guidelines.
Many of the regulations under which PHPs must be administered are as strange and offensive as the bogus complaint against my colleague. Rules are purportedly derived from the enabling legislation, which is then explained by the HCFA Program Memorandum, which is then further elaborated by the 1997 Medicare Model Local Medical Review Policy (MMLMRP). The latter document has no legal standing, but many fiscal intermediaries have adopted all or parts of its language, leading to inappropriate decisions by reviewers. The APA hopes to influence the development of a uniform, professionally determined, and responsible alternative to the clinically uninformed guidelines now in use.
There are ten areas of concern under consideration by the Work Group. Each area is plagued by progressively narrower interpretations as one moves from the statutory language to the guidelines used by reviewers, and by variations not only among the documents, but also among states.
Issue #1 is Eligibility. There is little uniformity and the potential inconsistency from case to case and among state reviewers is troubling. There is no specification as to how often recertification must be done. Many guidelines focus on requirements for acute illness, obfuscating and undermining the intent of the law, which includes language specifically allowing the treatment of patients in order to maintain functioning. Very narrow interpretations prevent the admission of patients early in relapse, putting them at risk for higher levels of care and longer lengths of stay. The requirement to document a relapse of the primary Axis I disorder in DSM IV terms frequently causes delays in admission until the patient displays more severe symptoms.
Issue #2 is Admission Criteria. The list of eligible diagnoses is incomplete and the requirement of a GAF score below 40 is inappropriately rigid. It is inconsistent and frequently not clinically realistic to focus narrowly on the acuity of the patient's condition while requiring that a less intensive treatment must already have been attempted. It may not be possible to try a less intensive treatment in acute conditions. The narrow interpretation leads to the expectation for discharge as soon as a patient demonstrates symptom control. Patients are not given time to demonstrate maintenance of functioning. The psychiatrist should be able to determine the maintenance needed for each patient within flexible guidelines. The requirement that substance abuse must be treated within the program is often unrealistic. True dual diagnosis treatment is beyond the capacity of most programs. This rule excludes collaborating with a concurrent substance abuse treatment or self-help program outside the program.
Issue #3 is Discharge Criteria. The GAF should not be used as a discharge criterion. We have received denials because of having documented improvement with terms like "stable mood" and "euthymic in session," in spite of concurrent documentation of the need for continued assessment to determine that patient's ability to maintain the gains achieved. There is a fine line between who is too sick and who his not sick enough. We have received denials on patients whom the reviewer felt were not sick enough for the program, yet who did not meet criteria for immediate hospitalization. Mandated attempts to step down to a less intensive level of care often result in denials because the patient is not present in the program enough during a transition phase.
Issue #4 is Program Availability. Various arbitrary numbers of hours per day and days per week do not appear clinically reasonable and are inconsistent from state to state. Rules do not take into account special situations, such as rural settings and elderly populations. Our requirements are for twenty hours per week over a minimum of five days per week, with a rapid titration during the last week. A range of hours and days would provide flexibility in planning how to overcome barriers to stepping down.
Issue #5 is Covered Services. The documents covering this area are generally adequate for the needs of providers and patients. But some fiscal intermediaries limit the amount of billable services an RN can provide. Our RNs provide much more direct services than individual illness education related to medication noncompliance (our rule). RNs are a vital and logical resource in diagnostic clarification and medication management.
Issue #6 is Noncovered Services. There are no particular concerns with this area. However, the MMLMRP says that attempts to "maintain psychiatric wellness" are not covered, since this is equal to day care. Using the word, "maintenance," as an excluded service subverts the intention of the legislation and has got to be confusing to reviewers.
Issue #7 is Ineligible Individuals. The psychiatrist should be the one who makes determinations about the time a particular patient should spend in the program. The MMLMRP mandates a minimum, but HCFA's only official statement on the topic (March 1991) supports our view. "Active" participation in treatment can be difficult for persons with psychosis, especially in the beginning. Those who cannot initially tolerate a full day may eventually benefit from the intensity of service in a PHP in order to prevent hospitalization. Flexibility would allow us to provide services to a broader range of patients.
Issue #8 is Initial Psychiatric Evaluation. The requirement to document a failure to benefit from less intensive treatment is in some cases not realistic. It is unreasonable to mandate certification, psychiatric evaluation, and H&P prior to admission. This results in delays in providing needed care. It seems more realistic to order an H&P at admission and schedule an appointment with the patient's primary care physician. Complications include the inability of most of our patients to afford medical treatment, the lack of primary care physicians for many of our patients, and the fact that Medicare will not pay for an H&P. It is often unreasonable to expect the psychiatrist to see every patient on the day of admission, especially in rural areas where psychiatric services are not available daily. Allowing the psychiatrist to go over admission information with the RN, to give verbal admitting orders, and to see the patient the next day will facilitate emergency admissions and those that come directly from inpatient units.
Issue #9 is Treatment Plan. The rules are quite detailed and highly prescriptive, yet there is far too much inconsistency from state to state. Rigid rules that question the validity of objectives extended for more than one week remove the treatment team's ability to determine the best individualized care possible.
Issue #10 is Progress Notes. The requirement that a separate progress note is required for each service rendered is beyond the level of documentation required for inpatient care. This excessive mandate not only detracts from patient care, but also invites the use of rote, pre-packaged and meaninglessly repeated phrases in the medical record. Our staff spends half their time with patients and the other half justifying the medical necessity of the services. Documentation requirements and time spent on appeals often outstrip the capacity of many CMHC-based PHPs, contributing to increased staff turnover.
I put out the word on the Internet, asking for help for my beleaguered friend. Within two days I had received seven substantive responses from psychiatrists around the country coming to the aid of the unnamed colleague. Similarly, a network of concerned psychiatrists, who bring to their considerations the values of daily work with very ill people, will produce a set of guidelines for PHPs that is practical and clinically realistic. The AACP is a model of this kind of cooperative effort among volunteers - hammering out and fine-tuning the descriptors of our values and our understanding of what actually helps people. If you wish to contribute to the effort toward the development of uniform PHP guidelines, please contact Clif Tennison at Helen Ross McNabb Center, 1520 Cherokee Trail, Knoxville, TN 37920.
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