Insurer seeks personal details on mental health form

The state's largest health insurer wants mental health patients to begin routinely filling out forms that include detailed questions about their sleep patterns, sex lives, and suicidal thoughts.

The questionnaire, designed to gauge a patient's state of mind, is part of an effort by Blue Cross Blue Shield of Massachusetts to measure the quality of mental health treatment its members receive. About 100,000 Blue Cross subscribers will receive the form, which was described in a mailing last week to psychiatrists and other mental health counselors.

Until now, psychiatrists and therapists have been required to file reports on patients' progress with Blue Cross. Starting next year, patients will be asked to make self-assessments by answering 58 questions, on paper or through a secure website. They will receive questionnaires after every eight counseling sessions, or more often if the insurer decides it's warranted.

The questions address a range of emotions and conditions, from guilt and worry to substance abuse and sexual satisfaction. Blue Cross says the responses will provide detailed snapshots of a patient's mental health. Over time, the company said, the forms will allow it to monitor progress, assess the quality of counseling and treatment, and identify patients who could benefit from more intensive therapy. As is the case now, decisions about care will be made in consultation with doctors, Blue Cross said, and the forms will not be used to deny coverage.

The questionnaires could eventually be used to establish quality rankings to help patients select doctors, as well as to reimburse providers based on their performance, the insurer said.

But some psychiatrists are skeptical about the accuracy of self-assessments, and others say patients will be reluctant to divulge highly personal information.

"Who in their right mind would fill out such a form?" said Dr. Marc Whaley , a Chatham psychiatrist and president of the Southeastern Massachusetts Psychiatric Society . "It's just an intrusive invasion of privacy."

Participation is voluntary, but if large numbers of a doctor's or therapist's patients don't return the assessments, the practitioner could fail to qualify for annual increases in Blue Cross reimbursement.

Blue Cross officials say they are determined to treat mental health the same as other medical care, and that means finding ways to measure outcomes and improve accountability. Insurers already assess providers' performance by gathering information on patients' high-blood pressure, cholesterol tests, pap smears, blood-sugar levels, and other measures of health.

Gauging someone's mental health is more complicated, said Dr. Jeffrey L. Simmons , Blue Cross medical director for behavior health. "There's no test that tells you how ill someone is," he said. The questionnaire is the insurer's attempt to "undertake a way to measure how people are progressing," Simmons said. "It's revolutionary."

Harvard Pilgrim Health Care, the state's second-largest health insurer, has distributed self-assessment forms to mental health patients for about two years. Use of the form is "encouraged," Harvard Pilgrim said, but it has not been required for providers to receive reimbursement increases. About 60 percent of patients fill them out, the company said. Harvard Pilgrim believes some patients are more likely to use a form to reveal intimate issues -- such as homicidal thoughts or sexual dysfunction -- than they are to talk about them with a therapist, said Dr. Joel Rubinstein, Harvard Pilgrim's associate medical director.

Regular patient self-assessments are also used at McLean Hospital in Belmont, the well-known psychiatric institution. Over the past year, McLean doctors have expanded their use to cover all patients.

"We believe that they have considerable value," said Dr. Joseph Gold , the hospital's chief of clinical quality.

The Massachusetts Psychiatric Society, which has been briefed on the Blue Cross plan, raised concerns about using questions about moods and feelings as the basis for quality rankings and reimbursement.

"We are skeptical that any measures they are going to do will be truly meaningful," said Dr. Eugene Fierman , president-elect of the Massachusetts Psychiatric Society . "In general medicine you can measure deaths in surgery and adverse outcomes. It's very difficult to do that in mental health."

For many patients with mental illnesses, a stabilized condition is considered "a very good outcome," said Fierman. Blue Cross will have to be careful not to penalize doctors who treat high-risk and severely ill patients whose conditions are bound to worsen, he said.

Too many psychiatrists are already dropping out of insurance plans because of low reimbursement rates, Fierman said. More administrative burdens and pegging reimbursement rates to patient performance will likely cause even more to reject patients' insurance, Fierman said.

Bruce Mermelstein , president of Comprehensive Outpatient Services, which serves 2,000 clients at mental health clinics in Newton, Chelmsford, Lowell, and Fitchburg, said patients should be concerned about privacy issues.

"We generally don't feel positive about sharing any information with an outside source. That's a legitimate worry," he said.

Questionnaires will only be seen by the patient, his or her therapist, and the insurer, Blue Cross officials said.

The company plans to make other changes in its mental health programs in 2007, including payment cuts of as much as 50 percent for out-of-network providers, an 8 percent cut in reimbursement rates for patients covered under its PPO plan, a 4.7 percent increase in HMO patient reimbursement rates, and the elimination of an outside contractor to manage its mental health programs.

Christopher Rowland can be reached at crowland@globe.com.