ACKNOWLEDGMENTS OF THE TASK FORCE CHAIRMAN The Chairman would particularly call attention to the active work of Kenneth A. Ritter, M.D., of New Orleans; Jerome S. Beigler, M.D., of Chicago; Morton R. Weinstein, M.D., of San Francisco, Jean CratonNeher, M.D., of Palo Alto, California and James M. Trench, M.D., of Hartford, Connecticut; among many individuals who worked actively in whatever we accomplished on the national scene. Special credit should be given to Dr. Richard Johnson for the formulation of the Type I-VI Coding, and for the chronology and detailed reporting of our activities which has made it easier to compile this report; and to Frank M. Ochberg of H.E.W. for valuable suggestions. The help of Central Office from Walter Barton, M.D. and his staff in counseling and cheerful cooperation not only made it possible for us to function, but added to the pleasure we derived from our task. As Chairman, I can only state the obvious, that my co-workers on the Task Force were all a dedicated, hard-working group. Their individual inputs balanced extremely well in reaching an aggressive, actionoriented approach, but still tempered with reason. 12 APPENDICES Appendix A: General Principles Governing Confidentiality 1. Every person has a basic right to the pursuit of health and happiness, and privacy is a necessary prerequisite for this. 2. Psychiatric practice cannot properly achieve maximal effectiveness except where there is a secure atmosphere of confidentiality. 3. We are, together with the patient, chief advocates of an affirmative atmosphere of confidentiality. 4. Any authorized release of information to a third party should be made only after full discussion with the patient. 5. Only the minimum information required to meet legitimate needs should be released. 6. We should never collude with the patient in making false representation to a third party. 7. In rare and special cases where danger to persons, self, or others is imminent and can no longer be handled in the context of treatment, our obligation to society requires that we break confidentiality, but only to the minimum extent necessary to protect life or property. 8. The psychiatrist has the responsibility to determine whether disclosure of information to family members or other third parties will work for or against the patient and his treatment. 9. The boundaries of disclosure to third parties should be determined with the patient in the early stages of treatment. 10. Blanket consent for release of information is never satisfactory. Patients should give specific consent each time for each disclosure to each third party; informed consent should be limited to the specific purpose at issue and indicate that it is time limited for the purposes of the claim. 11. Insurance companies and other third parties have a legitimate right to certain information about a patient and his treatment. 12. Information should be released in a way that will promote the best interests of the patient and in such a way that it cannot be used against his best interest. 13. Information released to meet a legitimate need of a third party should be held in confidence by that third party. Such information must not be re-released to other third parties without the specific consent of the patient. 14. No person should be penalized by his insurance company because of receiving treatment. 15. Insurance cost accounting should always be made in aggregate without reference to confidential information concerning individuals. 16. Eligibility to obtain insurance or employment should be determined by examination for that purpose, not by reference to information from treatment. 17. National Health Insurance laws must have specifically detailed outlined legislative safeguards for the protection, gathering, storage, retrieval and distribution of data about patients, and not be cloaked in general terms. 18. Schools and employers should get information about treatment only when such release is in the interest of the patient and must take into account that the patient's condition is subject to improvement. School and work records reflecting treatment must therefore not brand the patient unfairly with no longer current information. Furthermore, such records should be destroyed after an appropriate short interval. 19. We should apply these same general principles to the problem of privilege, which is a separate and distinct sub-category of confidentiality. 20. We should work for the strengthening of laws and procedures to protect privilege, confidentiality, and the privacy of our patients and to secure the support of the public including our patients in this effort. Appendix B: Proposed Coding for Mental Disorders The realities of current and future health insurance coverage for psychiatric treatment will include the need to report some justification for the treatment, whether for hospital costs or physicians' services. In the past, using official diagnoses often led to the demand for completing detailed questionnaires plus repeated experiences of breach of confidentiality that were destructive both to the patient and the treatment process. Efforts have been made to demonstrate to the insurance industry that other forms of reporting might better serve the needs of our patients while meeting the needs of the industry more effectively. The Coding System which is listed below has been formulated to divide reportable conditions, not due to physical or organic factors, into six general categories. These categories represent a synthesis of diagnosis with varying degrees of impaired function. It is for that that some diagnostic categories appear in more than one of the six designations. The category type may possibly be changed in later evaluations as the clinical function of the patient changes. Insurance reports would merely signify "Category I (or II, III, IV, V, or VI)" instead of DSM II diagnosis and code number which should be kept in the doctor's confidential file. This private evaluation would be available only under proper safeguards to peer review colleagues or to the Medical Director of the carrier. Such reports would go directly to the Medical Director and not through ordinary channels and would be protected by the medical ethics of the Medical Director. We recognize that the insurance industry needs certain data for actuarial purposes. However, the extensiveness of treatment required and choice of treatment approaches can not be indicated by diagnosis alone. It is suggested that in reporting, the nature of proposed treatment be made available to medical representatives of the insurance carrier and any question about the appropriateness of the intensity or duration of treatment be referred to peer review procss. A criticism from the insurance industry is that conditions in Category I would indicate no need for compensible treatment. This overlooks the factors of anxiety and/or depression liberated by such conditions. At the minimum it would require a diagnostic interview. In general, the code tries to convey the general nature and seriousness of the condition at the presenting time of the report. While prognosis might be inferred, it cannot be specifically determined from the code number used. It is assumed that inquiries from the insurance carrier will be made by their Medical Director for a specified, concrete purpose. It is expected that this would not be a frequent occurrence, and under no circumstances be made available to any other party, nor even to the patient. Proposed Coding For Mental Disorders A. Mental Retardation. B. Mental Disorder associated with physical or organic factors. (Would suggest the nature of the physical or organic factor be reported in general terms, e.g., endocrine, infectious, circulatory, tumor, etc.) C. Mental Disorder currently considered of psychogenic origin. 1. Acute Situational (basically healthy personality reacting abnormally to stress situation.) 2. Characteriological or Emotional with fair adaptation in most areas (e.g., mild neuroses or character disorders, etc.) 3. Characteriological or Emotional with less adequate adapta tion in some areas (e.g., oral type character disorders or neuroses, etc.) 4. Characteriological or Emotional with poor adaptation in some or involving many areas (e.g., infantile type neuroses or character disorders, and some forms of psychotic reactions, etc.) 5. Severe Emotional Disorder with poor or no adaptation in one or more crucial areas of functioning (e.g., extremely severe neurotic or psychotic syndromes.) 6. Most Severe Emotional Disorder with poor or no adaptation in enough areas to require constant supervision and not responding to continued, active psychiatric treatment (e.g., totally withdrawn psychotics, totally incapacitated conversion hysterics, some character disorders, etc.) It is recognized that most patients cannot clearly fit a text book picture. The category selected will depend on the judgement of the psychiatrist considering all factors that pertain to any specific patient. The above examples are just that and are not intended for determining any one specific case designation. Similarly, the comparison below of the Type Codes to the DSM II Manual of Diagnoses is to be considered in like manner. DSM II Breakdown for the Above Codes Category I Acute Situational Category II Characteriological or Emotional Problem with fair adaptation, but with interfering symptoms requiring treatment |