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 School and work records reflecting treatment must therefore not brand the patient unfairly with no longer current information.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 reason 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

1

Personality Disorders

301.5

301.4

Hysterical

Obsessive Compulsive (less severe symptoms) NOTE: A good example where treatment can be difficult and long.

Behavior Disorders of Childhood and Adolescence (any of the less severe behavior problems in an otherwise apparently healthy young person)

Alcoholism

303.0

Drug Dependence

304

Episodic excessive drinking (addiction not clearly established)

Series as listed (less severe and with good ego strength)

Psychophysiologic Disorders

305

Series as listed (less severe with basically good ego strength)

Special Symptoms

306

Series as listed (less severe speech disturbances, tics, etc. with basically good ego strength)

Behavior Disorders of Childhood and Adolescence 308

Series as listed (more severe and in more troubled personality)

Category IV Characteriological or Emotional with poor adaptation in some or involving many areas

Psychoses

295

296

Schizophrenia series as listed, with some social functioning

Major affective disorders series as listed, with some social functioning

302

Paranoid

Explosive (severe with poor control)
Anti-social (severe)

Inadequate or infantile (marked)

Series as listed (more severe problem with poor ego strength)