FMOLHS OLOL Physician Group Zielinski 'lemondropped' Medicaid beneficiary in COVID PHE defying Federal, State, Local Involuntary Disenrollment Moratoria Act for any reason--Blackballed and Dismissed and Denied Treatment by 2 more providers, while never offered Due Process or Appeal - Medical Record Locked - Ignored in Silence Never Contacted by ANY physician, administrator, nor executive (including my cousin) I was Referred for Cancer Biopsy - I thought I MIGHT receive Care: After 1 week No Contact I have Appointment ... in 1 month--FOR CANCER

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   Continuity of  medication between mental health providers (MHPs) and primary care providers (PCPs) after a new consultation 

2. bMedication groups: hypnotic-benzodiazepine, alprazolam, buspirone, clonazepam, diazepam, lorazepam, triazolam, zaleplon, and zolpidem; dementia medications, donepezil, rivastigmine, and memantine; antidepressants, amitriptyline, bupropion, citalopram, doxepin, duloxetine, escitalopram, fluoxetine, mirtazapine, nortriptyline, paroxetine, sertraline, trazodone, and venlafaxine; antipsychotic and related, aripiprazole, benztropine, haloperidol, olanzapine, perphenazine, quetiapine, risperidone, thiothixene, and ziprasidone Appealing Treatment and Reimbursement Denials Appeal Strategies The APA recommends the following: 1.

3. Request and review a copy of the MCO’s appeals procedures and utilization review (UR) criteria before initiating any appeals.
4. 2.
5. Ask for the case manager’s credentials.
6. Denials of psychiatrists services should be made only by psychiatrists.
7. 3.
8. Request written notification of the reasons for denial and a description of the information required for approval.
9. This will ensure that subsequent submissions “fit the bill.” 4.
10. Request names and addresses of the people who should receive applications for an appeal and find out the MCO’s deadline for appeals.
11. 5.
    
    
    
    
    
    
    
    
    
    
    
    
12. Meet all UR and appeal deadlines.
13. If you do not, the merits of your case may not matter.
14. Certification denials due to “administrative noncompliance” are rarely overturned.
15. If the case is denied on an administrative basis (i e , a request for continued certification was not made within the specified time, precertification procedures were not followed, or there were benefit coverage exclusions), you’ll need to explain any extenuating circumstances in your appeal.
16. 6.
17. If your appeal is denied, appeal again.
18. Many companies offer three or four levels of appeal.
19. It is advisable to exhaust all levels of appeal before initiating litigation, should you be forced to proceed that way.
20. 7.
21. Be concise.
22. Don’t send more information than necessary and be sure to get permission from your patient to release that information.
23. 8.
24. Request peer review with a psychiatrist trained in the same subspecialty who has experience in the treatment requested.
25. 9.
26. In an emergency situation, request an “expedited appeal” over the telephone with the consulting psychiatrist.
27. Most MCOs have such services.
28. 10.
29. If applicable, ask the patient to enlist the support of his or her Personnel/ Human Resources Department.
30. MCOs are often more responsive to their paying clientsscomplaints than to complaints from physicians.
31. 11.
32. In cases that are slow to respond to standard treatments, ask the company to “flex benefits” by working with you to find a cost-effective, alternative treatment approach.
33. 12.
34. If coverage is denied after appealing, some companies may allow you to request an external review of the case with or without some cost-sharing.
35. 13.
36. In truly egregious cases, copy your appeal to the state insurance commissioner.
37. Seeing such a “cc” may elicit a more rapid and favorable response.
38. 14.
39. Contact any professional association you belong to and any consumer advocacy groups that may be helpful.
40. A complaint lodged by several parties will be stronger.
41. Letter of Appeal The following are some suggestions for inclusion in a letter of appeal: • Include any literature that supports your case, including references to the APA’s practice guidelines.
42. This may help convince the reviewer that the proposed treatment will result in the desired outcome.
43. • Be candid about the patient’s condition.
44. Describe any changes in diagnosis, comorbidities, progression, or regression of the patient’s condition; special treatments such as suicide restraints and seclusion; neurological testing and other medical tests; medications; and any self-injury or assaultive behavior.
45. • Clearly relate the level of care requested to the patient’s condition.
46. Information should be based on objective reasoning, not just opinion.
47. • Describe the next step of treatment, providing goals and an approximate time frame for the completion of treatment.
48. This will promote the idea that you have an action-oriented approach.
49. • If applicable, recommend alternative treatments for the patient.
50. • Present evidence of similar cases where the care was approved by the same plan.
51. • Appeal with a collaborative spirit.
52. If you need further assistance, call the APA Practice Management HelpLine at (800) 343-4671.
53. Independent Review Organizations (IROs) Most states have enacted independent review laws that require disagreements over what constitutes a health plan coverage to be decided by a review done by a medical expert or panel of medical experts who have no affiliation with the health plan.
54. Laws vary from state to state as to whether the review decisions are binding, but they are in most states.
55. Currently, approximately 50 percent of the disputes taken to independent review result in the reversal of a coverage denial.
56. An independent, external review, however, can only be accessed after the internal appeals process established by individual MCOs has been completely exhausted.
57. Although independent reviews have been around for years, there is still a lack of public awareness about the process, and patients generally do not take advantage of the reviews despite claims denial letters that inform them about their availability.
58. In 2005 the Kaiser Family Foundation published a guide to handling health plan disputes that provides specific information about how to access the independent review organizations in each state that has mandated the independent review process.
59. 
    
    
    
    
     
60. This document still has valuable information.
61. It can be downloaded at handling-disputes-with-your-employer-or-private-health-plan/ .
62. The APA encourages patients, and their physicians, to take advantage of this vehicle for resolving disputes that arise in obtaining appropriate mental health care.
63. Mental Health and Substance Use Disorder Insurance Coverage and Model Legislation APA has created parity-implementation legislation for all 50 states and the District of Columbia.
64. The legislation is designed to require transparency and accountability from insurers and state regulators.
65. Each state has legislation that is tailored specifically for that state's terminology and formatting.
66. Overview of Mental Health and Substance Use Disorder Parity State Model Parity Legislation Adapted to All 50 States and the District of Columbia Comprehensive State Model Parity Legislation for Each State Model Parity Legislation Addressing Insurer Reporting Requirements Model Parity Legislation Addressing Commissioner Implementation Requirements Model Parity Legislation Addressing MAT Coverage Provisions Contact APA's Department of Government Relations Team Overview of Mental Health and Substance Use Disorder Parity President George W Bush signed the Mental Health Parity and Addiction Equity Act into law on October 3, 2008.
67. The Act was sponsored by Congressman Patrick J Kennedy (D RI).
68. Parity as a concept is very simple: insurance coverage for mental health and substance use disorder care should be no more restrictive than insurance coverage for any other medical condition.
69. However, the Federal Parity Law is very complex, and implementation of the law can be challenging.
70. Insurers have done a very good job of coming into compliance with some of the more straightforward components of the law, such as making sure copays and visit limits for mental health and addiction care are no more restrictive than they are for other medical care.
71. how long is too long for a cancer biopsy 
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73. However, insurers are likely not complying with some of the more complicated components of the law, albeit unintentionally.
74. Many of these trouble spots relate to how insurers design and apply their managed care practices, such as prior authorization requirements, step therapy, and requirements for providers to join an insurer's network.
75. Often, insurers design and apply these managed care techniques in ways that are more restrictive for mental health and substance use disorder treatment than for other medical treatment, which violates the Federal Parity Law and can lead to deaths from suicides, overdoses and other forms of preventable death.
76. States have primary enforcement authority over insurers that sell health insurance policies in their states.
77. While there is growing interest by state insurance departments to implement the law and increasing willingness by insurers to submit data to regulators demonstrating compliance, there is much uncertainty about how to do so in an efficient manner that meets the tests of the law.
78. This legislation provides a roadmap for how insurers and regulators can secure compliance without undue administrative burden.
79. First, the legislation establishes reporting requirements for insurers to demonstrate how they design and apply their managed care tactics, so regulators can determine if there is compliance with the law.
80. Second, the legislation specifies how state insurance departments can implement parity and then report on their activities.
81. And third, the legislation eliminates some managed care barriers to medication-assisted treatment for substance use disorders.
82. While those provisions are not purely parity requirements, they can be a vital tool in combating the opioid epidemic.
83. Top State Model Parity Legislation Adapted to All 50 States and the District of Columbia One of the American Psychiatric Association's major legislative goals is to achieve mental health parity and parity enforcement across the country.
84. To that end, model parity legislation has been specifically adapted for each state, amending the appropriate sections of state code or creating new sections in the right titles or chapters.
85. This model legislation also uses the correct terminology for MH/SUD used in each state, the correct terminology for health insurers, and the right terminology for the insurance commissioner.
86. Additionally, each bill is formatted exactly as bills are drafted in that state.
87. There are four versions for each state: one comprehensive bill and then three smaller bills that are each of the components of the comprehensive bill (addressing insurer reporting requirements, addressing commissioner implementation requirements, or addressing MAT coverage provisions).
88. This allows each state to address the needs within that state, such as pursuing an incremental strategy or the comprehensive model legislation.
89. Please find the different versions for each state below.
90. Top Comprehensive State Model Parity Legislation for Each State This is the comprehensive version of the state model parity legislation, which includes provisions for insurer reporting requirements, commissioner implementation requirements, and addressing MAT coverage provisions.
91. Find your state's comprehensive model parity legislation Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Top Model Parity Legislation Addressing Insurer Reporting Requirements This version of the model parity legislation is the section that only addresses insurer reporting requirements.
92. 
    
93. Contact APA's Department of Government Relations Team For more information on how your state can get involved in advancing mental health parity, please contact APA Director of Government Relations Erin Berry Philp at ephilp@psych.org 
94. [Date] [Name and mailing address of payer] To Whom It May Concern: I have been seeing [patient name] since [provide date care began] to treat his/her [provide diagnoses, and any problems this may cause in patient’s life if applicable.
95. For example: Anxiety that has limited her ability to fulfill her duties at work].
96. [Provide a chronology of the patient’s treatment and explain why you need to either continue or initiate the denied care.
97. If the company is denying the frequency of care, the chronology will provide an example of how patient decompensated when care was provided with less frequency.
98. If the denial is for a medication, provide a history of prescribing and explain why you have come to the decision that it’s necessary to either continue or initiate treatment with the denied drug.
99. Explain any of the patient’s stated concerns/preferences that influenced your decision.
100. Be sure to provide examples of what might occur if care continues to be denied and how this would be detrimental to the patient’s health.
101. Always be as specific as you can.] I have attached articles that support provision of this care to [patient name].
102. [if you can find literature to support the care that is being denied, this can be a very valuable asset.
103. The APA’s Practice Guidelines can be a good source for support since most insurers say they use them in developing their treatment guidelines.] Sincerely, [Name and contact information] 
104.  

     A Key Acronyms The following abbreviations are used in this Guide, and are defined in the glossary or within the text: ACA—The Patient Protection and Affordable Care Act (see also PPACA) AHP—Association Health Plan CMS—U S Centers for Medicare and Medicaid Services COC—Certificate of Coverage DOL—U S Department of Labor EAP—Employee Assistance Program EHBs—Essential Health Benefits EOB—Explanation of Benefits EOC—Evidence of Coverage EPO—Exclusive Provider Organization ERISA—Employee Retirement Income Security Act of 1974 FDA—U S Food and Drug Administration FEHB Program—Federal Employees Health Benefits Program FFS—Fee-for-Service FR—Financial Requirement HDHP—High Deductible Health Plans HHS—U S Department of Health and Human Services HIPAA—Health Insurance Portability and Accountability Act HMO—Health Maintenance Organization HSA—Health Savings Account IOP—Intensive Outpatient Program IRO—Independent Review Organization MBHO—Managed Behavioral Health Organization MEWA—Multiple Employer Welfare Arrangement Plans MH/SUD—Mental Health and Substance Use Disorders MHPAEA—The Mental Health Parity and Addiction Equity Act of 2008, also known as the Federal Parity Law NQTL—Non-Quantitative Treatment Limitation PCP—Primary Care Provider PHP—Partial Hospitalization Program PPACA—The Patient Protection and Affordable Care Act (see also ACA) POS—Point of Service PPO—Preferred Provider Organization QTL—Quantitative Treatment Limitation SBC—Summary Benefits and Coverage SPD—Summary Plan Description TPA —Third Party Administrator UCR—Usual, Customary and Reasonable UM—Utilization Management Call to Action: Ten Steps A lthough many success stories exist where a patient or ordering provider’s appeal was handled in a timely and efficient manner by a health plan, those cases are the exception and not the norm.

105. The good news is that the building blocks to achieve true parity implementation are now in place, but more remains to be done.
106. The following ten steps will advance mental health parity by improving the appeals process for all: 1.
107. Increase Awareness of the Appeal Process.
108. The appeals process is enormously complex.
109. Many individuals do not know they have the right to file an appeal upon receiving an adverse benefit determination.
110. Health plans and regulators should work together to ensure that all enrollees are aware of their rights through targeted public education campaigns.
111. Regulators should also reinforce health plans parity disclosure requirements and make clear that in both internal and external appeals, a parity violation is grounds for reversal of a coverage denial.
112. 2.
113. Promote More Due Process and Transparency.
114. When an adverse benefit determination or denial takes place, more transparency must be provided surrounding how the decision was made and documented.
115. At a minimum, health plans must disclose the clinical and/or coverage criteria used in the decision and clearly explain the specific steps required to file an appeal.
116. Regulators should also enforce requirements that denial letters include a detailed explanation of why the patient does not meet the plan’s clinical criteria, a description of the evidence reviewed by the plan, and address evidence submitted by the patient or their provider.
117. Otherwise, consumers cannot avail themselves of their appeal rights.
118. Filing An Appeal Based On a Parity Violation The Kennedy Forum • 3.
119. Allow Attending Providers and other Advocates to File Appeals.
120. In some instances, ordering or attending providers are not allowed to file an appeal on behalf of their patients.
121. This is counterintuitive and inefficient as the provider is often in the best position to understand the denial decision and then explain why the service or treatment is still recommended or why the care was already delivered.
122. Providers also have a “leg-up” as they are familiar with the medical jargon used in the denial letter or throughout the appeals process.
123. 4.
124. Simplify the Appeals Process.
125. Many patients and ordering providers complain that too many bureaucratic hurdles and inconsistent requirements exist within the appeals process.
126. These obstacles have a chilling effect that discourages patients or their representatives from filing an appeal.
127. Originally, the appeals process made clear that utilization management (UM) appeals handled medical necessity or clinical denials, and grievance procedure appeals handled administrative denials.
128. Today, model laws from the National Association of Insurance Commissions (NAIC) and many jurisdictions have issued regulations that have eroded this formerly clear bifurcation.
129. We recommend that one integrated and streamlined appeals process apply no matter the basis of the initial denial.
130. 
     

5.

Standardize the Appeal System Across Market Segments and State Lines.

A national and consistent standard must be implemented to make the appeals process effective.

At present, many different appeal pathways exist.

These pathways vary based on how the health plan is regulated, the type of coverage provided, the type of plan sponsor, the jurisdiction,

 

131. the type of denial (e g , based upon a medical necessity or benefit determination), the timing of the denial (e g , prospective, concurrent and retrospective), the urgency of the care being requested (i e standard care versus urgent care), and where the patient is in the appeals process.
132. 
     
133. Our goal should be to establish one national appeals standard that promotes transparency, fairness and due process to all parties involved.
134. We can accomplish this unified system through new model legislation, accreditation standards and Requests for Proposal (RFP) requirements.
135. 6.
136. Upgrade the External Review Appeals Process.
137. Currently, the patient or their authorized representative must specifically request an external review of their claim.
138. In most cases, the external review appeal only can be pursued after a patient first successfully completes an appeal through the health plan.
139. In some instances, the aggrieved party may not even know they have the right to appeal to an external party.
140. One simple way to address this confusion is to automatically refer the appeal to an independent review organization after the internal appeal is completed.
141. For example, Medicare beneficiary appeals are automatically referred to the external review level, resulting in more due process.
142. Filing An Appeal Based On a Parity Violation 
143. The Kennedy Forum • In addition, the external review process as currently regulated should be re-examined and potentially upgraded to better protect consumers.
144. Ideas include: n Reviewer Identification.
145. In many cases, the patient does not know who made the final ruling during the external review.
146. Should the identity of the external reviewer be revealed or remain anonymous? Does due process require the person making the judgment to be disclosed like a judge in court? The Kennedy Forum recommends that the identity of the reviewer be routinely disclosed.
147. n Public Disclosure of Decisions.
148. In some states, regulators post de-identified external appeal decisions on their websites, a practice that allows consumers and providers to understand the types of issues being sent to external appeals, how external decisions are made, and to identify trends (such as frequent overturns of denials of coverage for specific treatments).
149. Greater disclosure of external appeal decisions would benefit individual consumers and help frame dialogue with health plans regarding practices that should be reformed.
150. n Payment.
151. In most cases, health plans contract with two or more external review organizations to handle the external reviews of their insured population.
152. Does the external review organization have an incentive to rule in favor of the health plan if the health plan also is paying for the cost of the external review? Should the patient’s health plan pay for the external review? Or should it be funded by a government agency or through some sort of fund supported by all health plans in a particular jurisdiction? The Kennedy Forum recommends that some sort of payment system be set up through the local jurisdiction rather than through the health plan to avoid any perceived or real conflicts of interest that might bias the external review decision in favor of the health plan.
153. Exhausting Internal Review.
154. Should the patient or their advocate always have to exhaust the health plan internal appeals process before filing an external appeal? Should the patient have the right to skip right to external review? The Kennedy Forum recommends that the patient be permitted to skip the internal UM appeals process and go right to external review if that is their decision.
155. However, once this decision is made, the patient or their advocate loses the right to use the health plan’s internal appeal system for that particular issue under dispute.
156. Filing An Appeal Based On a Parity Violation The Kennedy Forum • 7.
157. File More Appeals.
158. While working to lower the number of denials issued on claims, stakeholders should simultaneously work to ensure that every questionable denial is subjected to the appeals process so that enrollees receive the care they are entitled to.
159. Each stakeholder group should do the following to promote the filing of appeals: n Consumer/Provider.
160. Every patient who has experienced a denial or care restriction of mental health or addiction services should file a complaint at and/or with the applicable government agency.
161. Filing a complaint will help us develop comprehensive data to better understand the different types of parity denials.
162. Industry.
163. When an appeal is filed, health plan personnel must make a good faith effort to respond in a timely and meaningful manner.
164. Health plans and medical management organizations must ensure they are complying with existing regulations and the patient’s plan documents on how these appeals should be processed (e g , timeframes, disclosure requirements).
165. n Policymakers/Regulators.
166. Policymakers and public officials must ensure they enforce existing state and federal regulations on how appeals should be filed and processed.
167. In addition, the current regulatory and accreditation requirements should be updated to create a more efficient and effective appeals process for all parties.
168. 8.
169. Leverage Technology to Improve the Efficiency of the Appeals Process.
170. Much like TurboTax has helped tax filers, it is time to leverage technology to promote a more efficient appeals process.
171. All too often, the appeals process is still paper-based or otherwise very fragmented.
172. While is one step in the right direction, more can be done.
173. 9.
174. Update Regulatory Oversight Mechanisms.
175. It is time to update regulations to capture recent trends in how best to monitor and promote the appeals process.
176. This could include updating the model laws, regulations and accreditation standards covering utilization management, grievance procedures, external review and mental health parity compliance, both at the federal and state levels.
177. It also could include promoting value-based and outcome measures.
178. Regulations need to keep pace with changes in health care delivery, technology capabilities, and communication platforms.
179. Filing An Appeal Based On a Parity Violation The Kennedy Forum • 10.
180. Promote Advocacy and Sponsor Education Programs.
181. States should sponsor and subsidize experts who can help patients understand, file, and process appeals by creating consumer advocate offices, like the Office of the Health Care Advocate in Connecticut or Health Law Advocates in Massachusetts.
182. Regulators and health insurers can support this effort through customer service lines, supplemental educational programs, broker materials and other resources that are specific to their agency or plan.
183. These agencies should also actively connect consumers interested in filing an appeal with non-profits capable of supporting individuals throughout the process.
184. Final Thoughts The appeals process, especially for parity violations, remains a complex and confusing system for most stakeholders.
185. It is time to rethink and improve on existing appeal systems with an eye towards making the appeals process more efficient, transparent and meaningful.
186. The impact of doing so will be meaningful for individuals—and their families—who need and deserve care and are entitled to services.
187. For more information on this topic, contact Garry Carneal, JD, Senior Policy Advisor, The Kennedy Forum, at info@thekennedyforum.org. See also Organize Your Materials What papers do I need? Keep copies of all information related to your claim and the denial.
188. This includes information your insurance company provides to you, and information you provide to your insurance company, such as: The Explanation of Benefits (EOB) forms or letters showing what payment(s or service(s were denied A copy of the request for an internal appeal that you send to your insurance company Any additional information you send to the insurance company (such as a letter or other information from your doctor) A copy of any letter or form you are required to sign, if you choose to have your doctor or anyone else file an appeal for you.
189. Keep a diary of phone conversations you have with your insurance company or your doctor that relate to your appeal (include the date, time, name, and title of the person you talked to, as well as details about the conversation) Keep your original documents and submit copies to your insurance company.
190. You will need to send your insurance company the original request for an internal appeal, and your request to have a third party (such as your doctor) file an internal appeal for you.
191. Make sure you keep copies of all documents for your records.
192. What kinds of denials can be appealed? You can file an internal appeal if your health plan won’t pay some or all of the cost for health care services you believe should be covered.
193. The plan might issue a denial because: The benefit is not offered under your health plan Your medical problem began before you joined the health plan You received health services from a health provider or facility that is not in your health plan’s approved network Your health plan determines the requested service or treatment is “not medically necessary” Your health plan determines the requested service or treatment is an “experimental” or “investigative” treatment You are no longer enrolled or eligible to be enrolled in a health plan Your health plan revokes or cancels your coverage, going back to the date you enrolled, because the insurance company claims you gave false or incomplete information when you applied for coverage The Kennedy Forum @kennedyforum Followers you know Followers Following See new Tweets Followers you know American Psychological Association @APA With more than 121,000 members, the American Psychological Association (APA) advances psychological science to promote health, education and human welfare.
194. Dr Vivek Murthy, U S Surgeon General @Surgeon_General 19th & 21st U S Surgeon General.
195. Dad, husband, doctor, author.
196. Dedicated to building a healthier, kinder, more connected world.
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198. RT ≠ endorsement CatholicHealthAssoc @TheCHAUSA Sharing news and information from CHA and members of the Catholic Health Association of the United States.
199. #CatholicHealth #LoveThyNeighbor APA Foundation @PsychFoundation American Psychiatric Association Foundation - building a mentally healthy nation for all American Psychiatric Association @APAPsychiatric American Psychiatric Association (APA) is the leading psychiatric organization in the world representing more than 37,400 psychiatrists.
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207. Questions? Email: PTEditor@mmhgroup.com. APAHelpCenter @APAHelpCenter Tips, news and talk about stress, mind-body health, behaviors and emotional well-being from the American Psychological Association.
208. US Drug Policy NARA @ONDCP44 Office of Nat'l Drug Control Policy.
209. This is an archive of an Obama Administration account maintained by the National Archives and Records Administration (NARA)udge Jackson appointed the Southern Poverty Law Center, National Health Law Program, National Center for Law and Economic Justice, Disability Rights Louisiana, and O Melveny & Myers, LLP as legal counsel for the class.
210. The class counsel would like to hear from you if you believe you are a class member or you are impacted by this lawsuit.
211. If you or a child in your care is a Medicaid recipient under age 21 who has been unable to get Medicaid home or community-based mental health or behavioral health services, please contact the Southern Poverty Law Center at: or 1-800-358-2337.
212. LA Health Care Services Division Agency Description The LSU Health Care Services Division (LSU HCSD) includes Executive Administration and General Support (Central Office) and six (6) hospitals that have entered into cooperative endeavor agreements (CEA) for public-private partnerships and the Lallie Kemp Regional Medical Center.
213. The six hospitals that currently have CEAs are the Earl K Long Medical Center, University Medical Center, W O Moss Regional Medical Center, Washington-St.
214. Tammany Regional Medical Center, Leonard J Chabert Medical Center, and the Medical Center of Louisiana at New Orleans LSU A M LSU Agricultural Center LSU Alexandria LSU Eunice LSU Shreveport LSU Health Sciences Center, New Orleans LSU Health Sciences Center, Shreveport LSU Pennington Biomedical Research Center The Hospital and Central Office of the LSU Health Care Services Division Commitment authorizations for $1,964,876,382 LA Health Care Services Division Lallie Kemp Regional Medical Center HCSD - 8 Executive Budget Supporting Document [FY 2016-2017] DHHS Centers for Medicaid and Medicare Services online survey, certification and reporting database.
215. Medicare metrics tied to reimbursement.
216. Clinical quality measures hospitals submit patient record data MyQualityNetís (Hospital Consumer Assessment of Healthcare Providers and Systems) HCAPHS survey.
217. experiences with medical, surgical, or maternity care quarterly benchmark ourselves against other similar hospitals towards meeting national standards of care, maintaining patient safety, providing quality care, efficient use of federal and state budgeted resources.
218. An emergency room visit is an immediate treatment of treated by ER staff/associates to be counted as an ER visit.
219. ED visits include ER visits (ED Encounters) plus ER admits.
220. Patient satisfaction The Myers Group Centers for Medicare and Medicaid Services (CMS) approved vendor, and is summarized in overall rating of hospital and willingness to recommend hospital.
221. It should be noted that CMS' patient satisfaction survey is a standardized instrument which measures inpatient care across the United States.
222. The LSU Health System is working with the University Healthsystem Consortium to further define performance indicators and peer group comparisons.
223. Patient satisfaction is measured using The Myers Group, a Centers for Medicare and Medicaid Services (CMS) approved vendor, and is summarized in overall rating of hospital and willingness to recommend hospital.
224. LSU-HCSD has set its performance standards above the state, national and west south regional averages.
225. LSU-HCSD will follow the CMS rules for reporting; which represents data from a prior quarter being reported due to timing 1: the several campuses as defined below (Sec.
226. 2B).
227. The President and the academic officers of the University 2: fulfill the duties of the faculty.
228. The Board, the President, and the Chancellors will rely on those elected 3: which, in the judgment of the Chancellor, or of the President, is administrative or which seriously affects 4: or of the University itself, may be suspended by the President and such action shall be reported to the Board 5: or, for LSU or in inter-campus situations, by the President.
229. 4.
230. Meetings.
231. Each faculty, or its representative 6: for that purpose may be called at the request of the President as chair or of the Chancellor of the campus or, 7: shall be given.
232. It shall be the prerogative of the President to preside; otherwise, the Chancellor of the 8: officer concerned, shall be reported to the President.
233. The President may then refer any such action on 9: concerned, shall be reported to the President.
234. The President may then refer any such action on academic 10: the several campuses as defined below (Sec.
235. 2B).
236. The President and the academic officers of the University 11: fulfill the duties of the faculty.
237. The Board, the President, and the Chancellors will rely on those elected 12: which, in the judgment of the Chancellor, or of the President, is administrative or which seriously affects 13: or of the University itself, may be suspended by the President and such action shall be reported to the Board 14: or, for LSU or in inter-campus situations, by the President.
238. a Minutes of all actions taken by the faculties 15: officer concerned, shall be reported to the President.
239. The President may then refer any such action on 16: concerned, shall be reported to the President.
240. The President may then refer any such action on academic 17: purpose may be called at the call request of the President as chair or of the Chancellor of the campus or, 18: shall be given.
241. It shall be the prerogative of the President to preside; otherwise, the Chancellor of the 19: officer concerned, shall be reported to the President.
242. The President may then refer any such action on 20: concerned, shall be reported to the President.
243. The President may then refer any such action on academic 21: that should be brought to the attention of the President and Board 5.
244. An explanation of any significant 22: to the reporting format will be approved by the President with notification to the Board.
245. ARTICLE I ACADEMIC AND ADMINISTRATIVE ORGANIZATION Section 2.
246. Academic Organizational Units A The Faculty of the University The faculty of the University shall consist of the faculties of the several campuses as defined below (Sec.
247. 2B).
248. The President and the academic officers of the University shall be members of the University faculty and the former shall be its highest officer.
249. B The Faculties of the Several Campuses 1.
250. Membership.
251. Full-time members of the academic staff having the rank of Instructor or higher (or equivalent ranks) shall constitute the faculty of the campus on which they are appointed.
252. As a class, part-time members of the academic staff having the rank of Instructor or higher (or equivalent ranks) may be enfranchised to the degree deemed appropriate by the faculties of the several campuses.
253. 2.
254. Duties.
255. Under the Constitution of the State of Louisiana, the Board of Supervisors of Louisiana State University and Agricultural & Mechanical College has the authority to organize and manage the university.
256. The Board authorizes the general body of the faculty, or its representative body, to establish curricula, fix standards of instruction, determine requirements for degrees, make recommendations for the granting of degrees through its respective colleges or schools not within a college and generally determine educational policy, subject to the authority of the Board.
257. Except as otherwise provided, each faculty shall establish its own educational policies.
258. The Board authorizes the faculty to establish admissions criteria for graduate and professional programs, however, standards for undergraduate admission to the University shall be approved by the Board.
259. 3.
260. Faculty Representative Body.
261. Except as otherwise provided, the faculty of each campus shall establish its own governance policies.
262. The faculty may establish one representative body, such as a Senate or committee, to represent the will of the faculty and exercise legislative power to conduct its own meetings and fulfill the duties of the faculty.
263. The Board, the President, and the Chancellors will rely on those elected representative bodies as the voice of the general faculty.
264. Any action a faculty representative body which, in the judgment of the Chancellor, or of the President, is administrative or which seriously affects the interests of faculty of the University or of the University itself, may be suspended by the President and such action shall be reported to the Board at its next meeting.
265. All questions of jurisdiction among colleges, schools not within colleges, or divisions shall be determined by the Chancellor, or, for LSU or in inter-campus situations, by the President.
266. 4.
267. Meetings.
268. Each faculty, or its representative body, shall meet at least once each academic year.
269. For the purpose of replacing or reconstituting the representative body, a meeting of the general faculty for that purpose may be called at the request of the President as chair or of the Chancellor of the campus or, for LSU, the President’s designee, as vice-chair, or upon the written request of 50 members or 20 percent of the membership, whichever is the fewer.
270. The written request must be received within a 14-day period from the time of original solicitation.
271. At least five days notice of meeting shall be given.
272. It shall be the prerogative of the President to preside; otherwise, the Chancellor of the campus or, for LSU, the President’s designee, will preside.
273. Minutes of all actions taken by the representative bodies, together with appropriate recommendations of the major administrative officer concerned, shall be reported to the President.
274. The President may then refer any such action on academic matters of general University concern to the appropriate council, or a committee thereof, for consideration.
275. 1.
276. Quorum.
277. Not less than 25 percent of the membership of the faculty or Faculty Council shall be necessary to constitute a quorum, provided, however, that any faculty or Faculty Council (at a meeting at which a quorum of 25 percent of the members is present) may, by majority vote, establish a higher percentage of the membership as a quorum for future meetings.
278. BE IT FURTHER RESOLVED, the Board does hereby amend Article V Section 12B of the Regulations approved on August 6, 2021 to read: Article V Section 12 a Consolidated Financial Report (the annual financial report shall suffice as the report for the second-half of the year) NOW BE IT FURTHER RESOLVED, the revised Regulation adopted on September 10, 2021 will be effective on September 13, 2021.
279. BE IT FURTHER RESOLVED, the Secretary is authorized to make technical adjustments for the appropriate and accurate codification of these Rules and Regulations.
280. REGULATIONS OF THE BOARD OF SUPERVISORS ARTICLE I ACADEMIC AND ADMINISTRATIVE ORGANIZATION Section 1.
281. Order of Communications and Reports The official recommendations and communications of any member of the academic or nonacademic staff shall be sent through channels to the appropriate officer.
282. An administrative officer shall, when so requested, promptly transmit any such recommendations or communications, with the officer's own comments and recommendations thereon, to the next higher office.
283. Section 2.
284. Academic Organizational Units A The Faculty of the University The faculty of the University shall consist of the faculties of the several campuses as defined below (Sec.
285. 2B).
286. The President and the academic officers of the University shall be members of the University faculty and the former shall be its highest officer.
287. B The Faculties of the Several Campuses 1.
288. Membership.
289. Full-time members of the academic staff having the rank of Instructor or higher (or equivalent ranks1) shall constitute the faculty of the campus on which they are appointed.
290. The faculty may organize itself into a Faculty Council which shall include all full-time members of the faculty and members of the Administrative Council (see sec.
291. 1-3.1). As a class, part-time members of the academic staff having the rank of Instructor or higher (or equivalent ranks) may be enfranchised to the degree deemed appropriate by the faculties of the several campuses.
292. Members of the Administrative Council, not holding academic rank, shall be non-voting members of the Faculty Council.
293. 2.
294. Duties.
295. Under the Constitution of the State of Louisiana, the Board of Supervisors of Louisiana State University and Agricultural & Mechanical College has the authority to organize and manage the university.
296. The Board authorizes the general body of the faculty, or its representative body, Faculty Council2 shall to establish curricula, fix standards of instruction, determine requirements for degrees, make recommendations for the granting of degrees through its respective colleges or schools not within a college and generally determine educational policy, subject to the authority of the Board.
297. Except as otherwise provided, each faculty shall establish its own educational policies.
298. It shall, within the framework of the educational policy of the University, have legislative power over all matters pertaining to its own meetings and may delegate its own authority to an elected Senate and/or to standing committees, whose authority shall be limited to matters which are proper to the faculty and which have been specifically delegated by the faculty.
299. It shall make recommendations for the granting of degrees through its respective colleges or schools not within a college.The Board authorizes the faculty to establish admissions criteria for graduate and professional programs, however, standards for undergraduate admission to the University shall be approved by the Board.
300. 1See Section 2-6.
301. 2The terms faculty and Faculty Council are used interchangeably in this Section (2).
302. 3.
303. Faculty Representative Body.
304. Except as otherwise provided, the faculty of each campus shall establish its own governance policies.
305. The faculty may establish one representative body, such as a Senate or committee, to represent the will of the faculty and exercise legislative power to conduct its own meetings and fulfill the duties of the faculty.
306. The Board, the President, and the Chancellors will rely on those elected representative bodies as the voice of the general faculty.
307. Actions.
308. Any action of a faculty or Faculty Council which faculty representative body which, in the judgment of the Chancellor, or of the President, is administrative or which seriously affects the interests of another faculty of the University or of the University itself, may be suspended by the President and such action shall be reported to the Board at its next meeting.
309. All questions of jurisdiction among colleges, schools not within colleges, or divisions shall be determined by the Chancellor, or, for LSU or in inter-campus situations, by the President.
310. a Minutes of all actions taken by the faculties or Faculty Councils, together with appropriate recommendations of the major administrative officer concerned, shall be reported to the President.
311. The President may then refer any such action on academic matters of general University concern to the appropriate council, or a committee thereof, for consideration.
312. 4.
313. Meetings.
314. Each faculty, or its representative body, or Faculty Council shall meet at least once each academic year.
315. For the purpose of replacing or reconstituting the representative body, a meeting of the general faculty for that purpose may be called at the call request of the President as chair or of the Chancellor of the campus or, for LSU, the President’s designee, as vice-chair, or upon the written request of 50 members or 20 percent of the membership, whichever is the smaller number fewer.
316. The written request must be received within a 14-day period from the time of the original solicitation.
317. At least five days notice of meeting shall be given.
318. It shall be the prerogative of the President to preside; otherwise, the Chancellor of the campus or, for LSU, the President’s designee, will preside.
319. Minutes of all actions taken by the representative bodies, together with appropriate recommendations of the major administrative officer concerned, shall be reported to the President.
320. The President may then refer any such action on academic matters of general University concern to the appropriate council, or a committee thereof, for consideration.
321. 5.
322. Quorum.
323. Not less than 25 percent of the membership of the faculty or Faculty Council shall be necessary to constitute a quorum, provided, however, that any faculty or Faculty Council (at a meeting at which a quorum of 25 percent of the members is present) may, by majority vote, establish a higher percentage of the membership as a quorum for future meetings.NOW, THEREFORE, BE IT RESOLVED that the Board of Supervisors of Louisiana State University and Agricultural & Mechanical College does hereby approve the operating budget for the fiscal year ending June 30, 2022, providing: (a Final approval and commitment authorization of funds for unrestricted educational and general, medical, and related expenses in the amount of $1,190,016,205 for the campuses shown below.
324. LSU A M LSU Agricultural Center LSU Alexandria LSU Eunice LSU Shreveport LSU Health Sciences Center, New Orleans LSU Health Sciences Center, Shreveport LSU Pennington Biomedical Research Center The Hospital and Central Office of the LSU Health Care Services Division (b Commitment authorizations for auxiliary enterprises, grants and contracts, and other restricted funds estimated to be $1,964,876,382.
325. (c Transactions included or referred to in the operating budget that otherwise require Board approval are not approved by mere inclusion in the operating budget.
326. BE IT FURTHER RESOLVED that each campus shall prepare a semi-annual financial report.
327. The format of the report will include the following: 1.
328. Budget and actual for unrestricted revenues by source of funds 2.
329. Actual for unrestricted expenditures by object and by function 3.
330. Beginning account balances and actual revenues and expenditures/transfers for restricted operations 4.
331. Any significant changes in the budget that should be brought to the attention of the President and Board 5.
332. An explanation of any significant reduction in anticipated revenues or significant increase in expenditures Any subsequent modification to the reporting format will be approved by the President with notification to the Board.
333. © Copyright, American Psychiatric Association, all rights reserved.
334. • Keeping a cell phone readily available, • Scheduling sessions at a time when colleagues are also seeing patients in the office suite or clinic, • Forming a safety network among colleagues, and • Planning an escape route (Manca, 2005; Pinals et al., 2007).
335. B Prevention and Intervention Carr and colleagues outline a model of primary, secondary, and tertiary prevention for both the individual psychiatrist and the healthcare setting (e g , university, hospital, private clinic, etc.) (Carr et al., 2013).
336. Primary strategies can be routinely incorporated into clinical care; secondary strategies may be considered when the psychiatrist has concerns about patient behavior, such as when expected boundaries are tested; and tertiary strategies become important when stalking behaviors may include actual threats to cause harm or actions resulting in harm.
337. Examples of primary prevention measures include: • Providing detailed information at the outset of treatment regarding how therapy will work, the frame of the therapeutic setting and context, and the importance of collaboration in a way that helps maximize a sense of safety for all parties, • Minimizing one’s online presence (e g , social media).
338. This particularly applies to personal information, such as one’s private phone number, home address, details about personal or family schedules, or even online photos that might easily identify these details, • Using post office boxes and answering services, and • Becoming familiar with telephone services (e g , the procedure to block caller ID when making outgoing calls from a cell phone) (Manca, 2005).
339. Periodic reviews of basic security measures at home and at work are also important.
340. These measures could include: • Checking the proper functioning of any locks, alarm systems, motion sensors, and security monitors, • Training video cameras on entryways and having peepholes on office or clinic doors (Manca, 2005), • Participating in self-defense classes (Pinals et al., 2007), • Consulting with private security services or local law enforcement for specific safety strategies (Pinals et al., 2007).
341. While outside the scope of this document, psychiatrists may also consider consulting with hospital or private cyber security experts.
342. Examples of secondary measures that might be taken by psychiatrists include: • Providing and seeking supervision and consultation as soon as possible in a potential escalating situation and informing other members of the patient’s treatment team, • Thoroughly documenting boundary violations, problematic behavior, and attempted interventions.
343. © Copyright, American Psychiatric Association, all rights reserved.
344. Finally, examples of tertiary measures that might be taken by psychiatrists include: • Seeking consultation with experts in behavioral threat assessment and management (see “Consultation” below), • Participating in ongoing risk assessment, especially at critical junctures such as anniversaries and court dates, which may elevate the potential for the stalker to become violent, and • Careful consideration of whether, when, and how to terminate patient care and provision of thoughtful referrals (of the patient) to an appropriate provider (see “Legal and Ethical Issues” below) (Carr et al., 2013).
345. A special note about boundary-setting: in general, in any therapeutic relationship, setting firm limits and establishing clear boundaries is important (Manca, 2005).
346. Psychiatrists should examine boundary testing by patients with the possibility that they may progress to stalking.
347. If a patient violates expected prosocial behaviors and there is a specific concern for stalking behavior, the psychiatrist may consider sending one clear, unambiguous message to the patient to change this behavior (Sandberg et al., 2002; Pinals et al., 2007; McIvor et al., 2008).
348. However, this approach can require a more nuanced consideration of when and whether to do so.
349. Caution related to this communication is advised because this may escalate the behavior and increase the risk of retaliation from the stalker in some situations (Sandberg et al., 2002; Pinals et al., 2007).
350. After a careful weighing of the facts, a decision to “do nothing” may be as impactful and helpful as proactive measures, but each situation requires individualized planning and direction.
351. Also, victims or identified stalking targets must often make their own decision (preferably with support and guidance) as to what intervention, if any, to take, early in the course of the stalking behavior.
352. Regardless, if the patient’s behavior persists after reasonable attempts at limit setting, the psychiatrist should try to avoid any direct subsequent engagement with the patient until consultation has been sought (McIvor et al., 2008) (See “Consultation” below).
353. C Consultation Seeking consultation, particularly from a multi-disciplinary team, is one of the early steps a psychiatrist should consider in situations involving stalking.
354. Even for experienced psychiatrists, getting another perspective about their level of concern (e g , “Am I overreacting or underreacting?”) can be very helpful.
355. It is also important to acknowledge that each consultation requires a risk assessment and that the facts can evolve, especially as new information about a case becomes available.
356. Thus, it can be helpful to have a consultant available for the duration of the stalking situation, which may be brief or extend for years.
357. The specific make-up of the multi-disciplinary team may vary, but often includes law enforcement, hospital security, legal counsel, forensic psychiatric experts, and other hospital or administrative and personal victim supports.
358. Depending on the setting, a hospital or university may have a threat management team or a forensic psychiatry service (Binder et al., 2017) that can be particularly useful in scenarios that take place in an institutional context.
359. In a private setting, psychiatrists may consider contacting the nearest university’s forensic psychiatry program, professional organizations like the Association of Threat Assessment Professionals (ATAP), or local law enforcement that has specialized services (e g , San Diego County District Attorney’s Stalking Unit).
360. Questions that are commonly asked of consultants beyond violence assessment instruments are: © Copyright, American Psychiatric Association, all rights reserved.
361. • How dangerous is the stalker? • How can the behavior be stopped? • How do I protect myself? • Will the behavior stop, or get worse? • If [the behavior] stops, is it going to come back again? (Binder, 2006; Mackenzie et al., 2011).
362. While further research is needed regarding the management of stalking behaviors and the effectiveness of specific interventions, (Mullen et al., 2006; Binder, 2006; Mackenzie et al., 2011), a multi-disciplinary consultation approach can systematically assess prevention and risk management strategies.
363. For example: • Community law enforcement may have seen many stalking cases, have experience or even actuarial knowledge about stalking behaviors, easier access to legal records (e g , court documents) that could be useful in risk assessment, and understanding of local practices and enforcement regarding anti-stalking laws (Mullen et al., 2006; Binder, 2006), • Hospital security can help plan on-site safety measures, and • A private attorney, hospital legal counsel, and/or attorney from a malpractice insurance provider can provide input regarding local criminal stalking laws and about privacy laws related to the release of medical records and pursuit of criminal charges related to one’s patient.
364. A forensic psychiatric team can help determine what types of risk assessment (e g , HCR-20, SAM, or RSP [Carr, Goranson, & Drammond, 2013; Binder, 2006]) and management options (e g , psychotherapeutic who, medications, etc.) are reasonable (Mackenzie et al., 2011) for the patient who remains in the care of the psychiatrist or in the care of other psychiatric personnel.
365. A forensic team may also help balance relevant clinical and legal considerations (e g , confidentiality, duty to third parties, termination of patient care, impact on therapeutic relationship, etc.). Furthermore, a clinical forensic psychiatric consultation service, especially within the same institution, may not require patient consent to review protected health information (though each institution may have unique policies that should be reviewed prior to accessing a patient record).
366. D Mental Health Counseling Psychiatrists who are being stalked may also consider seeking personal mental health counseling.
367. Situations involving stalking can be intense, anxiety-provoking, and potentially lengthy (on average two years) (Carr, Goranson, & Drummond, 2013; Mullen et al., 2009).
368. Though further research is needed on the impact of stalking among physicians, in a questionnaire completed by 274 psychiatrists in Ireland, of those who were stalked (n 69), 85% reported suffering psychological distress as a result of their experience (Nwachukw et al., 2012).
369. Another survey of 1190 physicians, including 117 psychiatrists (Abrams and Robinson, 2013) found feelings of anger (73.8%) frustration (73.1%), anxiety (69.7%), fear (67.6%), helplessness (44.8%) and loss of control (52.4%). A UK study of 10,424 psychiatrists with 2,585 responses found a variety of impacts on psychiatrists, including feeling anxious and afraid (80.65%), having difficulty sleeping (52.19%) and ceasing to enjoy life’s enjoyment (11%) (Whyte et al.
370. 2011).
371. Regardless of the basis for the stalking behaviors, the consequences “personally and professionally, can be disruptive and potentially devastating” (MacKenzie et al., 2011).
372. Many victims of stalking may feel or actually be alienated, blamed, and criticized by supervisors and colleagues (Mackenzie et al., 2011; Carr et al., 2013).
373. In a qualitative U K study of 2,585 psychiatrists, © Copyright, American Psychiatric Association, all rights reserved.
374. respondents described variability of support from supervisors, colleagues, and law enforcement; some respondents felt very well supported, and others encountered a dismissive attitude that being stalked is inevitable for psychiatrists.
375. Those who received help experienced less distress than those who did not (Maclean et al., 2013).
376. E Documentation Detailed documentation of a patient’s stalking behavior toward the psychiatrist or staff is useful for both future legal interventions as well as behavioral management.
377. Victims of stalking are advised to maintain detailed records of any communication attempts on behalf of the stalker, such as emails and phone calls, including dates, times, recordings, and fear about safety (some stalking laws are based on the victim’s sense of fear) (Manca 2005).
378. Whether to keep such detailed records separate from the official patient medical record can be complex, and psychiatrists should seek further advice (e g , from legal counsel, administration, and supervisors) about which details should be part of the medical record and which should be kept as a separate file.
379. In general, clinically relevant information, such as behaviors (e g , gifts, boundary testing, breaches of privacy etc.), risk assessments, diagnoses, interventions, and issues surrounding termination, can be important to document in the medical record, especially to communicate to the treatment team or other providers involved in the patient’s care.
380. F Civil Protection Orders Protection orders are also known by a variety of other names, including restraining orders (Benitez et al., 2010) and intervention orders (Mackenzie et al., 2011).
381. Though the U S Interstate Stalking Punishment and Prevention Act of 1996 established that protection orders issued in one state are enforceable in other states (Benitez et al., 2010), the effectiveness of protection orders can vary greatly across jurisdiction.
382. For example, some statessprotection orders are designed for specific types of relationships such as domestic or interfamilial violence only whereas other statessorders can be more expansive (Knight, 2014).
383. Moreover, the utility of protection orders is debated and may not be helpful in every stalking scenario as they may fail to protect the potential victim, have high rates of violation, may provide a false sense of security, or even exacerbate the stalking behavior (Ostermeyer et al., 2016).
384. Police and court responses to protection orders may vary considerably since interpreting the point at which patterns of behavior cross the legal threshold and become criminal can be complicated (Mackenzie, et al., 2011).
385. Nonetheless, while they may not necessarily deter stalking behavior, protection orders may give law enforcement leverage to take the stalker into custody (Binder, 2006).
386. Thus, consultation may be particularly useful to draw on experiences, knowledge of the perpetrator’s prior response to such orders, and any available scientific literature to make recommendations.
387. For example, in a review of 15 publications, factors such as timing, potential escalation of behaviors, victim characteristics, perpetrator characteristics, abuser-victim relationships, and the context of the legal system were useful to consider in determining whether a protection order can be useful (Benitez et al., 2010).
388. Some additional considerations with protection orders are that they may be more effective earlier than later (Ostermeyer et al., 2016; Pinals, 2007), a stalker’s reaction to any previous protection order may be useful to guide decisions, and, if agreed to be ordered, the psychiatrist must make a commitment to report all violations to the appropriate authorities (Pinals et al., 2007).
389. Overall, even if protection orders are in place, they do not replace other personal protection and safety measures.
390. It can be helpful to work closely with one’s local law enforcement leadership in the jurisdiction where such a protective © Copyright, American Psychiatric Association, all rights reserved.
391. order might be issued so that they are aware of the protection order and the psychiatrist has points of contact in case of an untoward situation.
392. IV) Healthcare Setting Obligations Organizations and businesses generally have a legal and ethical responsibility to ensure workplace safety.
393. Unfortunately, many healthcare settings and organizations do not have well-defined procedures on how to handle stalking situations (Carr, Goranson, & Drummond, 2013).
394. First and foremost, organizations should strive to create and maintain work environments that are conducive to persons reporting concerns and receiving supports.
395. In addition, there is a progressive escalation of interventions which organizations might undertake.2 Examples of primary prevention measures that might be taken by institutions include: • Educating providers around issues such as the importance of setting and maintaining appropriate boundaries in a therapeutic relationship even when those boundaries are challenged or tested; • Ensuring that healthcare providers are educated about community contacts and support, such as law enforcement, so as to be able to readily seek assistance for any concerning patient behaviors, and • Establishing and educating staff about policies and procedures with regard to stalking behaviors by patients.
396. An important consideration for risk management personnel in universities, hospitals, and healthcare settings is what policies and/or procedures are needed to handle situations involving stalking.
397. These types of protocols would be separate and distinct from a sexual harassment type protocol or policy.
398. A stalking-related protocol or policy would include safety measures, expected legal responses, and a mechanism to provide staff with emotional support, resources, and multi-disciplinary consultation (McIvor et al., 2008).
399. Provisions for staff to take a leave of absence to address any psychological distress and to tend to practical matters, such as court appearances, may be necessary.
400. It is also important for administrative supports to be prepared to step in to manage communication with the patient and assist in the transfer of care when clinically appropriate (Mackenzie et al., 2011).
401. The healthcare setting may additionally consider a standardized debriefing with staff - with appropriate discretion regarding victim and patient privacy - regarding what patterns or conduct has occurred, how the clinic responded, what risks may persist, and what is needed from the rest of the clinical staff.
402. Creating this culture and establishing related policies can provide an opportunity to educate staff about preventative measures, such as boundary and transference issues, and violence risk assessment and management resources.
403. On a practical level, creating a collegial atmosphere that facilitates the disclosure of problematic patient behavior may allow earlier recognition, assessment, and treatment of the potential stalker, while also protecting co-workers and other clients (Mackenzie et al., 2011).
404. V Legal and Ethical Issues 2 As already noted, this document focuses on safety pertaining to patients as potential stalking perpetrators, and does not address workplace safety related to co-workers or domestic partners who may pose separate risks in a workplace setting.
405. © Copyright, American Psychiatric Association, all rights reserved.
406. Legal and ethical issues, such as concerns regarding breach of confidentiality and abandonment when terminating patient care, often arise when psychiatrists are concerned about being stalked.
407. Psychiatrists may be in a “double bind,” in which taking appropriate steps may result in a violation of confidentiality or even result in negative consequences for the patient (Carr, Goranson, & Drummon, 2013).
408. Seeking consultation, and proactively establishing appropriate procedures in healthcare settings for such situations, can help address some of these concerns.
409. In some settings, for example, psychiatrists may establish a zero-tolerance termination policy (Manca 2005), though legal and risk management guidance for such considerations is strongly advised.
410. Specific administrative strategies for termination and referrals should also be considered, such as, if indicated, provisions for clear communication to the patient that any contact with the previous psychiatrist (who was stalked) may be criminally prosecuted.
411. If a termination letter is sent, it should be by certified mail and include referrals to another professional, and might be better to come from the administrative director or clinic rather than the psychiatrist who was stalked (Pinals et al., 2007).
412. However, there should also be a careful determination of what if any final contact should be generated from the psychiatrist with clear instruction that leaves no room for ambiguity.
413. If the patient is being referred to an out-of-system provider, then ethical and legal transfer of information is important.
414. The psychiatrist (who was stalked) should develop a strategy to manage any future contacts - for example, one way to address the issues is that once the patient care has been terminated, it might be prudent for the psychiatrist who was stalked to not respond directly to the ex-patient’s future contacts.
415. Instead the hospital risk management division should send a clear and polite letter stating that it is hospital policy for the psychiatrist not to respond to the ex-patient, but to address the ex-patient’s needs through the hospital system (e g , a request for a release of records).
416. The psychiatrist who will be taking on the treatment of the patient should also carefully consider unique challenges in these situations, such as “stalking by proxy,” which in this case reflects when the patient passes notes or communication to their previous psychiatrist through their new psychiatrist (Carr et al., 2013).
417. VI) Special Considerations involving Medical Students and Psychiatric Residents Given the higher prevalence of psychopathology in individuals who stalk medical professionals (McIvor, Petch, 2006) and the higher prevalence of stalking victimization amongst psychiatrists as compared to other physicians (Abrams, Robinson 2011), trainees in psychiatry, from medical students in clinical clerkships to fellows in subspecialty fields, might be at risk for becoming stalking victims in these contexts.
418. To these authorssknowledge, there have been no published reports or protocols about how psychiatry residency training programs approach this issue.
419. Unlike practitioners already in independent practice, psychiatric students and trainees may not be as skilled at picking up any early warning signs of stalking.
420. Stalking may escalate from repeated phone calls to showing up to appointments outside of a scheduled session (Lee, Missett 1994).
421. Such behaviors may be minimized as part of the patient’s psychopathology and not reported quickly to a supervisor.
422. There may be a sense, too, that the professional role offers protection when care is delivered objectively (MacKenzie et al., 2011).
423. Trainees who are just learning about the boundaries of a treatment relationship may inadvertently encourage behavior that may lead to stalking.
424. For an example, a boundary crossing (aimed at enhancing the therapist’s treatment efforts), such as giving a hug instead of a handshake at the end of a particularly difficult session could be misinterpreted by a particular patient (Marshall, Teston 2008).
425. © Copyright, American Psychiatric Association, all rights reserved.
426. The American College of Graduate Medical Education (ACGME) Common Program Requirements stipulate that accredited residency programs monitor residentsswell-being, evaluate workplace safety data, and address “the safety of residents and faculty members.”3 They also have requirements about supervision and progressive independence over the course of the residency.
427. The ACGME makes clear that “at each participating site, there must be a sufficient number of faculty with documented qualifications to instruct and supervise all residents at that location (ACGME, 2019).” The presence of a readily-available and approachable supervisor is a critical component in reassuring trainees that they are not alone in their work, that they have a safe space in which to discuss the dynamics of a wide variety of therapeutic relationships, and that they have someone to whom they can go when they have concerns.
428. Unfortunately, many supervisors themselves are unfamiliar with how to best to handle, or possibly even identify, a stalking situation.
429. In addition, trainees may not report problematic behavior to their supervisor for fear of being perceived as a failure in the treatment relationship, shame, or a misplaced sense of a duty to treat the patient despite risk to the resident (Appel, Kleinman 2012).
430. Supervisors should be educated about steps to take in the event that a supervisee reports concerning patient behavior.
431. Program directors should have a protocol in place that addresses such issues by bringing in additional faculty supports, consulting with in-house forensic psychiatrists or even consulting with other programs, determining when to notify law enforcement and the risk management division of the resident’s training institution, and how to prioritize resident health and safety in the context of the stalking situation.
432. Residents should also be instructed on careful risk assessments and warning signs about problematic behavior to ensure their safety early as part of preventive strategic planning.
433. Recommended Elements of a Stalking Prevention and Response Program for Trainees Examples of measures that might be taken by institutions include: • Didactics early in training regarding boundary crossings, boundary violations, patient stalking and other behaviors are important to increase knowledge about such issues.
434. Didactics should include: o Definitions of Stalking o Clear guidance indicating that psychiatrists are responsible for managing transference and boundary issues as well as safely navigating patient relationships, and as such they may need assistance when their capacity to cope or manage is outweighed by their concerns and fears related to patient behavior.
435. • A clear protocol about potential notifications which should include: o Direct supervisors (senior resident, chief resident, or attending resident), o Program Directors o Hospital Safety Officer and Security (if available) to consider security measures for the resident while they are in the hospital, o Multidisciplinary threat management team if one exists (including the police, who can do a search regarding that individual’s legal history), Institutional police who may be able to research the perpetrator’s legal history, put an institutional restraining order in place, and contact the local police department in the jurisdiction of the resident’s home to provide extra protection.
436. The recommendations above with regard to Consultation, Mental Health Counseling, Documentation and Protection Orders may be equally applicable to scenarios involving psychiatrists in training.
437. © Copyright, American Psychiatric Association, all rights reserved.
438. Resources for the Patient A final issue of paramount importance is how to continue providing care in some way for the patient or how to safely refer the patient to the next psychiatrist who may need information as to the reason for the transfer.
439. There is a fiduciary duty on the part of the physician that needs to be balanced against concerns for their safety.
440. Depending on the location where the stalking is occurring, several options for patient care include transferring to a different provider in the same location (but possibly in another building) or transferring the patient to another provider altogether.
441. These can also be items for consideration in Consultation.
442. 8 More than half of patients with mental illness and substance use disorders also have an underlying physical illness.
443. For example, people with diabetes or heart disease often suffer from depression.
444. The complex interactions between mental and physical health conditions and the medications used to treat them require advanced medical training in order to ensure high-quality clinical care through adherence to best practices, which typically leads to highly positive health outcomes.
445. We know that mental health and substance use related conditions can compromise outcomes and drive costs of medical care.
446. Efforts at integrated care models are increasing, with funding streams being designed to help improve quality while containing costs.
447. These models depend on thoughtful clinical judgment and proper management of complex conditions.
448. A physician who provides oversight or collaborative consultation, with comprehensive knowledge of clinical needs, is essential to achieve these aims.
449. As such, PAs should be authorized to provide patient care services only so long as the PA is functioning under the direction and supervision of a physician or group of physicians.
450. The training PAs receive does not substitute for the comprehensive knowledge and skills physicians acquire as a function of their medical school education and experience.
451. The key difference between medical and physician assistant education and training is the fact that medical students spend four years focusing on the entire human body and all of its systems—organ, endocrine, biomedical, neuropsychiatric, and more—before undertaking three to seven years of residency training to further develop and refine their ability to safely evaluate, diagnose, treat, and manage a patient’s full range of medical conditions and needs.
452. By gradually allowing residents to practice those skills with greater independence, residency training prepares physicians for the independent practice of medicine.
453. Combined, the most basic medical school and residency training total more than 10,000 hours of clinical education and supervised training experience, including basic course work as well as years of practical supervised experience with patients.
454. The very nature of physician assistant training involves working with physicians; physician assistants are not trained to provide patient care without physician supervision.
455. Even physicians do not work independently before the end of their residency, even though at that point they have much more education and training than physician assistants.
456. Physician assistants just do not have extensive training in pharmacology, differential diagnoses, or the years of education and training regarding the human body and its systems that physicians have.
457. The vast majority of statess regulations reflect the necessity for oversight of PAs and the importance of physician-led care.
458. In 48 states a PA’s scope of practice is determined with the supervising or collaborating physician at the practice site.
459. Moreover, in 34 states PAs are supervised by physicians and in 16 other states PAs are subject to other forms of collaborative or alternative agreements.
460. Thus, as the billing abilities of PAs change it is important to ensure that this change does not impact the care the patients receive or the scope of practice requirements that are in place.
461. Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) (sections III.A , III.B , and III.C ) APA fully supports CMSsproposal to allow RHCs, FQHCs, and Critical Access Hospitals to provide audio- only services, in a patient centered-manner and based on the clinical judgement of the clinician.
462. As we stated previously with regard to expanded telehealth services, APA is concerned about any requirement 9 for a patient to be seen in-person by a practitioner in order to be eligible for any telehealth encounter.
463. Again, implementing requirements such as this may dilute the benefits of the expanded policy.
464. We also encourage CMS to expand audio-only coverage to include treating patients with substance use disorders.
465. We support RHCs and FQHCs receiving their usual PPS or AIR rates for audio-only telehealth services and support the billing for both G0511 and G0512 in the same month for the same patient as long as the time and effort is not counted more than once.
466. Medicare Shared Savings Program (section III.J APA is supportive of the Medicare Shared Savings Program and the Accountable Care Organization concept; facilitating better coordination and integration of care is critical to improving the quality of mental and behavioral health care, and the Shared Savings program is an important step in promoting these goals.
467. However, we are concerned that some of CMS’s proposed policies may undermine the ability of ACOs to meet requirements under the program.
468. Electronic clinical quality measures are important for reducing data collection burdens and incorporating clinically-enriched data into measurement activities, but a continued lack of EHR standardization raises concerns about the feasibility of aggregating data from diverse and disparate systems that may be in use across an ACO.
469. Furthermore, the practice of introducing new measures on a pay-for-reportingsbasis before incorporating them into payment calculations is an important step in the process of building a valid and feasible measure set, allowing participants to identify potential problems or unintended consequences that may arise with measure implementation.
470. We would encourage CMS to continue consulting with the ACO and clinician communities and patient representatives to determine the best-balanced measure set and measurement approach for the Medicare Shared Savings Program.
471. APA also supports the inclusion of the Behavioral Health Integration codes (99492-99494, G2214, and 99484) in the definition of primary care services for the Shared Savings Program.
472. Modifications Related to Medicare Coverage for Opioid Use Disorder (OUD) Treatment Services Furnished by Opioid Treatment Programs (OTPs) (section III.O).
473.  We appreciate the two proposed changes included in this section to improve access to care for patients with opioid use disorder by allowing payment for a recently FDA-approved higher dose of naloxone hydrochloride nasal spray product to treat opioid overdose.
474. We also support allowing the therapy and counseling portions of the weekly bundles, and any additional counseling or therapy provided by opioid treatment programs, to be furnished using audio-only telephone calls rather than via two-way interactive audio/ video communication technology for the duration of the PHE for COVID–19.
475. This is important given many patients do not have smart phones that allow for two- way communication.
476. Requirement for Electronic Prescribing for Controlled Substances for a Covered Part D Drug under a Prescription Drug Plan or an MA-PD Plan (section 2003 of the SUPPORT Act) (section III.Q APA appreciates CMS continued flexibility around the compliance date requiring the electronic prescription of controlled substances (ECPS) for Part D clinicians in light of the PHE.
477. As noted in this 10 proposed rule, and in APA’s previous letters to the Administration, the PHE resulted in numerous practical and administrative constraints of physicians in transitioning to ECPS by the original date of January 2021, and we appreciate CMS's previous action in moving the compliance date to January 2022.
478. APA supports CMSs current proposal to move compliance to January 2023.
479. APA also supports the proposed compliance threshold that would apply to all ECPS for Part D clinicians, including: 
480. When it would be impractical for the patient to obtain medication (prescribed by electronic prescription in a timely manner and such delay would adversely impact the patient’s medical condition.

481. When the National Council for Prescription Drug Programs (NCPDP) standard does not support transmitting the prescription, APA also recommends that CMS consider an additional compliance threshold based on clinician practice size, such as used in the MIPS Promoting Interoperability program.

482. Updates to the Quality Payment Program (section IV.) 
483. APA appreciates CMS’s effort to make minimal changes to the QPP program in light of the COVID-19 Public Health Emergency and the unique pressures our health care system continues to be under at this time.
484. Our comments focus on the MIPS Value Pathways (MVPs) program and efforts to incorporate cost measures into the MIPS program.
485. Cost measures APA continues to have strong concerns about application of episode-based cost measures (ECBMs) to individual clinicians, both as part of the overall MIPS program and through MVPs specifically.
486. As APA has expressed previously, existing and proposed ECBMs, as applied to psychiatrists, present serious challenges across multiple dimensions, including but not limited to:  
487.  
488. Psychiatrist control over key cost-related factors There is a limited range of costs that are directly within the control of individual psychiatrists, particularly those practicing in the inpatient environment, and minimal opportunities to exert indirect control over many of the costs included as part of the current ECBM attribution methodology.
489. This undermines both the validity of the measures and their effectiveness of measures as incentives for behavioral change, as clinicians will find it difficult to understand how their behavior is connected to increases or decreases in cost measure scores.
490. Potential for unintended consequences Without a full understanding of contributors to the varying costs of psychosis related care, emphasizing cost reduction creates a significant likelihood of unintended consequences, including potential for the measure to exacerbate problems with access to care.
491. Many psychiatrists care for a highly vulnerable population of patients who experience high rates of unemployment high and where socioeconomic challenges are common.
492. We know that individuals with serious mental illness have substantial physical health comorbidities and a lifespan that is as much as 20 years less than that of the population as a 11 whole.
493. Cognitive aspects of aging also appear to be accelerated in these individuals.
494. Efforts to reduce costs of care in these individuals may place them at even further disadvantage, with even greater disparities among Blacks, Latinx, and Indigenous People as has been starkly evident in health care delivery during the pandemic.
495. We urge CMS to avoid implementing measures or policies that have the potential to deepen inequities in access to care.
496. Transforming MIPS: MIPS Value Pathways APA supports the concept of MVPs and applauds CMS’s efforts to develop a measurement program that is more conceptually coherent, focused on improvement, and relevant to specialty practices than past activities.
497. However, as expressed above, there remain serious practical concerns about the implementation of cost measures, which are a key component of MVPs.

498. We are concerned that use of problematic cost measures will undermine the intent and effectiveness of the MVP program, and could lead to unintended consequences, such as cherry-picking of patients who are likely to be lower-cost, or further reduction in the number of psychiatrists willing to accept Medicare patients.

499. There also continues to be gaps in clinically-relevant quality measures for psychiatrists; we hope and expect that this will be improved over time, but at present, the set of measures available for mental and behavioral health is limited and is focused largely on process metrics that have not been demonstrated to have a high impact on patient outcomes.

500. CMS requests comment on what should happen when specialty clinicians cannot identify an applicable and relevant MVP.

501. APA would suggest that CMS slow the transition from traditional MIPS to MVPs to accommodate clinicians who cannot identify MVPs that are directly relevant to their clinical practices, allowing those clinicians to continue their participation in traditional MIPS until an appropriate MVP is available.

502. Other CMS measurement policies In addition to our comments on the proposed rule, APA would like to note that having a sufficient number of quality measures available for psychiatrists and members of the mental health care team is a priority for APA.

503. We anticipate that this will likely involve developing and then moving QCDR measures through the Measures Under Consideration process and into the MIPS program.
504. Over the course of the last four years, the number of measures approved via the MUC has declined precipitously, from several dozen measures to only four quality measures last year.
505. Combined with measure attrition, the availability of quality measures for groups to report has become much tighter.
506. CMS should rebuild the library of MIPS measures available for reporting by encouraging the submission of QCDR measures through the MUC process.
507. However, rebuilding a library of quality measures will be challenged by regulations finalized by CMS last year.
508. We are very concerned about CMS’s policy on measure testing for 2023 and beyond.
509. In the 2021 quality payment program rule, CMS finalized a proposal to require face validity testing for measures in 2022 and then “full testing” for measures submitted as part of the QCDR in 2023.
510. Because data to fully test a quality measure for validity is difficult to capture, we cannot support requirements that each measure be tested for validity beyond face validity.
511. 12 We recognize that CMS will attempt to implement these testing requirements over the next year.
512. In 2020 and again in 2021, CMS rightly allowed groups that were disrupted by the COVID-19 pandemic to apply for and receive a hardship exemption.
513. That policy, however, reduced the amount of data available for measure testing.
514. Because the extreme and uncontrollable circumstances policy decreased the number of groups able to report quality data, we ask that measure testing requirements (not including face validity testing) be delayed until two years after the end of the public health emergency (PHE).
515. In addition, CMS should approve an improvement activity for groups that assist measure stewards with measure development and testing efforts.
516. Measure development requires a significant amount of time, money, and analysis to complete, and often relies on volunteers to collect and report data to help assess measure feasibility, reliability, and validity.
517. Offering MIPS eligible clinicians and groups opportunities to earn improvement activities credit for helping improve the measures offered in MIPS is a worthwhile and meaningful action CMS can take immediately.
518. Proposed Changes to the Medicare Promoting Interoperability Program The APA appreciates the continued flexibility in reporting requirements under the Promoting Interoperability program for Eligible Clinicians (ECs), including options surrounding measure choice, scoring, and opportunities for bonus points.
519. Please find feedback regarding the proposed changes below: 4(b ...the performance period for the Promoting Interoperability performance category is a minimum of any continuous 90-day period within CY 2022...we are not proposing any changes to the Promoting Interoperability performance category... APA appreciates that CMS has maintained the 90-day reporting period for these electronic measures since the inception of MACRA in 2015.
520. APA supports maintaining this reporting period window, keeping consistent with previous reporting years.
521. Proposed Changes to the Query of Prescription Drug Monitoring Program Measure Under the Electronic Prescribing Objective (4 (c (i ) APA supports maintaining the PDMP measure as optional for CY2022, and also supports increasing the bonus for reporting on this measure from 5 points to 10.
522. As we have stated in previous letters to CMS, it is still premature to require the Query of PDMP measure and then include it in the Promoting Interoperability score.
523. As CMS has acknowledged, there are still technical challenges associated with connecting PDMPs with various EHR systems.

524. Our membership remains affected by these technical challenges, which include: a a lack of standards connecting PDMPs and EHRs, b the policy (e g , statutory) and other technical challenges around integrating state PDMPs with HIEs and hospitals, c addressing the challenges in integrating PDMP queries seamlessly into physician workflows, d the cost and time required for developers—and subsequent downstream financial impact on physicians/hospitals—to develop standards and technological solutions to better integrating PDMPs with other health IT software and finally, e the burden in tracking and calculating numerator/denominator requirements for the PDMPs.

525. 13 Moreover, not only do these challenges remain, but they were difficult to address during the PHE by healthcare organizations, as they shifted resources to mitigate the ongoing public health crisis.
526. Additionally, as ONC and CMSs Final Rule around Interoperability and Information Blocking were released in 2020, with the revised Applicability Date of April 2021, clinicians sand vendors priorities had to be adjusted to meet the expectations around complying with these regulations.

527. Thus, waiting to require the Query PDMP measure under the Electronic Prescribing Objective would give hospitals and vendors more time to adapt their systems accordingly.

528. As the technology necessary to connect PDMPs with HIT systems matures, requiring this measure will become less burdensome.

529. For example, the 2020 PFS outlined a transition to the updated CEHRT 2015 Edition standard and a transition for CEHRT to use the NCPDP SCRIPT 2017071 standard for electronic prescribing; the ONC, in its 21st Century Cures Final Rule, requires those vendors developing CEHRT for Promoting Interoperability will use FHIR open APIs to connect providers and other users of HIT.

530. Given these advancements, APA is optimistic that, in time, the data captured by PDMPs will be able to flow through the HIT ecosphere without significant burden to hospitals and providers.

531. We look forward to continuing to be part of the conversation regarding how the Query PDMP measure can be successfully implemented in the Medicare Promoting Interoperability Programs in the future.

532. (B to modify the Provide Patient’s Electronic Access to Their Health Information measure to establish a data availability requirement beginning with encounters with a date of service on or after January 1, 2016, beginning with the EHR reporting period in CY 2022 Currently, the Provide Patient Access to Their Health Information does not specify how long MIPS eligible clinicians are required to make patient data available, or to ensure that patient data remain available to patients in the event that an EC switches EHR vendors.

533. APA appreciates CMSsintent to align the Provide Patient Electronic Access to Their Health Information measure with the look-back period finalized in the Patient Access and Interoperability final rule.

534. While the January 1, 2016 date seems reasonable for ECs, the APA recommends that CMS delay enforcement discretion from July 1, 2021, to the end of CY 2021, to account for the ongoing COVID-19 PHE.

535. Moreover, APA seeks clarification that, during this lookback period, and other proposed future accessibility requirements around changes to the Provide Patient Access PI measure, that ECs can exercise the pertinent Exceptions under the Information Blocking and Interoperability Final Rule.
536. Specifically, that the Infeasibility, Content and Manner, and Health IT Performance Exceptions may be employed, when applicable, by the EC, when maintaining patient data in near-perpetuity may not be possible for MIPS- eligible clinicians.
537. Additionally, APA seeks clarification on whether this change to the Provide Patient Access measure will only apply to the reporting years for which the clinician was eligible and did not meet any of the MIPS program exceptions, such as the low-volume threshold.
538. Clarifying the above points will help to reduce burden among solo and small group psychiatrist ECs who may not participate in MIPS in consecutive years.
539. 14 Reweighting the Promoting Interoperability Performance Category for MIPS Eligible Clinicians in Small Practices APA appreciates CMS scontinued efforts to reduce administrative and financial reporting burden for small practices endeavoring to participate in MIPS.

540. As noted in this Proposed Rule, many small practices may be eligible for the LVT; or, qualify as small practices (i e , under 15 ECs), and therefore can apply for an Exception to the Promoting Interoperability category, when there are “overwhelming barriers” to participating.

541. In response to the questions posed in this Rule, APA is unable to ascertain the specific reason(s as to why some small practices may fail to apply for the Small Practice Hardship Exception for the Promoting Interoperability performance category, while still participating in MIPS as a whole.

542. This is possibly because many of our members in solo or small group practices qualify for a total exemption for all of MIPS under the Low Volume Threshold; or, as CMS contemplates in this rule, they may be unaware of the Exception itself, or may believe that they do not meet the requirements of “overwhelming barriers.”

      

     Regardless of reason, APA supports CMS recommendation to automatically redistribute points from the PI performance category to other performance categories of MIPS for small practices who do not apply for the Exception, but who would have been eligible, in order to avoid receiving a score of zero for the PI category.

543. (ii)  

544. We are proposing to add a new SAFER Guides measure to the Protect Patient Health Information objective...we are proposing that a MIPS eligible clinician must attest to having conducted an annual self assessment using the High Priority Practice Guide, at any point during the calendar year...with one “yes/no” attestation statement accounting for the complete self-assessment using the guide.

545. Generally, the APA supports the use of the Safety Assurance Factors for EHR Resilience (SAFER) Guides, particularly the High Priority Practices Guide, as a part of the Promoting Interoperability performance category.

546. Requiring ECs to attest to completing these guides has the potential to help many clinicians enhance and optimize health IT, ensuring that they are “responsible operators of technology tools,” as stated in this proposed rule.

547. This attestation is reminiscent of the existing Security Risk Assessment measure in its utility to safeguard patient information, and in that it will not be scored for PI.

548. While we appreciate CMS acknowledgement ECs (especially those in solo or small group practice) vary in terms of resources with respect being able to complete the SAFER attestation annually, APA recommends that, for the 2022 RY, CMS conduct an audit of those entities that attest “no,” in order to ascertain why they did not complete a SAFER attestation, to see if additional resources might support them in doing so for future reporting years.

549. 
     
550. We are also more broadly soliciting public comment to help us better understand the resource costs for services involving the use of innovative technologies, including but not limited to software algorithms and AI.
551. In addition to this broader prompt, CMS poses a list of questions for consideration regarding the use of innovative technologies within physician practices.
552. For example, the Rule considers how technologies, 15 such as AI, have affected physician work time and intensity of furnishing services (e g , possibly reducing the amount of time that a practitioner spends time reviewing and interpreting results of diagnostic testing), or how technologies are changing cost structures, affecting access to services for Medicare beneficiaries, and more.
553. While APA and psychiatry continues apace in adopting new technologies into clinical workflows—such as adjunctive therapeutic mobile applications, and wearables—it is qualitatively different from how other specialties are using it.
554. For example, in the Rule, CMS uses examples such as a simulation software analysis of functional data to assess the severity of coronary artery disease and how trabecular bone score software can supplement physician work to predict and detect fracture risk.
555. These examples might be considered as straightforward use cases of emerging technology where an attempt to codify and quantify their value to Medicare practitioners and beneficiaries seems reasonable.
556. For psychiatry some analogous use cases, such as various emerging technologies utilizing focused on discrete physiological symptoms (e g , neuropsychiatry, movement disorders, clinical decision support, work on neurolinguistics in detecting changes in language use patterns in predicting psychopathy or dementia); however, presently, there are too few data points and replicated research into how AI or other technologies are or can affect psychiatric work flows, physician time, and other considerations as contemplated in this Rule.
557. The use of AI in healthcare is still nascent.
558. With respect to psychiatry, most AI-driven tools are embedded within health IT products more appropriately described as “augmented intelligence” rather than “artificial intelligence.” The scope of this technology tends to encompass features of electronic health records (EHRs), such as electronic clinical decision support (eCDS), and in mHealth, such as apps that rely on patients behavioral history to send warnings to the patient about environmental factors that could potentially be triggering for mental health conditions, such as substance use disorders.
559. While APA is optimistic that the future of AI may improve patient care and lead to better outcomes, we are concerned that there are presently very few standards to which industry is being held in the development of AI in healthcare.
560. For instance, standards around privacy, security, and confidentiality within health IT is currently in flux.
561. There are also limited regulatory standards on the development and implementation of AI tools, which further complicates how such tools may be accounted for in terms of quality care and outcomes when integrated into Medicare payment considerations.
562. ermination Do you have a policy on circumstances that may lead to terminating the relationship with a patient? Does the policy include the state requirements to properly terminate the relationship? The APA is also concerned around background development of AI systems that may not include specific populations within standardization samples in AI beta testing/research studies.
563. Presently, some algorithms may be based solely on a certain population for various medical conditions (e g , men or women; various ethnicities; various socioeconomic groups) resulting in algorithms that may not compute the best treatment options or interventions for patients with unique vulnerabilities (e g , developmental disorders, suicidal ideation, substance use disorders).
564. Before the technology can be incorporated into Medicare payment models, there needs to be a comprehensive examination (by CMS, the FDA, other entities), of which data are being used to develop any algorithms that influence physician decision-making and patient care.
565. There needs to be an assurance that AI helps patients regardless of one’s race/ethnicity or other social determinants of health and isn’t introducing or magnifying disparities.

 

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