Fixing the physician credentialing process to reduce mental health stigma in health care – American Medical Association

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What is medical credentialing and why is it important? What questions should be asked about mental health? Is mental health treatment becoming less stigmatized?
Our guests are Steven Defossez, MD, vice president of clinical integration at the Massachusetts Health & Hospital Association, and Stefanie Simmons, MD, chief medical officer for the Dr. Lorna Breen Heroes’ Foundation. AMA Chief Experience Officer Todd Unger hosts.
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Unger: Hello and welcome to the AMA Update video and podcast. Today, we’re talking about a big win for physician well-being in Massachusetts that can help provide a framework for other states. With us today are two guests who, along with the AMA, helped to make this win a reality.
Dr. Steven Defossez is the vice president of clinical integration at the Massachusetts Health and Hospital Association in Burlington, Massachusetts, and Dr. Stefanie Simmons is the chief medical officer for the Dr. Lorna Breen Heroes Foundation in Ann Arbor, Michigan. I’m Todd Unger, AMA’s chief experience officer in Chicago. Dr. Defossez, thanks for joining us, and Dr. Simmons, welcome back.
Dr. Simmons: Thank you.
Unger: Well, the win we’re talking about today involves something that maybe is not expected when we think about physician well-being, and that is about Physician Credentialing Applications and how they’re used in the Commonwealth of Massachusetts. Dr. Simmons, I’ll ask you to start. For those who may not be familiar, give us kind of a brief explanation of the connection that comes between credentialing, that process, and physician well-being.
Dr. Simmons: Thanks, Todd. This is really about access to mental health care. And so when a physician credentials at a hospital, a necessary step in order to practice at that hospital or in that health system, there’s an application that they fill out. In that application, they have to go through their training, their credentials, their licensing. But they also answer a series of questions that are designed to assess their fitness to practice in that organization.
And, unfortunately, in many organizations, one of those questions asks about the health care worker or the physician’s history of mental health care diagnosis and treatment. This is really rooted in an antiquated view of mental health care as a signifier of a moral or ethical fault, as opposed to a necessary part of self-care for a health care worker. These questions have a stigmatizing effect of mental health care and a chilling effect on physicians’ willingness to seek mental health care, even therapy or counseling, when they want it.
Unger: Well, it might be obvious. But why is that the case? What happens? What’s the dynamic there?
Dr. Simmons: There’s a few reasons. And I like to think of this in terms of stigma and then risk assessment. The first is that these questions are included along with questions about history of felonies, right, history of malpractice or of lawsuits, and so it really paints mental health care with a brush that is stigmatizing for health care workers.
The second is that people value their privacy, and health care workers and physicians are no different. And so there is a knowledge and an understanding that your employer, your colleagues, may see this application, may be reading it and may be privy to your personal health information because of that. For both of these reasons, physicians choose not to seek care, rather than being faced with the decision of having to disclose their private information on these types of applications.
Dr. Defossez: That’s very well said, Stef. And for our listeners who may not be aware, the credentialing questions are seen by about a dozen of your colleagues on the credentialing committee at the hospital. And then from there, they go to the med exec committee, which is a bunch of physician leaders and lay leaders in the hospital. It might be two dozen people will look at the results of these questions.
And then from there, they go to the Board of Trustees, which might be up to three dozen community members and health care leaders in the area. So you’re really sort of, when you’re answering these questions, you’re cognizant of the fact that dozens and dozens of other people are going to see these. And obviously, all these people don’t need to be privy to your private health situation.
Dr. Simmons: That’s absolutely correct. And it is important that the credentialing process ensures the safety of patients being cared for. The history of diagnosis or treatment of mental health conditions really doesn’t further that aim. We don’t ask about diagnosis or treatment of physical health conditions. And so there is a different differentiation in the stigmatization of mental health, as opposed to physical health in these applications.
Unger: And that’s a really interesting discussion. And until the two of you talked about that, that privacy issue, well, it made a lot more sense to hear you talk about it and what a terrible issue that would be for someone. Earlier this year, leaders at every hospital health system and local health plan in Massachusetts committed to eliminating these stigmatizing questions from their credentialing process, which, as you point out, is a huge development. Dr. Defossez, can you give us an overview about how a win like this came to be?
Dr. Defossez: I’d be happy to. The Massachusetts Health and Hospital Association, or MHA, has a long history of supporting our members, staff, physicians and clinicians’ well-being. As part of that, I’ve been the co-chair of a joint task force between MHA and the Massachusetts Medical Society on physician burnout for over five years.
Through that work, we were able to convince the Board of Registration in Medicine to remove these types of overly intrusive, well-meaning but harmful, credentialing questions on the licensing application for physicians. And then leaders inside MHA came up with this idea for this initiative. What we decided was we’re going to look at the credentialing questions, every single question, every hospital in the state and then look at it through the lens of, does this represent a barrier to clinicians obtaining necessary health care and then bring those questions up to best practices.
We first, when we got this idea for the initiative, we processed it with the physician leaders across the state in physician leader meetings and had 100% support for this. Then, MHA leaders brought it to the Board of Trustees, where we had a unanimous approval to go ahead and do it. The nuts and bolts of how we did it is we had every single hospital send their credentialing questions to me, both MHA members and the few hospitals in the state that aren’t members.
And then, along with the chief medical officer at the Physician Health Services, we—he and I—reviewed every one of these questions through that lens and identified areas or opportunities for improvement. Bottom line up front, we’re absolutely delighted to tell you that, as of today, 34 MHA member hospitals are currently following best practices regarding credentialing questions. Another 38 hospitals in the state, both MHA members and some non-MHA members, utilize something called the Integrated Massachusetts Application. It’s a standard set of credentialing questions.
And that standard set of credentialing applications is actually owned by the health plans, and it’s hosted on CAQH’s website, as of March 11. That set of questions will be brought up to absolute best standards. And there are two other hospitals in the state that we’ve identified opportunities for improvement and they’re committed to improving those opportunities, and they’re working their way through the system or process. So we’re really quite excited about this initiative.
Unger: That’s quite an undertaking and what an outcome. And I’ll say that AMA was proud to work with you to make this much-needed change happen. Dr. Simmons, can you tell us a little bit about the collaboration that took place behind the scenes and why it’s so important?
Dr. Simmons: Absolutely. What we found over and over again, as we are working nationally to make this change, is that it takes people from all parts of health care coming together to be able to make these changes for organizations. So when the hospitals and the physicians and the advocacy groups around mental health can come together to make this change, then all of a sudden, it happens, instead of being sort of debated—right—over and over again. And so what we’re hearing and seeing nationally is people putting their voices together towards this change.
So our partnership with the Dr. Lorna Breen Heroes Foundation and the AMA has been very fruitful. The AMA provides expertise in reviewing applications and questions to identify any sources of stigma in the questions. And the foundation, we help to advocate for this change nationally, and then we also, once those questions are reviewed, award a Licensing and Credentialing Champions Challenge badge. That serves to help communicate to health care workers that the organization has been reviewed and has been found consistent with best practices.
Unger: Well, let’s take a look toward the future. Dr. Defossez, you’ve been through this process before. What advice would you have for other states who want to follow your lead?
Dr. Defossez: Well, I would absolutely encourage every state in the union to follow MHA’s lead. Audit the questions, the credentialing questions throughout the health care ecosystem, not just the hospitals but the health plans, the Board of Registration and Medicine, the Board of Registration in Nursing, the medical malpractice carriers. I’m delighted to say, throughout Massachusetts, all of those are following best practices. If I could at all be of service to any of the organizations across the country, in terms of detailing exactly how and why we were able to succeed, I’d be happy to do that offline.
Unger: And Dr. Simmons, when you look ahead to the coming year, what’s on your agenda?
Dr. Simmons: Well, the very exciting thing for the Dr. Lorna Breen Heroes Foundation is that the National Association of Medical Staff Services just released their ideal credentialing standards for 2024. And those ideal credentialing standards are consistent with best practices around asking questions around mental health. So that includes for credentialing applications and also for peer reference forms. So we are issuing a challenge for hospitals and health systems across the country to audit, change and communicate that change to their health care workers. And we really hope that we’ll get a great uptake nationally with this change and make a difference in the availability of mental health care for the health care workforce, as well as start to change some of the stigma around seeking care for health care workers.
Unger: Well, before we close, I wanted to ask you if, after you make changes like this in the state of Massachusetts, for instance, do you hear back from physicians about a more positive experience or gratitude?
Dr. Defossez: Yeah, no, I have been really happy to hear, so many people across the state have come up and said, thank you for doing this. It’s really important. In fact, one physician, who is an alcoholic who’s been in recovery for 20 years, who was an outstanding leader at his organization, told me how personally important it was to him.
And I would just say, all across the country, we ought to be doing this. It’s great for the clinicians. It’s great for the organizations where they work. And oh, by the way, it’s super for the patients, too.
Dr. Simmons: I was asked the question once, if I’d be worried about having a physician for myself or one of my family members who’d had depression or anxiety. And I said, I would be thrilled to have a physician for myself or a family member who had gone through the process of treating a mental health condition because they would have a sense of compassion and understanding of what others may be going through, right? And so it’s important to view seeking mental health care as a sign of strength in health care workers. And what I’ve heard, when health care workers across the country come to our foundation and share their experience, is that they are seeking out organizations that have made these changes to work there. Even if they’ve never received mental health care themselves, it’s a signifier of that organization caring about their health care workforce.
Dr. Defossez: Absolutely.
Unger: What a great point. Dr. Defossez, Dr. Simmons, thank you so much for joining us today and for your partnership on this incredibly important work. If you want to support the AMA’s efforts to reduce physician burnout and promote well-being, you can join the AMA at ama-assn.org/join. That wraps up today’s episode, and we’ll be back soon with another AMA Update and be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us and please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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