Complaint Exhibit B
Petition Exhibit D

DANIEL S. SHRAGER, M.D.

May 8, 2000

Ms. Judith Kadosh
Network Manager
Magellan Behavioral Health
4 Gateway Center, Fourteenth Floor
Pittsburgh, PA 15222

Dear Ms. Kadosh

    I am writing in response to Magellan's request to perform a site visit at my office and to "review" 5 of my patient records. I must say to you that allowing anyone to see any of my patients' records, with or without their consent, regardless of whether records are blinded or not, goes against every ethical and professional grain of my being and goes against all that I've ever been taught in my psychiatric and psychoanalytic training. Psychiatric records are not the same as other medical records. Indeed, how records are handled and dealt with have a profound effect upon the very psychotherapy that goes on in each and every session with a psychodynamically oriented psychiatrist such as myself. A patient's knowledge that the very private material that he is asked to share may, at a future time, be read by a total stranger, no matter what that stranger's purpose, can't help but affect that patient's ability to be forthright and candid in subsequent sessions with that therapist. Moreover, the intimate detail noted in each chart would make a patient recognizable to anyone who just might happen to know that person from some other setting, not such an unlikely occurrence in a city the size of ours. Additionally, charts contain the therapist's own thoughts, feelings, and associations, this being necessary in order for the treater to be in touch with his or her own countertransferences and projective identifications, a vital part of psychotherapy as practiced in the year 2000. How can a psychiatrist candidly write down such things, knowing that the private thoughts he is writing may be "reviewed"? And what about names of friends, family, lovers, etc, or details of events, and happenings that are an important part of a patient's everyday life. How can these be ethically "reviewed"? --- and, if sufficiently disguised and abbreviated, how will the therapist be able to read and recognize his own writings? I really believe that by pursuing such a record review policy for mental health professionals your managed care company, in the name of "ensuring quality", wreaks the destruction of the very thing that you wish to ensure, viz. "quality".

      Unhappily, I am now faced with a dilemma not unlike the one which faced me prior to my deciding to join managed care in the first place. Namely, I can just say "No." and face possible decredentialing which at this time would, in effect, cause scores of my patients to lose their psychiatrist, thereby creating a great amount of emotional pain in the very people whose pain I work to alleviate. Alternatively, if I, without remonstrance, go along with this basic infringement upon privacy, then I am, in effect, passively supporting this process and agreeing with your credentialing body that the assurance of record uniformity and completeness via a "review" is worth all of its negative consequences. My ambivalent compromise, given the duress that I am under, is to plead my case as I have in this letter in the fervent hope that you will understand more fully what you are doing and reconsider. If you will not reconsider, then I, reluctantly, will be forced to accept your suggestion that I present blinded charts for review after obtaining full informed consent and a written release from each of the patients involved. I would in that circumstance further request that I be fully informed regarding the background of the person who will be doing the review. I think it not unreasonable that I be given an outline of the training, background (both personal and professional), as well as the professional qualifications of the reviewer. I also request that I be informed as to what teaching/training in the area of confidentiality that the reviewer has received. At the risk of sounding self-aggrandizing, I wish to remind you that, while your job is to "manage", mine is to heal. I look forward to receiving your prompt response.

Sincerely,

Daniel S. Shrager, M.D.

cc: Ms. Gwen Lehman
Pennsylvania Psychiatric Society

cc: Ms. Heather White
American Psychiatric Association