article: "Is Confidentiality Still Protected Under Managed Behavioral Health Care?"

[Peter Marshall <techdiff@ix.netcom.com>]

http://www.medscape.com/SCP/DBT/1999/v11.n02/d5903.pome/d5903.pome-01.html.

Behavioral Health Matters - Is Confidentiality Still Protected Under
Managed Behavioral Health Care?

Jay M. Pomerantz, MD

[Drug Benefit Trends 11(2):2, 56, 1999. © 1999 SCP Communications, Inc.]

Introduction

The big secret these days is that what patients tell therapists is no longer
confidential. Managed care companies demand detailed accounts of patients'
workplaces, family problems, love life, addictions, suicidal ideation,
episodes of anger, and so on. These data are required to substantiate the
diagnosis and treatment plan at remote sites where case managers sit at
their computers. The information, which includes case assessments, mental
status exams, and progress reports, comes in by telephone, fax, and
mandatory written reports and questionnaires. Everything is entered on the
computer; written reports may be microfilmed for future reference. Almost
all behavioral health companies file the material by the patient's health
insurance number, which is usually the same as his or her social security
number.

Furthermore, these companies are constantly merging and expanding. For
example, Magellan Behavioral Health now owns Green Springs Behavioral Health
(which had previously purchased Vista Behavioral Health), Human Affairs
International, and Merit Behavior. That puts Magellan in charge of the
behavioral health care of 62 million people across the US, 58,000 providers,
more than $1.5 billion in revenues, and perhaps 70% of the behavioral health
market. Not to be outdone, Options Health Care, Inc., purchased Value
Behavioral Health from HCA/Columbia (the for-profit hospital chain under
investigation for Medicare billing fraud and other illegal activities) to
become the second largest behavioral health care company, managing 20
million people. Charter Behavioral Systems bought Behavioral Healthcare
Corp. in 1997 to become a combined entity of 139 mental health care
facilities in 36 states and Puerto Rico, with revenues of $1.2 billion.[1,2]

Large corporate consolidations necessarily lead to huge collections of
patient data and, of course, a large number of employees. Although companies
use passwords and other safeguards to limit access to patient files, a
haunting question remains about whether any system can satisfactorily guard
a huge collection of sensitive, personal data derived from supposedly
confidential conversations between patients and their therapists. (What a
gold mine for private detectives and political operatives, not to mention
the possibility of blackmail!)

Unreliable Data

There is another unfortunate complication. As the behavioral health budget
has shrunk, managed care has approved only urgent situations and high-risk
patients for ongoing treatment. It is thus not uncommon for therapists,
usually trying to help their patients (but perhaps also to help themselves
if business is slow), to exaggerate their patients' difficulties. The data
in the behavioral health companies' archives are therefore not necessarily
accurate and are possibly skewed toward psychopathology and the dramatic.
The patient with suicidal ideation may slide into the category of someone
with an obsessive need to kill him- or herself; the moderately angry worker
may be portrayed as ready to blow up the workplace. What happens later when
either of these individuals is running for political office and this highly
charged, supposedly substantiated material leaks to the press?

The best way to guard these patient data may very well be to not collect
them in the first place. Yet how else can one manage behavioral health care?
Like other parts of the health care system, behavioral health has begun to
sign capitation contracts with groups of providers. From an information
management perspective, especially confidentiality, capitation is helpful.
Data can usually stay with the providers, where they traditionally have
remained quite safe and carefully protected. Capitation, of course, has many
other problematic features that may be discussed in future columns. Other
management strategies, utilizing peers and detailed cost data, as in the
Professional Affiliation Group (PAG) model, also avoid the central
collection of sensitive clinical data.[3]

Some hope for change in the current system comes from an unexpected source:
the behavioral management companies themselves. The large costs associated
with information collection (required for case-by-case management) make the
current system vulnerable. Unfortunately, the most likely scenario is that
the problem will be solved by technological advances (eg, continuous and
rapid Internet connection). Man's ability to invent tools often moves ahead
of the ability to use those tools for good rather than evil purposes (or so
it seems from a confidentiality perspective).

Yet if the system were to vanish tomorrow, I would still worry about what
happens to the mass of information already collected. In the meantime, any
form of managed behavioral health treatment within HMOs, PPOs, or even
indemnity insurance (ie, with a behavioral health carve-out arrangement) is
a caveat emptor situation. I would personally advise paying very careful
attention to what the therapist is releasing to whom and having a frank
discussion including what constraints the managed care company is placing on
the therapist. It is amazing that the confidentiality problem has not
destroyed behavioral health treatment. Perhaps most patients feel so badly
when they arrive for treatment that they do not care so much (at that time)
who knows about it. It also may mean that neither managed behavioral health
companies nor therapists have been candid with patients. The routine
signature for release of data for managed care purposes, like other areas of
managed care, has implications beyond the immediate and obvious.

References

  1. Anonymous: Industry round up: Behavioral Health Tomorrow 6(6):29,
     December 1997.
  2. Anonymous: List of MCOs keeps getting shorter. Psychiatric Practice &
     Managed Care (a publication of the American Psychiatric Association
     Office of Economic Affairs and Practice Management) 4(5):6-7,
     September/October 1998.
  3. Pomerantz J, Liptzin B, Carter A: The Professional Affiliation Group: A
     case study in behavioral health management, in Schamess G, Lightburn A
     (eds): Humane Managed Care? Washington, D.C., NASW Press, 1998.

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