Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report

by Suzanne Felt-Lisk and Jennifer Humensky

For the Department of Health and Human Services,
Office of the Assistant Secretary for Planning and Evaluation,
Office of Science Policy
by Mathematica Policy Research, Inc.

January 17, 2003

CONTENTS

EXECUTIVE SUMMARY

I INTRODUCTION

  1. the "Minimum Necessary" Principle
  2. Purpose of the Study
  3. Privacy Issues under Managed Care
  4. Legal and Regulatory Context
  5. Methodology

II PERSONAL HEALTH INFORMATION COLLECTED BY MCOs: CURRENT PRACTICE

A. MCO REASONS FOR COLLECTING DATA
  1. Utilization Review
  2. Quality Management
  3. Audits
  4. Case Management and Care Coordination

B. INFORMATION COLLECTED BY MCOs FOR OUTPATIENT TREATMENT

C. DEGREE OF VARIATION IN TYPES OF INFORMATION COLLECTED

  1. Variation by Type of Plan
  2. Plan to Plan Variation

D. HOW DATA ARE COLLECTED

  1. Outpatient Utilization Review
  2. Clarifications
  3. Appeals
  4. Inpatient Authorizations

III STAKEHOLDER VIEWS ON WHAT CONSTITUTES "MINIMUM NECESSARY" INFORMATION FOR MCO OPERATIONS

A. PROVIDER ASSOCIATIONS, CLINICIANS, AND ADVOCATES
  1. Administrative Data Only for Most Cases
  2. Names Removed
  3. Some Additional Summary Information Is Justified
  4. Controversial Items
  5. Beyond Routine Outpatient Treatment
  6. Appropriate Information Sharing Depends on Who Will Review the Information and the Patient's Explicit Consent

B. MANAGED CARE ORGANIZATIONS

IV EXISTING PRIVACY-SENSITIVE APPROACHES TO COLLECTING PERSONAL HEALTH INFORMATION UNDER MANAGED CARE

A. THREE PRIVACY-SENSITIVE APPROACHES
  1. Maryland Uniform Treatment Form
  2. Magellan Outpatient Treatment Request Form
  3. APA Guidelines
  4. Understanding the Three Approaches in Context

B. USE OF ASAM CRITERIA AS A BASIS FOR DETERMINING NECESSARY INFORMATION FOR SUBSTANCE ABUSE TREATMENT

V POTENTIAL NEXT STEPS

A. POSSIBLE CONSEQUENCES OF NO ACTION

B. DEVELOPING A NATIONAL STANDARD FOR WHAT CONSTITUTES "MINIMUM NECESSARY" INFORMATION

  1. Role of Scientific or Other Research Results in Considering What Information Is Needed
  2. Role of Consensus
  3. Need for or Desirability of Legislation

C. HOW THE HEALTH PLAN COMMUNITY CAN USE THIS REPORT TO ADVANCE THE PRIVACY-SENSITIVE COLLECTION OF MINIMUM NECESSARY INFORMATION

REFERENCES

APPENDIX A: LITERATURE REVIEW OF PRIVACY ISSUES IN MANAGED CARE FOR MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT

APPENDIX B: MARYLAND UNIFORM TREATMENT PLAN FORM

APPENDIX C: MAGELLAN TREATMENT REQUEST FORM

APPENDIX D: SUMMARY OF ALL PATIENT HEALTH INFORMATION REQUESTED IN OUTPATIENT TREATMENT REQUEST FORMS

APPENDIX E: PERSONAL HEALTH INFORMATION REQUESTED BY MCOs AND MBHOs

APPENDIX F: PERSONAL HEALTH INFORMATION REQUESTED BY LOCAL AND NATIONAL MCOs

APPENDIX G: AMERICAN PSYCHIATRIC ASSOCIATION MINIMUM NECESSARY GUIDELINES FOR THIRD-PARTY PAYERS FOR PSYCHIATRIC TREATMENT

TABLES

I.1 INTERVIEW PARTICIPANTS, BY TYPE

II.1 PATIENT HEALTH INFORMATION COMMONLY REQUESTED IN OUTPATIENT TREATMENT AUTHORIZATION, BY TYPE OF RESPONSE

IV.1 COMPARISON OF PERSONAL HEALTH INFORMATION SHARED VIA THREE APPROACHES VIEWED AS PRIVACY-SENSITIVE OUTPATIENT TREATMENT REQUIRING PRE-AUTHORIZATION

IV.2 PRIVACY LAWS OF NEW JERSEY AND THE DISTRICT OF COLUMBIA: DISCLOSURE TO THIRD-PARTY PAYERS

ACKNOWLEDGMENTS

This report would not have been possible without the many clinicians, advocates, managed care executives, association representatives, and other experts who provided us with relevant documents and took the time to discuss their perspectives on and experience with privacy issues in managed care for mental health and substance abuse treatment. In addition, the authors would like to thank Myles Maxfield for insightful comments on a draft of this report, Daryl Hall for editing the report, and Donna Dorsey for producing it. Finally, for their guidance throughout the project, we thank John Fanning and Kevin Hennessy of the Office of the Assistant Secretary for Planning and Evaluation (OASPE), and Sarah Wattenberg of the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services.