Privacy Issues in Mental Health and Substance Abuse Treatment: Information Sharing Between Providers and Managed Care Organizations: Final Report. 2. Role of Consensus

01/17/2003

A second critical consideration is whether HHS might be able to establish a set of minimally necessary information that can be shared between providers and payers.  HHS might establish this set of information, with relevant stakeholders providing input during the process.  Alternatively, HHS might choose to convene a set of experts to reach a consensus on what information should be considered minimally necessary, as was done in Maryland in the development of the Uniform Treatment Plan Form, and adopt this consensus as the official minimally necessary set of information.

Insight into Constructive Participation by Stakeholders.  Providers do not agree on whether personal health information should support routine care management by MCOs.  Some do not even view compromise on this issue as an appropriate option.  This group—a subset of the providers who hold the “administrative data only” view described in Chapter III—would not be expected to participate constructively in an effort to generate a set of minimum necessary information by consensus.  As noted in Chapter III, other providers hold less extreme views, finding it acceptable to share certain information beyond administrative data with MCOs.  Still others acknowledge privately that the sharing of information that supports utilization and quality management overall benefits the consumer by avoiding fraudulent and unnecessary treatment and offering some protections regarding quality of care.  Because they agree with providing some personal health information to MCOs for the purpose of care management, these two groups of providers might be expected to contribute to the effort to develop a minimum necessary information set by consensus.

On the other side of the equation are the MCOs, which may or may not buy into the idea that a common set of minimally necessary information would benefit them.  The extent of their participation may depend on the extent to which they view the specifics of how they use personal health information as proprietary—a component of their corporate strategy that allows them to keep costs lower than their competitor.  However, one health plan respondent we spoke with supported the concept of a single set of minimum necessary information collected through a standardized form, and in fact told us of some overtures he had made to advance the concept.  A nationally applicable form that captures the minimum necessary information set could benefit MCOs and providers alike by reducing the burden on both parties.  For instance, such a form could reduce provider errors, since providers would become accustomed to responding to the items on the form.  This could, in turn, help to reduce the need for MCO follow-up, which taxes both MCO staff and providers.  The burden of responding to follow-up could also be lessened for providers if MCO follow-up were voluntarily or otherwise restricted as a result of a carefully considered process to identify the minimally necessary information for managing care.  Moreover, the routine completion of a standardized form should simplify the administrative burden on providers; in addition, to the extent that the form would be less extensive or require less narrative than many current forms, it would reduce providers’ workload.  The resulting lower burden on providers could enhance their relationship with MCOs.  Finally, the development of a standard set of minimum necessary information would offer plans a way to ensure that they are abiding by the “minimum necessary” information principle articulated in HIPAA.

HHS’ Role.  While providers and MCOs, as well as consumer advocates, must participate in development of a standard set of minimum necessary information, HHS has at least two options for defining its role in the effort.  One option is for the agency to act as a facilitator, convening representatives from the various stakeholders and securing a commitment to developing a group product, which HHS could decide to adopt or help disseminate.  Based on our interview with a respondent who was heavily involved in Maryland’s development of its Uniform Treatment Plan Form, a legislative mandate or deadline for producing such a product may be a prerequisite to the success of this type of strategy.  Alternatively, HHS could consult with representatives of the provider, advocacy, and managed care communities, using the resulting information to establish guidelines for what constitutes minimum necessary information under its own authority. 

Some Potential for Unintended Consequences.  A standardized set of minimum necessary information could inadvertently increase the amount of personal health information collected by those plans that now collect the least information.  However, as discussed in Chapter IV, the amount of data collected routinely must be interpreted in the context of how much follow-up information a plan collects.  If, as in Maryland, the standardized set represents all of the information a plan may collect outside a formal appeals process, then more personal health information may be collected routinely.  However, the net effect of this approach may be the same or better for the consumer than if less information is collected routinely and follow-up is open-ended—that is, if free-form discussions between case managers and providers lead to the sharing of more personal details for some cases.

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