In this chapter, we report on what the provider associations, clinicians, consumer advocates, and managed care plans we interviewed see as “minimum necessary” information. In addition, we identify which items of personal health information are especially controversial. We observed that in many cases, respondents’ views on privacy have been shaped by their experience with and views on managed care more generally.
A. Provider Associations, Clinicians, and Advocates
The provider association representatives, clinicians, and consumer advocates we interviewed agreed that many MCOs request more personal health information than they need to manage care. There was less than full agreement, however, on just how much information MCOs do need. We begin by discussing the views that allow for the least information to be shared. Many of the consumer advocates we spoke with were not comfortable with being specific about what they believe would be acceptable to share with MCOs. The issue has not typically been a pivotal one for them, and they often said they did not hear about it much from their membership.
B. Managed Care Organizations
The MCOs we spoke with believe they collect only the personal health information they need to manage care. Those who commented directly on the APA guidelines do not believe that the guidelines provide for the sharing of enough information. The MCOs do not want to manage every outpatient case, but they do value the ability to flag outlier cases that might be problematic. They use the information both at the individual case level—to avoid treatment that is either not minimally necessary or inappropriate—and in some cases at the provider practice level as a profiling device, noting that problems are typically concentrated among certain providers. 4
One MCO explained that access to a considerable amount of clinical information is important to managing care in terms of both patient use and cost. That is, it is important to the plan to use medical necessity and quality criteria, but the plan also feels a need to protect itself against artificial cost increases. In the MCO’s words, “with the enactment of parity, we have seen ‘diagnosis drift,’ so someone with an adjustment disorder might be characterized as having depression or bipolar disorder [so the provider could obtain payment for the additional treatment expected for patients with bipolar disorder]. Clinicians tend to be influenced by their own financial needs as well as the patient’s needs.” The routine record audits described in Chapter II presumably help to protect against this tendency.
4 One MCO we spoke with currently uses provider profiling, while a second is working towards this ability.