Who’s Making Money from Healthcare Reform?

Before I get too far into this post, let me be clear about a couple of assumptions.

1. I am an advocate of Healthcare Reform. I was disappointed in the bill that finally passed because I believe it was not a strong enough protection for consumers. Given that, I am glad we have a healthcare reform law on the books.

2. I believe that most consumers would benefit in the greatest possible way from a single payer system. This could be modeled on Medicare or utilize some other possibilities, but I think a single payer system is the only way we will ever get a healthcare system that truly meets the needs of most consumers and costs the least.

Given those assumptions, you will understand my reaction when I read a new article in FierceHealthPayer, a weekly newsletter for healthcare plan executives. If you are involved in the purchase of health insurance for your organization, the title of the article, Insurers Profit from Health Reform, will come as no surprise to you. Of course insurers are the primary ones who will profit from health reform in its current incarnation.

After dropping almost $90 million to oppose the health reform law, repeatedly claiming its provisions would raise costs and disrupt coverage, health insurers actually have benefited the most from the law, according to a Bloomberg Government report released Thursday.

The article goes on to explain that most of the increases in revenue are the result of these companies expanding into government programs. You see, even though Medicaid and Medicare are government programs, they are often administered by private insurance companies. With the expected expansion of the Medicaid program mandated by the Affordable Care Act, there should be even more income growth for insurance companies.

So who’s going to lose money on healthcare reform? Guess what….it’s us again. Those of us who purchase insurance in the private marketplace were subjected to 9% increases on average in 2011…increases aimed at covering the costs of the mandates of the healthcare reform law long before required by the law. That way, we absorb the costs and the insurance companies get to go on paying their executives outrageous salaries and making their profits.

I wonder what it will take for people to finally realize that healthcare and health insurance need not cost so much. I don’t expect it to happen as long as corporations control our government and our lawmakers. I know many folks believe the problem is just the opposite. Government should get out of the middle of the relationship between the healthcare provider and the consumer. Competition and market forces would take care of costs.

What do you think? Who will pay for care for the chronically ill . . . and the chronically mentally ill if we don’t all chip in to do it? Is there enough compassion in the marketplace to assure that children, the poor, and those unable to pay for health insurance because of mental illness will also receive good quality healthcare? Please share your thoughts. I would love some help in understanding how we can assure that we will all get the healthcare we need without spending half our income on health costs.

Change in Healthcare is Upon Us…Law or not

In 1992, when Bill Clinton was elected President of the United States for the first time, I was a member of the Committee for the Advancement of Professional Practice (CAPP) of the American Psychological Association. CAPP is charged with general governance oversight of the Practice Directorate, the part of APA responsible for promoting “the practice of psychology and the availability and accessibility of psychological services, providing resources and services to practicing psychologists in all settings and to the public.”

Our first meeting immediately after the election was highly charged. Staff had been studying President Clinton’s healthcare proposals, and the notion of controlling cost through “managed care.”

President Clinton’s healthcare proposals did not fly, but the industry picked up the notion of controlling costs by managing the care provided to consumers, and psychological practice has never been the same. For private practitioners, “managed care” continues to be a primary obstacle to the practice of psychology. Costs might have been suppressed by managing care, but some would argue that the primary effect of the managed care revolution was the creation of a new industry that made money as the middle-men at the cost of providers. Indeed, after a few years of leveling of the costs of care, the rise has been renewed and expanded.

In mid-November, the Supreme Court of the U.S. agreed to hear an appeal of the Affordable Care Act, our nation’s most recent effort to reform our healthcare system.

The Supreme Court agreed to hear appeals from the United States Court of Appeals for the 11th Circuit in Atlanta, which is the only court to have struck down the individual mandate because it overstepped Congressional authority and wasn’t justified by the constitutional power “to regulate commerce” or “to lay and collect taxes.” FierceHealthPayer, November 18, 2011

According to editor Dina Overland of FierceHealthPayer newsletter, even a complete overturn of the law would have little significant impact. She believes that consumers like the changes the law is mandating and there is no stopping this train.

Mercom Capital Group, in their HIT Report of November 21, 2011, says the same thing about the massive changes in the healthcare arena at large. Basing their conclusions on a report by PwC (PricewaterhouseCoopers, LLC), Mercom reports that health organizations will continue to move forward with changes to their health technology and other innovations because the multiple drivers in the marketplace have finally come to a head. No matter the political or the financial uncertainties, PwC believes this movement will continue. These are changes consumers like, and the movement will continue no matter which market forces might change.

In their HIT Report of November 28, 2011, Mercom reports that Harvard and Aetna will ally to work to improve healthcare costs and quality. The two have formed a research collaborative focused on improving the quality and cost of healthcare. They will use bioinformatics, the interface of computer science and information technology with the fields of biology and medicine, to analyze healthcare data in innovative ways. They will focus on outcomes of various treatments considering quality and cost, factors that predict adherence to medical and drug treatments for chronic diseases, examining how claims and clinical data can be best used to predict disease and follow outcomes, as well as other treatments of data that will emerge over time.

Where is your organization in the midst of this dramatic change in how we manage healthcare? How do you see yourself participating in the sea change that is under way? Where does behavioral healthcare fit into this picture?

Just type in your thoughts below. Thanks for commenting.

Emergency Alert System Test: Share with your clients

Several years ago, I signed up with the federal Office of Civil Rights online Privacy listserv so I would get notifications about HIPAA. I have been delighted with that subscription over the years. If you are an organization that provides healthcare services, you too should subscribe.

Today I received a new sort of notice from the listserv…one aimed at informing as many individuals as possible about an upcoming test of the federal Emergency Alert System.

Date:    Thu, 3 Nov 2011 12:11:48 -0400
From:    “OS OCR PrivacyList, OCR (HHS/OS)” <OCRPrivacyList@HHS.GOV>
Subject: First Nationwide Test of the Emergency Alert System; November 9 at 2pm EDT

FIRST NATIONWIDE TEST OF THE EMERGENCY ALERT SYSTEM
Test to Take Place November 9 at 2 p.m. EDT

Dear Colleagues;

We need your assistance in notifying everyone about the November 9th nationwide test of the Emergency Alert System.  Please help distribute this to all your stakeholders, as far and wide as possible, to ensure the entire community is aware that

As part of our larger efforts to strengthen our nation’s preparedness and resiliency, the Federal Communications Commission (FCC) and the U.S. Department of Homeland Security’s Federal Emergency Management Agency (FEMA) will conduct the first nation-wide test of the Emergency Alert System on November 9th at 2pm Eastern Standard Time.

The national Emergency Alert System is an alert and warning system established to enable the President of the United States, if needed, to address the American public during emergencies.  It is another critical communications tool that can protect the public and strengthen our nation’s resiliency.  The National Weather Service, governors, and state and local authorities also use parts of the system to issue more localized emergency alerts.  The test is an important exercise in ensuring that the system is effective in communicating critical information to the public in the event of a real national emergency.

This national test will help federal partners and EAS participants determine the reliability of the system, as well as its effectiveness in notifying the public of emergencies and potential disasters both nationally and regionally.  The test will also provide the FCC and FEMA a chance to identify improvements that are needed to build a new, modernized, and fully accessible Emergency Alert System.

To support the disability community, FEMA has developed a toolkit that will allow you to reach out to your constituents and local partners.  The toolkits, attached here in multiple formats, allow you and your organization to quickly disseminate information about this test.

In addition, we’re also releasing two new videos created to support the outreach efforts of our disability community partners.   FEMA Administrator Craig Fugate has long been a champion of the whole community and ensuring that FEMA represents the diversity of the people we serve.  In one video, Neil Mc Devitt, from FEMA’s Office of Disability Integration and Coordination joins Administrator Fugate in outlining the need for the upcoming Emergency Alert System test and the accessibility challenges posed by the test.   The video has American Sign Language, open-captions, and is voiced throughout.   We’re also happy to provide a Spanish version of the message with open-captions.

If you have additional questions for FEMA-Office of Disability Integration and Coordination questions, please contact our office at

Marci Roth
Director
Office of Disability Integration and Coordination

 

*        FEMA Administrator’s Message – http://www.fema.gov/medialibrary/media_records/6407

*        ASL Video: http://www.fema.gov/medialibrary/media_records/6407

*        Spanish Video: http://www.fema.gov/medialibrary/media_records/6408

Please share this information with your constituencies, colleagues, friends, and families.   Remember, on November 9th at 2pm ET, “Don’t stress; it’s only a test.”

I was fascinated at using the HIPAA listserv for this purpose. As I read through the notice, it became clear that FEMA is quite concerned about insuring that disabled individuals of all sorts receive notice of this test so they are not alarmed when the test occurs. Using a listserv that reaches healthcare providers is actually an excellent use of this list. After all, most disabled individuals are in touch with healthcare providers.

Please feel free to pass this information…or even this blog…on to your clients. It is important that consumers of behavioral health and other health services realize that the event scheduled for Wednesday, November 9, 2011 at 2pm is a TEST of the Emergency Alert System.

Good for you to know it too!

Thanks for reading and sharing the information in our blog.

Health Insurance: How do you feel about yours?

According to a newsletter aimed at the insurance industry, 70% of comments made about health insurers on social media sites in the past year were negative. FierceHealthPayer reports:

It’s time to face the facts–the American public dislikes health insurance companies. And that’s putting it mildly, considering that 70 percent of all opinions and comments about insurers posted on social media sites in the last year were negative.

(Read more: Insurers should take to social media to combat negativity – FierceHealthPayer http://www.fiercehealthpayer.com/story/insurers-should-take-social-media-combat-negativity/2011-10-07?utm_medium=nl&utm_source=internal#ixzz1aYo3DrmA 
Subscribe: http://www.fiercehealthpayer.com/signup?sourceform=Viral-Tynt-FierceHealthPayer-FierceHealthPayer)

I can understand some of that negativity. This past summer brought major upheaval for me as I searched for affordable health insurance for our employees. I asked our insurance agent early on to get us quotes. I was appalled at what came back from the company who provides our plan. As a small group (only 8 members plus one spouse) we are subject to huge variations in cost and are very limited in benefit choices. Health insurance is our second largest expense.

I interviewed employee leasing companies and other groups that claim to make you part of a larger group so you can benefit from lower pricing structures. Unfortunately, none of them were able to save us enough money to justify the severe limitation in benefits or the cost of membership. We ultimately bought a plan that increases copays and deductibles, but maintains most of the benefits we had….we think. How the insurer will choose to interpret those benefits when one of us actually needs to take advantage of them remains to be seen.

My experience is no surprise. Employers across the nation were faced with a  9% average increase in family premiums in 2011 while many of us were presented double digit increases, in spite of the recession.

The article mentioned above suggests that insurers should get involved in social media to combat their negative perception by the public. They should

Create a social media policy and then get out into the social world and establish a strong, positive presence. Tweet some healthful recipes, post exercise tips on Facebook, make announcements on Google+.

Whatever your specific strategy, though, make sure you monitor all social media sites for comments made about your company and then contact the poster to try and resolve the problem. Even if you can’t fix the particular issue, say because someone is griping about the lack of universal health insurance, you’ll have made an effort to connect with the public, which over time just might change their perception of the industry. – Dina (@HealthPayer)

In other words, they should get their marketing people to work in the social media sphere. Don’t do anything real to correct the negative perceptions of the public, just do your best to appear to care and to look good. Don’t let anybody realize that one of the major reasons the cost of healthcare is so high in the U.S. is because of the part played by the cost of health insurance.

I was rather distressed by that recommendation. Don’t do anything real…just do your best to appear as if you care about these negative perceptions.

I wonder what your experience is with health insurers. Does your organization provide health insurance for your employees? Is everybody satisfied with their plan and the cost of it? Have you ever made a negative comment about your health insurance on Facebook or Twitter? Ever made a positive one?

Please share your comments below.

Clinical Decision Support: Is Watson up to it?

Are you a Jeopardy fan? If you are, I am sure you know that in January of 2011, IBM’s supercomputer, Watson beat two of Jeopardy’s all time money winners, Brad Rutter and Ken Jennings. Watson is an Artificial Intelligence that can understand questions posed to it in natural ‘human’ language.

WellPoint, a BlueCross collaboration, is the largest provider of health benefits in the country. Their plan is to utilize Watson to sift through their patient databases to make diagnosis and treatment recommendations to WellPoint physicians.

This idea is not at all far-fetched and certainly a reasonable way for IBM to make some money off their huge research and development investment in Watson. They have also purchased some other companies that position them well for movement into the medical sphere.

Over the last four years, IBM has spent more than $7.8 billion to acquire database analytics specialists Cognos and SPSS, both formerly public, as well as data warehouse company Netezza, along with other private companies. In the first half of 2011, IBM spending on research and development exceeded $3.15 billion.
—International Business Times, 9/19/2011

What WellPoint is proposing to do is a starting point for a task all EMR’s will ultimately need access to and participation in. In order to meet the requirements for ARRA stimulus funds, eligible providers will need to utilize their EMR’s to help them make clinical decisions.

Clinical Decision Support (CDS) is a process whereby the physician gets notices and alerts from their software to assist them in making clinical choices that are based on data and evidence rather than memory and intuition. The Centers for Disease Control and Prevention (CDC) hopes to see public health organizations utilizing population data and statistics to guide their choices. They believe this will be one of the most impactful effects EMRs can offer the public health. The Office of the National Coordinator for Healthcare IT (ONC) wants to see individual physicians using Clinical Decision Support to advise their patients. Clearly, WellPoint plans for this level of intervention: physicians will have access to the data Watson can provide to assist them in making diagnoses and recommending treatments.

We talked in this blog about some of the potential benefits of CDS back in 2009. Since then, research on the benefits of supported clinical decision making has continued. A Google Scholar search of ‘decision support emr’ results in 16,800 hits. There have also been noted some shortcomings, most notably a phenomenon called ‘alert fatigue‘, wherein a provider gets so many alerts and notices that they stop attending to them or turn them off altogether. Obviously, we have lots to learn about how to present information to healthcare providers so they can use it most effectively for the benefit of their patients. WellPoint has decided to dive right in!

What do you think about being diagnosed by a computer? Will it be more effective or less so? What is the relevance of CDS for behavioral health?

Please share your thoughts below.

 

Prevention and Pain: A major way to save money

This morning I read an editorial (An ounce of prevention could heal a pound of pain) by Dina Overland of the FierceHealthPayer newsletter. She decided to use her platform as the editor of a newsletter that is aimed at insurance payers to directly address those payers about prevention of healthcare problems and diminishing future costs. She focused on an area that behavioral health and substance abuse professionals work in often . . . pain.

Ms. Overland’s review of the Institute of Medicine’s (IOM) report on pain and prevention cited some facts I had not heard.

Chronic pain affects 116 million Americans–that’s more people than affected by heart disease, cancer, and diabetes combined–and costs the United States
$635 billion each year. That’s what the Institute of Medicine (IOM) found in its report, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research.

If that’s not jarring enough, here are some more staggering facts: The United States spends $2 trillion on healthcare, but only 4 cents of every dollar goes to prevention and public health, despite being among the best tools to reduce spending. For every $1 invested in prevention, we save $6 in projected healthcare costs, says Sen. Tom Harkin (D-Iowa), who participated in the Department of Health and Human Services (HHS)’s announcement
of its guidelines to incorporating prevention throughout the healthcare industry.

***

 

I could not help but think about the number of people who would never have become substance abusers if their chronic pain had been addressed and treated at an early stage. How many behavioral health clients have you treated for depression after years of experiencing intractable pain?

The IOM and HHS see the coordination of care among primary care providers and specialists as the best way to address early intervention and prevention of pain. What role should mental health and substance abuse providers play in this coordination? How many of your patients also experience chronic pain? Where do behavioral health providers fit in?

Please share your thoughts and comments below. What role do you want to play in diminishing healthcare costs? Who should we see when it hurts?

 

HIPAA Privacy Requirements: Serious business

In the past year, the Office for Civil Rights, the federal office responsible for enforcing HIPAA privacy requirements, has finalized the rule by which all covered entities and their business associates are required to protect the personal and health information of patients they serve. The rule details the actions a breach of the privacy rule requires including notification of patients. In the past month, OCR has begun to publish significant fines to organizations who have been found responsible for a breach of that privacy rule.

Lots of folks have been waiting to see what kind of fines the OCR would impose upon organizations found responsible for breaches. We are beginning to find out.

On February 14, 2011, HHS entered into an agreement with Massachusetts General Hospital in which the hospital organization agreed to pay $1 million because of the loss of data of 192 patients of one of its outpatient practices. The information lost was on paper and was lost on a subway train. The hospital also agreed to enter into a Corrective Action Plan (CAP) including the implementation of policies and procedures to protect the PHI of its patients.

For those of you who thought these requirements do not affect you if you do not keep any patient information in an electronic form, it is clear that is not how OCR views it. Paper is also vulnerable and OCR is determined to protect that PHI.

The second announced fine was placed on Cignet Health of Prince George’s County Maryland. They were fined $4.3 million. They were accused of denying 42 patients access to their medical records, failed to cooperate with OCR in their investigation of the complaints, indeed failed to reply to OCR’s notifications. OCR determined that “the failure to cooperate was due to Cignet’s willful neglect to comply with the Privacy Rule.”

For those of you who have thought that not keeping records of treatment might be the safest course of action, please think again. If you cannot provide the record when a patient requests it, they have every right to complain and to seek a judgement against you.

Of course, your organizations all have Privacy Policies. Do you know what they are? Do you follow the Procedures that your organization has developed? Does everyone? Part of the requirement is that employees be properly trained in what the policies and procedures are and that their training is regularly refreshed. Oh, and yes, part of the requirement is that the Privacy Officer makes sure the owners of the practice or the Executive Director or Board of Directors is well-informed about how the policies are implemented.

How is your organization doing with the stricter Privacy Rule requirements imposed by the HITECH Act? Please share your thoughts, fears and struggles with these requirements and how they affect your organization. Just enter your comments below.

Parity Act Slow to Catch On

In January 2011, the American Psychological Association (APA) reported that nearly 90 percent of Americans have never heard about mental health parity or of the Mental Health Parity and Addiction Equity Act of 2008. In a survey conducted for the APA in December 2010 by Harris Interactive, 89% of those surveyed said they had not heard about the federal law that affects people who have health insurance through a group or employer plan. Only 7% even recognized the phrase ‘mental health parity.’

The American Psychiatric Association(aPa) participates in the Mental Health Parity Watchalong with 11 other organizations. This organization is aimed at educating the public about parity, recording and appealing problems experienced by consumers in accessing mental health benefits, and in general facilitating the broad dissemination of information about the parity law. The aPa reportedon it’s intervention with BCBS-IL regarding their new requirements for preauthorizations for mental health treatment. While BCBS-IL rescinded their requirement for 2011, it is this kind of action by insurers that the law was meant to prevent.

Companies like Aetna have added pages to their web sites on mental health parity. These are designed to communicate directly to members and panel providers what positions the company has decided to take relative to the law. This can be an excellent way for consumers who have health insurance to learn how their insurer plans to address the requirements of the law.

As part of the parity implementation coalition mentioned above (Mental Health Parity Watch), the National Council has produced fact sheets and other resources aimed at educating consumers and answering questions about the law. Their are additional resources available on their blog page including summary of the law, FAQ, and a Parity Toolkit.

What has been your organization’s experience with the parity legislation so far? Have you found that insurers are moving forward with equivalent benefits and preauthorization policies for both physical and mental health? If you have run into difficulties, what have they been and how have you handled them.

Please share your experience to date. Thanks for your comments!

Integrating Behavioral Health into the Healthcare Home

One of the many provisions included in the Patient Protection and Affordable Care Act (health care reform law) was the creation of pilot programs to integrate all health care services into a Health Home. The development of the ‘medical home‘ concept will be most important among those with complicated health concerns and in vulnerable populations. Those with significant health issues in addition to behavioral health disorders will be in special focus.

This attempt to integrate care will likely have major impacts on how behavioral health care services are provided to the seriously mentally ill and chemically dependent populations. The National Council has been actively involved in this movement and has received funds to found the Center for Integrated Health Solutions.

The National Council for Community Behavioral Healthcare has won a competitive cooperative agreement from the U.S. Department of Health and Human Services (HHS) to establish the Center for Integrated Health Solutions. The Center will address the comprehensive health needs of clients with mental illnesses and/or substance use disorders by improving the coordination of healthcare services in publicly funded community settings. The Center is funded jointly by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources Services Administration (HRSA).

In that role, on January 19, 2011, the National Council participated in an extremely informative webinar on current integration projects initiated by community behavioral health organizations. Each of the organizations that participated came to their ‘Health Home’ program in a different way and developed programs using different models. The presentation made clear that there are likely to be as many ways to accomplish the purpose of integrating health care for the most vulnerable populations as there are organizations that will provide that care. Even so, there are significant issues to be considered, challenges to be met, and goals to be accomplished for the establishment of a successful program.

A recording of this webinar is to be posted at http://coce.samhsa.gov/ at an indefinite date. Information about Co-Occurring Disorders Integration & Innovation can be obtained at contact@codimail.org

The hope that these programs can provide more effective health care at a lower cost is high. I am sure we will all be watching carefully to see how these and other initiatives progress.

I invite those  of you who have interest and experience with integrated care to share your perspectives. Your input will be valuable to your colleagues.

Healthcare Reform in 2011

Count on the National Council to keep us informed about Health Care Reform and how it might impact us as individuals or organizations. On January 6, 2011, The Council sent out their Public Policy Update giving a brief overview of the features of the law that will be implemented in 2011. Even as the new majority in the House of Representatives vows to repeal the law, very popular features go into effect.

Starting in January 2011:

  • States may now amend their Medicaid programs to provide Health Homes and chronic disease management, including behavioral health services;
  • Closing the ‘Donut Hole’: Drug companies will grant a 50% discount on brand-name drugs for Medicare recipients who reach the donut hole in 2011;
  • Free Medicare Preventive Benefits including annual wellness visits are available;
  • A 10% increase in Medicare payments for primary care providers will start;
  • Insurance companies must spend at least 80-85% of consumers’ premiums on paying for patient care rather than administrative costs or profits;
  • CMS will begin to reform itself to accomplish delivery system and payment reforms that will save money and improve the quality of care; and
  • Long-term care insurance for the purchase of home- and community-based services will become available. Community Living Assistance Services and Supports (CLASS) is a voluntary insurance purchase program.

The National Council has established a Mental Healthcare Reform blog that focuses on Healthcare reform. There you can find discussion of all of the changes as they occur along with implications of those changes. Don’t miss out on information your organization may need. Subscribe to the blog today.

Of the items listed above, only the first is likely to affect some behavioral health care providers in any significant way. Please let us know if your state is experimenting with medical/health homes within their Medicaid plan. How do you expect that to affect mental health providers?

Please share your thoughts . . . especially those of you who are participating in one of these pilot projects.

How’s Your Compliance Program Coming Along?

Last week I attended a webinar sponsored by The National Council: Healthcare Reform Expands Compliance Requirements: Prepare Now.  There is a recording of the presentation at the link above.

I attend lots of webinars to try to stay informed about what is happening in our industry. As indicated by the fact that I often write about those webinars, I am often stimulated by them. I am rarely alarmed, but this presentation by attorney Adam Falk was almost frightening. I found myself thinking that, if I were still in private practice of psychology, I would stop accepting Medicare patients. Since I just turned 60 and will become one of those Medicare patients in only five years, that thought was most distressing.

According to Mr. Falk, the Patient Protection and Affordable Care Act of 2010, as part of the attempt to save money by eliminating fraud, has placed new requirements on providers of service large and small, to demonstrate compliance with the law. It is not enough to comply; one must also be able to prove that compliance, hence the need for a formal Compliance Program.

The regulations have not yet been written to determine what must be included in such a Compliance Program, but Mr. Falk strongly suggests the need to be proactive rather than reactive regarding this matter. While compliance programs are to be ‘scalable’ based on the size of the organization and the amount of service provided as part of the Medicare or Medicaid systems, there are certain aspects that are essential.

The biggest danger to provider organizations is that the Affordable Care Act classifies much irregular activity as making a false claim. The penalties for false claims are significant. Fraud is rampant and HHS is tasked with eliminating as much of it as possible to protect the taxpayer’s dollar. The attempts to prevent this fraudulent activity provide the Secretary of HHS with broad authority.

Additionally, providers are required to identify, report and return overpayment by Medicare or Medicaid within 60 days of the provider’s recognition that an overpayment has been received. That recognition applies to the clerk in your accounts receivable department who mentioned the overpayment to a supervisor or to someone in authority. Training staff and providing formal procedures to follow will be an essential part of any compliance program.

I would suggest that you take an hour and listen to Mr. Falk’s webinar. Then start to research what might be required at your organization’s level to comply with the requirements of the law.

*****

I received an email notification today from the Office of Civil Rights indicating that HHS has scheduled a second public discussion on Confidentiality and Privacy Issues Related to Psychological Testing Data. The meeting will be held in Los Angeles on November 18, 2010.

Please share your comments below. Thanks for reading!

Primary and Behavioral Healthcare Integration

On Monday the National Council announced that they have won a competitive grant to provide training and technical assistance to move forward the process of integrating primary and behavioral health care services. They will provide support services and assistance to organizations that have received grants to develop integrated care within their organizations, as well as to other organizations seeking to move in this direction.

 One of the pushes in the ARRA stimulus funding and in the health care reform law (Patient Protection and Affordable Care Act) was more efficient and cost effective provision of health services. One possible way to accomplish this for those who experience mental health and addiction problems is to integrate the care they receive for all illnesses, physical and behavioral. The National Council has been at the forefront of this movement. Their snagging of this grant demonstrates their commitment to the cause of integrating primary and behavioral health care for vulnerable populations. The press release indicates the following:

The Center will provide training and technical assistance to 56 organizations that have collectively been awarded more than $26.2 million in grants as well as to community health centers and other primary care and behavioral health organizations. According to HHS Secretary Kathleen Sebelius, these grants are part of an unprecedented push by the Patient Protection and Affordable Care Act to help prevent and reduce chronic disease and promote wellness by treating behavioral health needs on an equal footing with other health conditions.

When I have mentioned this topic in previous blog articles, the response has been disbelief that such integration will occur any time soon. After all, behavioral health private practitioners of our generation are not likely to dramatically change the way in which they practice, and now they mostly practice independently of medical settings.

In fact, it is even the case that many of our community-based behavioral health  organizations have a hard time seeing themselves moving toward providing primary care services for their consumers. At least one of our customers tried establishing a primary care facility as part of their organization a couple of years ago. The service did not take hold and they closed it. Perhaps they were too far ahead of the curve to be successful.

According to the National Council, the motivation to integrate general and behavioral health care among the chronically and seriously mentally ill is the significantly shorter lifespan experienced by those with serious mental illnesses.

According to a 2006 national survey, persons with schizophrenia, bipolar disorder and major depression have lower than average life expectancy and die, on average, at the age of 53 — often from untreated and preventable chronic illnesses like hypertension, diabetes, obesity and cardiovascular disease. Lack of access to primary care and specialty medicine is a critical factor in these tragic outcomes. . . .

The average life expectancy of the population at large in the U.S. in 2006 reached an all time high of 78.1 years. This 25 year difference is unconscionable. It is believed by many in the public health and behavioral health communities that integrating health care services for the seriously mentally ill and chemically dependent populations will encourage treatment regimens that will benefit both physical and mental health.

Most of the organizations active in this integration movement are considered ‘safety net’ providers. Although part of an endangered system,  ‘safety net providers are providers that deliver a significant level of health care to uninsured, Medicaid, and other vulnerable patients.’ They are the health care safety net that is intended to keep vulnerable populations from falling through the cracks in our costly and difficult to navigate health care system.

Are any of our readers among the 56 organizations that have received grant funding to develop integrated physical and behavioral health services? Do you see this as a possible and worthwhile goal for private practitioners to move toward? What changes in training models and practice models would need to occur to integrate primary and behavioral health care?

Let us know your thoughts about these issues. Please enter your comments below.

It’ll Never Happen To Me…

This week one of our customers experienced a “happy ending” to a very unhappy story. We thought we would share it with you.

They were sure they had a good backup. When their server hard drive crashed, they were distressed but not terrified. Instead of dealing with the loss of all their data, it merely meant that they would need to get a new server and have someone spend time rebuilding the hard drive from installation CDs and all of the backed up data.

That’s when reality set in. Their consultant technician installed our software onto their new server from a CD and went to restore the data. The data folder was empty. He was unable to recreate his client’s practice management data from a usable backup. That is also when the customer’s panic started.

I don’t know if you have ever considered this scenario for your organization. After all, your IT specialist set up a tape or external drive backup for you and the system automatically backs up every day. Sometimes there is a strange error message on the monitor when you remove the tape or you get an email that says an error has occurred, but you don’t really have time to pursue it.

Have you ever tried restoring from one of your recent backups? Do you know that the data are usable? If someone in your organization has never restored one of your current backups to your system and made sure the restored data worked, then your backup process is incomplete and you are at risk for the same kind of upset our customer experienced this week.

Happy ending to this story. . . a hard drive retrieval company was able to pull data off the crashed drive. . . at a cost of $7500! Since that certainly played havoc with the budget, this happy ending is really a mixed one.

If you want reminders about backup procedures and our best thinking about what to consider take a look here and here and here and here. We have not written about this as recently as I thought, but data backup is a subject that we try to remind ourselves and our customers about regularly. Please think about and take action about yours.

Also from the ‘It’ll Never Happen To Me’ department. . . I attended a webinar on the HIPAA and HITECH breach notification requirements a couple of weeks ago. This was done by a company named IDExperts that specializes in guiding companies through the risk assessment process after a breach has occurred. They also have a software product that will walk you through the post-breach risk assessment and track the histories of all breaches. Their take on data security and the risks involved are like this: if you were interested enough to attend the webinar, the question is not if you will experience a data breach, but when. Statements like that always jar me. Since we are not a Covered Entity and have no PHI of our own, I am not too concerned about us experiencing a breach; our procedures are solid and any electronic PHI temporarily in our possession only resides on encrypted computers. Obviously the worry is not small for health care providers, especially large ones.

The concern about security and privacy of PHI has recently been complicated by the fact that HHS has decided to reconsider the final rule on breach notification. After privacy and security groups were distressed and complained to HHS about the methods for deciding whether the release of data presents a risk to involved patients, HHS decided to reconsider the final rule. There is speculation that the rule will be made tougher than it was. Up to this time, the organization that experienced the breach has been responsible for determining the severity of the risk to patients caused by the data loss and whether HHS needed to be notified off the breach. HHS did not indicate when a new rule could be expected.

Who in your organization is responsible for verifying that your backups are usable? When was the last time a test restore of crucial data was done? Would you have any idea how to do this; if not, who does? What is your plan of action if protected health information is accidentally released when it should not have been? Are you convinced it’ll never happen to you?

Please share your comments and your experience so all our readers can benefit from best practices on data backup and protection.

OpenNotes Project: Where does mental health fit in?

On Monday of this week, Seth asked me if I had a topic for my current blog. As I had none at hand, he pointed me to last week’s episode of the podcast/NPR show, Science Friday. Seth is a regular subscriber to this series and I listen when I find the time. That effort is always rewarded by fascinating discussions of current science issues. For the science professional, wanna-be-scientist or interested layperson, this show is a ready source of truly valuable information.

On Friday, July 30, 2010 the discussion topic was a medical records project called OpenNotes. With the advent of electronic medical records (EMRs) and patient portals into the medical records system, it is only reasonable to begin to consider the nature of the records that physicians keep on their patients. The OpenNotes project is an attempt to allow some 25,000 patients direct access to what 100 participating primary care physicians write in their notes after seeing them.

The project will study the experiences of both the physicians and patients, the impact on work flow of such note taking/sharing, the possible increase in communications between patient and physician, and the reactions of both sets of participants to their experiences. The details of the study are published in an Annals of Internal Medicine article, Open Notes: Doctors and Patients Signing On.

The Science Friday discussion included concerns about sharing sensitive information with the patient and the ability of the patient to understand and process the information included in the note. It has especially been argued that the mental health patient might be too fragile to be exposed to the psychotherapist’s or the psychiatrist’s true evaluation of their status as stated in the progress note.

On the other hand, Concurrent (Collaborative) Documentation has been touted by some community behavioral health specialists as an essential tool for increasing both quality and efficiency of client interactions while simultaneously increasing client buy-in to the treatment plan. The New York State Office of Mental Health writes:

It has been suggested that Concurrent Collaborative Progress Notes were the ‘way to go’. What about uninterrupted direct face to face contact as the best way to achieve high rates of engagement and retention in our clinics?

Concurrent documentation does not require the clinician to take notes during a session or to detach themselves from the recipient. Rather it is advised that at the end of the session, a brief review of the session takes place and the recipient and clinician collaboratively record the progress note. This process supports the delivery of person centered services and often provides the clinician with important feedback about the recipient’s perspective and information obtained from the session.

The process of creating this record concurrent with the meeting and collaboratively with the client is the epitome of an open record. While the OpenNotes project does not go quite this far, it certainly opens the door in this direction. Since the patient owns the record, it seems only fair that they should have easy access to that record and even participate in its creation.

My background as a Feminist Therapist has long given me a strong leaning in this direction. In the view of Feminist Therapy, the treating professional is a consultant having special expertise who is hired by the client to assist them in solving their “problem”. This is certainly also the case in the medical office. The physician has expertise the patient is seeking in their efforts to treat illness and to live healthier lives. This collaborative relationship is more a meeting of equals working together for the patient’s benefit than a dictation of treatment by an authority-figure intent on successful treatment and risk management.

What do you think about opening progress notes to your patients and consumers of service? How would that change the work done by the provider of services? How do you imagine it would change the experience of the consumer?

Please share your comments below.

The Healthcare Experience….Firsthand

Six weeks ago, I started writing this post. I think it is time to put finished to it.

The second half of May and first half of June were a challenging time for us. Two elderly parents had acute medical needs at the same time in different cities. Both were hospitalized, one in a critical care unit.

During this time I found myself thinking about different aspects of the experience. For those of you who have not yet had the responsibility to care for an elderly parent, these issues might be interesting to look forward to. For those of you who are our age-mates, you will probably have additional issues to offer.

  1. Medicare mostly works. (Medicare with a secondary insurance works even better.)
  2. Health care workers, for the most part, really seem to care.
  3. The quality of care you receive depends upon your ability to advocate for yourself…or to have surrogate advocates.
  4. In the heat of the emotional moment, having siblings helps, even if they are in a different state.
  5. A Health care Surrogate, an Advance Directive, or a Living Will are not optional.
  6. The toll on family caregivers is huge.

1. Medicare mostly works. Medicare with a secondary insurance works better. I know doctors complain about Medicare and the amount they are reimbursed and about dealing with Medicare claims. I also know that health care services are provided without question when Medicare is the payer. In an emergency situation, not having to be concerned about the method of payment allows everyone to focus on the care of the patient. I think there is a great deal to be valued in that.

2. Health care workers, for the most part, really seem to care. Health care workers are overworked and hospitals are understaffed. Nurses and nurse technicians are responsible for so much documentation that they often feel that direct patient care gets shortchanged. In two separate hospitals in two parts of Florida, my experience was that hospital staff did an excellent job in spite of the demands on them…and that they really cared about their patients and about the job they were doing for them.

3. The quality of care you receive depends upon your ability to advocate for yourself…or to have surrogate advocates. Without a spouse and/or children or some other sort of advocate, people do not get as good care as when an advocate is present. The reasons are simple. A sick person is not in any position to ask for assistance, to question the treatment being provided, to assure the medication they have been handed is the correct one, or to guarantee that they understand the instructions they have been given.  If no one is present to say that they are hard of hearing, verbal instructions and questions may be forever lost. Even if a staff person eventually realizes they are not being heard, all of the previous interaction including important questions about history, may have been in vain. Without another person who understands how to go between the patient and the staff, a person may well get sicker because they could not ask for help or did not want to be a bother, could not question the protocols being followed and give benefit of their personal experience with previous treatment, did not recognize the medication they were given or understand the name and function of the medicine when the nurse administered it, or did not understand the follow-up instructions and the rationale for giving them.

4. In the heat of the emotional moment, having siblings helps, even if they are in a different state. Siblings are an asset when dealing with ill parents. Having others with whom to discuss the events and issues is crucial. They help generate additional questions that should be asked. They remind one another of family health history and events that can easily be forgotten. They can share the responsibility for sitting with and encouraging Mom or Dad. Having others to participate in important decisions if a parent is not capable of making those decisions for themselves is invaluable.

5. A Health care Surrogate, an Advance Directive, or a Living Will are not optional. Rightfully, hospitals and health care workers do not want to make decisions for a patient. They especially do not want to make decisions that are inconsistent with the wishes of the patient. They will strongly and clearly recommend what they see to be the best course of care and, with the patient’s permission, they will implement those recommendations up to the limits that the patient sets. If the patient has no person or document setting the limits, all care will be provided as the staff recommends and all of the care they recommend will be provided. Being clear about the limits is only fair to one’s children and essential to one’s care providers.

6. The toll on family caregivers is huge. No matter the outcome of the health care incident, the emotional and physical cost to family caregivers cannot be underestimated, especially if the other elderly parent is one of those caregivers. We most often think about the sick person and how they handled the health care event. It is important that we also think about the family members who participated in the caregiving for Mom or Dad while they were in the hospital and during the caretaking that follows.

My quick Google search for “caregiving” yielded 2,270,000 results. “Family care giving for older adults” yielded 924,000 results. Obviously, this is an area in which interest has exploded. While many of the search results are for some sort of paid service, adding the word “free” at the end still resulted in 514,000 hits. Many communities offer respite care and support groups through their local hospice agencies. Online information and organizations abound. As we baby-boomers age, I fully expect that this will become an industry in itself, with paid and volunteer and not-for-profit organizations.

In the meantime, we are very glad that our elderly parents made it through this round with the health care system. I wonder what your experiences with elder care and our health system have been. Where do you see us heading and what role do you see for behavioral health care in this elder care world?

Please share you comments below.

Managed Care Organizations Oppose Parity

An organization called the Coalition for Parity, Inc. comprised of managed behavioral health organizations (MBHOs) has filed suit to halt the implementation of the Paul Wellstone and Pete Dominici Mental Health Parity and Addiction Equity Act. This group has as some of its members Value Options, Magellan Health Services Inc., and Beacon Health Strategies Inc.

As reported by Open Minds and American Psychological Association Practice Organization, the lawsuit challenges the rulemaking process and has requested a temporary restraining order to stop the rulemaking process from moving forward. They argue that the Departments of Health and Human Services, Labor and Treasury overstepped their rulemaking authority in how they interpreted the statutory language and violated federal rulemaking procedure in publishing the rule as they did. While the judge denied the temporary restraining order because the law will not be enforced until July 1, 2010, the court will hear the case as presented by the parties to the action.

On May 9, 2010, the NY Times reported that insurance companies and employer groups are also objecting to the rules.

In a suit over the rules, Magellan and other companies said the concept of nonquantitative limits was “boundless and ill defined” and would reach virtually every policy and procedure used to manage mental health benefits.

As most mental health providers can readily attest, the procedures used by insurers and managed care organizations to limit costs and usage of behavioral health services have themselves been “boundless and ill defined”; after all, a treatment plan certainly could not be a valid treatment plan if it is printed on the wrong form. The MBHOs have been innovative in their development of “every policy and procedure used to manage mental health benefits.” Unfortunately, most of that management has consisted of denying or limiting the amount of service provided and placing onerous requirements on providers.

The NYTimes article states that:

One premise of the law is that mental illnesses often have a biological basis and can be treated as effectively as many physical ailments. But insurers say it is impossible to use the same techniques in managing the treatment of colon cancer and schizophrenia, or heart failure and major depression.

What do you think? Is it reasonable to assume that mental illness and addiction can be managed using the same techniques as are used to manage the treatment of cancer or heart disease?

Please share your comments below.

Bits of News for Behavioral Health Providers

I have recently noticed several pieces of news that I thought would be of interest to providers of behavioral health services and others.

1. The National Council Public Policy Update of April 8, 2010 pointed out an important change in timely filing requirements for Medicare claims:

Requirements of the Patient Protection and Affordable Care Act makes (sic) several changes to the Medicare timely filing requirements. Under the new law, all claims from before Jan. 1, 2010 must be filed by Dec. 31, 2010. Beginning on Jan. 1, 2010, all claims must be filed within one year after the date of service in order to be considered timely.

Sec. 6404 of the law details the requirements. This is a change from the former allowance of 3 calendar years to file a claim. Be clear about this: you now have 1 calendar year after the date of service to file a timely claim for payment for those services.  Now might be a good time to use your billing software to learn which old Medicare claims have not been paid (the claims may have been lost) and if there are any Medicare services that have not been billed. If these are not already three years old, you have only until the end of 2010 to file them, and with services that are new in 2010, you have one calendar year to file a claim for the services.

2. Seth recently posted a message on our User Group about the potential privacy and security problems that can be caused by data left on newer copiers and multifunction machines. NJAMHAA Newswire of May 3, 2010 also commented on the possibility of HIPAA violations that can result from careless use of these machines. Seth’s comments follow:

Now that you finally got all your computer hard drives encrypted and you are feeling pretty smug, here comes another headache — thousands of images containing PHI stored on a hard drive hidden inside other office machines. Take a peek at this investigative report by CBS news:

http://www.youtube.com/watch?v=6pIFUOav2xE

This is a pretty big vulnerability. If you have one of these higher end digital copiers, printers, or multifunction machines and it is stolen — or you neglect to remove or wipe the hard drive before selling or trading it in, you have a reportable security breach. Nobody would be likely to have a list of the patient documents that had been copied over the years, so you
would have to assume that EVERYONE’s protected information was at risk. That means reporting to the Feds, taking out the newspaper ad announcing your negligence, and the rest of the breach notification nightmare!

Apparently all major manufacturers offer security add-ons of some sort. Now would be a good time to inventory your document devices to determine if they contain hard drives and whether you can retrofit appropriate security add-ons to avoid a potentially disastrous situation in the future.

3. The National Council on April 23 published a review of Parity Act implementation that will allow you to determine whether your insurer or the payer with which you are dealing is in compliance with the Parity Act. Is your insurer in compliance with the Parity Act? will help you ask the right questions and provides resources to help you answer the question.

4. On April 22, FierceEMR and other sources reported that hospital-based doctors are now eligible for ARRA incentive payments for meaningful use of certified EHR technology, and that a bill has been introduced by Rep. Patrick Kennedy (D-RI) and Rep. Tim Murphy (R-PA) seeking to include mental health professionals, Community Behavioral Health Organizations (CBHOs), psychiatric hospitals and chemical dependency programs in the ARRA incentives. Time will tell what will fly.

5. And finally, the Mercom Capital HIT Report of May 3 indicated that HHS is seeking comment on the anticipated impact the stricter disclosure reporting requirements included in the HITECH Act will have on providers.

To help guide the Health and Human Services Department in tightening rules for health information privacy, HHS has asked providers, payers and consumers to comment on the benefits and burdens of accounting for the disclosure of protected health information, even if the data is intended for treatment and billing purposes. The HITECH Act called for HHS to strengthen the privacy rule of the Health Insurance Portability and Accountability Act (HIPAA). With the changes, providers, plans and their business partners will have to account for disclosures of patient information contained in an electronic health record, even if the data is for healthcare provision and payment. 

HHS’ Office of Civil Rights (OCR), which oversees health information privacy, published a request for comments in the May 3 Federal Register 
“to inform our regulations under the HITECH Act,” according to the announcement. Under HIPAA, providers and plans currently do not have to report releases of protected data when the disclosures are related to patient treatment, payment and healthcare operations. HHS said in the notice that it will remove the exemption for those disclosures when it involves an electronic health record (EHR).

Needless to say, there is a great deal going on in the world of behavioral health care and health care in general. Please feel free to share news items you discover that might be useful to other readers.

Don’t forget, your comments are always welcome. Please share them below.

Health Care Reform and Behavioral Health

On March 21, 2010, the U.S. House of Representatives passed the Patient Protection and Affordable Care Act. Subsequently, they passed the Reconciliation Act  (H.R. 4872) making changes in the original bill. After some maneuvering, all the necessary legislation was passed by both houses of congress and on Tuesday, March 30, 2010, President Obama signed the Healthcare and Education Affordability Reconciliation Act of 2010 into law.

In the past week or two I have seen many questions about what the effects of this legislation will be. Behavioral health provider organizations are especially concerned about what the effects will be on mental health and addiction service funding.

One of the most useful resources I have come across was forwarded to the Florida Psychological Association member listserv by Dr. Bob Porter. The Bazelon Center for Mental Health Law has done an excellent job of summarizing the law and its impact on coverage for mental health services. While it will take years for all of the provisions of the new law to be implemented, a Congressional document summarizes some of the immediate effects.

In the private insurance sector, generic requirements of the law have particular impact for those with mental illnesses. In the past, such diagnoses have routinely triggered pre-existing condition clauses in policies. Within the first 6 months, the new law prohibits this discrimination.

  1. No discrimination against children with pre-existing conditions.
  2. No rescissions based on developing an illness.
  3. No lifetime limits on coverage.
  4. Tightly regulated annual limits on coverage.

In addition, for those who are currently uninsured, the law mandates:

  1. Immediate help for those with pre-existing conditions (an interim high-risk pool).
  2. Extending coverage for young people up to their 26th birthday through parents’ insurance.

Since so many who have been diagnosed with mental illnesses or with substance abuse issues have been denied coverage or have had coverage revoked or have reached the limits of their benefits, we should see immediate increased access to behavioral health and addiction services. The ability for parents to keep young adults on their insurance plans until they are 26 years old will assist some of the young people who experience late adolescent onset of serious mental illness or substance abuse conditions. This will allow a period during which their parents will be more able to facilitate transition to some other form of insurance coverage.

The National Council for Community Behavioral Healthcare, the trade association of behavioral health community service providers, hosted a webinar on healthcare reform and its impacts, Healthcare Reform: What Happens Next? Additionally, their Public Policy Update for April 1 gives links to resources as well as information about moving forward from here.

I attended the Council’s webinar this week and was struck by a couple of things. Because the Council primarily represents organizations that provide services in the public sector, their information is generally focused in this direction. For me, there were three take-aways from this session, and they were not all for public sector providers:

  1. The Council believes Fee for Service will probably go away in the long run, to be replaced by Case Rates with a Bonus for improvement of the consumer.
  2. Behavioral health providers need to position themselves for the long term. Integrated care is likely to be the way of the future and it is best to start to get positioned for that now.
  3. Private practices can be competitors in the new system; however, those with deep pockets who can manage the whole range of healthcare services will be better positioned to compete.

Community Behavioral Health Organizations (CHBOs) have been working on these steps for the past couple of years and there will be pilot programs using CBHOs together with Federally Qualified Health Programs to start to provide integrated care. Unless private behavioral health practitioners also start to position themselves to play in the Integrated Care setting, they are likely to get left behind.

Even the American Psychological Association’s advocacy efforts focus on the assurance that mental health services will be part of integrated care. This sounds very much like an integration of mental health services into such settings to me.

What do you think about how the new health care reform law will affect behavioral health services? Do you foresee changes in how care is provided? What changes are you willing to make in your organization in order to assure participation in a reformed health care system? Please enter your comment below. If you don’t see the comment box, just click on the title of the article and then enter you comment at the bottom.

Get Out of HIPAA Jail Free

Consider a couple of nightmares that might easily come true:

1. Your laptop, with a variety of documents and files containing confidential, protected health information on its hard drive, is stolen from your car, hotel, or disappears while you are traveling.

2. Your office is burglarized and all the desktop computers, as well as a server containing your patient database, are stolen.

I ran across the following set of statistics, or very similar ones, repeatedly, most often on web sites of security companies:

  • Every 53 seconds another laptop is stolen in the USA.
  • At least 600,000 laptops are stolen each year in the USA. 
  • Hardly any (3%) stolen laptops are ever recovered. 
  • Laptop computer theft trails only identity theft as the most common crime. 
  • Almost half of all data leaks and breaches are the result of lost or stolen portable computers, according to a study by The Identity Theft Resource Center .
  • Laptops are the number-one item stolen in San Francisco – San Francisco Police Department.
  • The Identity Theft Resouce Center’s recent list of 397 significant data breaches so far for the year of 2009 includes 51 healthcare breaches that compromised almost 9 million records.

Most of the sources of these data are trying to sell a security solution of one sort or another, but the vulnerability of laptops, especially in transit, is obvious. I don’t have any statistics for burglaries of computer systems from offices, but I’ll wager that most of you either know of a victim of such a crime, or have been a victim yourself.

Long before HIPAA, health professionals – especially mental health professionals – had a professional responsibility to safeguard the privacy of their patients/clients and the confidentiality of the personal and clinical information in their custody. HIPAA came along and increased our awareness of the special risks of electronic records and communications, defining Protected Health Information (PHI) at a federal level and providing some rules and guidelines for securing PHI stored or transmitted in electronic form. Now the Health Information Technology for Economic and Clinical Health Act (HITECH) has arrived and adds some pretty sharp teeth to HIPAA’s privacy and security rules.

If you need a push to get you to take privacy and security compliance seriously, consider the following from Section 13402 – Notification In The Case Of Breach. (This section is from HITECH/HIPAA: Notification in the case of breach at lawtechtv.com (a site I would strongly recommend that you visit). The bold italics are mine:

If PHI is secured as per the guidance then providers have a “safe harbor” and the notification requirements are not triggered in case of a breach. Despite the safe harbor, other federal and state PHI laws remain in full force and effect. Any PHI not secured as per the guidance is considered to be unsecured PHI whose breach will trigger the notification requirements. 13402(a): Covered Entities (CE’s) must notify individuals. 
13402(b): Business Associate’s must notify CE’s. 
13402(d): Notification must be no later than 60 days after discovery. 
13402(e): Specific notification methods are required depending on the number of individuals whose PHI was breached. 
13402(f): the notification must contain specific content.
13402(h): unsecured PHI* means PHI that is not secured through: 1) encryption; and/or 2) destruction—as provided by HHS guidance. Methods must render PHI “unusable, unreadable, or indecipherable” to unauthorized individuals (see HIPAA Security Rule  & NIST standards).

If PHI is secured as per the guidance then providers have a “safe harbor” and the notification requirements are not triggered in case of a breach. Despite the safe harbor, other federal and state PHI laws remain in full force and effect. Any PHI not secured as per the guidance is considered to be unsecured PHI whose breach will trigger the notification requirements.

If over 500 individuals’ PHI has been compromised then the media must be notified and the Secretary of HHS as well.

Breach: “the unauthorized acquisition, access, use or disclosure of PHI which compromises the security or privacy of such information, except where an authorized person to whom such information is disclosed would not be able to retain such information.”

Do you really want to have to choose between:

  1. Significant civil penalties (between $100 and $50,000 per violation, up to $1.5 million maximum per incident) and …
  2. Publishing in the local media a notice of your failure to protect your patients’ private information?

Of course not! Why not take advantage of the explicitly defined safe harbor? If the hard drive of that missing laptop has been encrypted, using appropriate technology, then there is no notification requirement at all! The same technology can be applied to every hard drive in your organization, especially the servers on which the bulk of the PHI resides. There are numerous commercial disk encryption approaches available, as well as free, open-source solutions such as TrueCrypt, that would provide you with the protection you want and owe to your patients, all penalties aside.

My previous post regarding encryption resulted in no reader response whatsoever. Does this information about your notification responsibilities make it more likely that you will move forward with data encryption? If not, why not?

Integrating Behavioral Health and Primary Care

The September 29, 2009 edition of NJAMHA Newswire reports on a trend appearing strongly in New Jersey and in many other states: attempts to provide primary care treatment at the behavioral health setting or alternatively, to integrate behavioral health treatment into the primary care setting. In fact, the National Council, the major membership organization of community behavioral health care providers, has introduced an online Resource Center for primary care and behavioral health collaboration on their web site. This center comes out of six years of work in this arena.

FierceHealthcare, a daily newsletter for health care executives, reported on this trend in its September 30, 2009 edition. The article mentions the research literature that documents the tendency of primary-care physicians to miss the signs of common mental health issues like depression. Overlooking the mental health issues can often complicate both behavioral health and physical health treatment. A diabetic who experiences some debilitating mental health issue may not be able to comply with their required diet and self-care, just as a pregnant woman taking lithium to manage her bipolar disorder faces consequences for her child from her medication. The behavioral health and physical issues are inextricably intertwined.

Behavioral Healthcare online edition of October 1, 2009 reported a SAMHSA-funded study that indicated that general practitioners, not psychiatrists, are the most frequent prescribers of psychotropic medications. This includes pediatricians among the GP category since they usually are the primary care physicians for children.

The FierceHealthcare article identifies the financial and health benefits of the integration of mental health screening and prescribing into primary health care settings. Making sure that mental illness is not overlooked is one way of assuring that patients get the most effective treatment for all of their illnesses.

Since mental health treatment has usually been considered specialist-level care, there is concern among behavioral health providers that such screening and treatment by GPs is not the appropriate care in the right setting. Given how busy primary care providers are, it is highly likely that medications will be prescribed without psychotherapy or other appropriate behavioral interventions.

Health care reform is focused on saving money and providing effective care as efficiently as possible. Some would argue that the primary care provider’s intervention in behavioral health issues is the appropriate, cost-effective way to assure proper diagnosis and treatment. Most mental health providers I know would disagree, perhaps arguing that screening and referral to specialists is the appropriate and most effective way to provide care.

What are your thoughts on this issue? Do you see the possible integration of behavioral health care and primary care as positive for you and your clients? How is this likely to impact the way you currently provide services? What about those of you who already work in primary care settings; is this the ideal way to provide care to all patients, to complicated patients, or to no one at all?

Please let us know your thoughts on this issue. Just click on the title of the article and enter your comments in the box at the bottom of the page.