Ever since psychotherapy became a way of treating patients with mental illness, confidentiality has become as fundamental a tool to the field of psychiatry as antibiotics are to the field of infectious diseases. Without patients being able to explore their innermost feelings openly and honestly without fear or appraisal, progress and diagnosis in treatment of mental illnesses is limited and often useless. Yet confidentiality of psychotherapy is being seriously eroded by the process of managed care and computerized medical record keeping.
Some patients are learning that their employers, as well as co-workers have learned details of their psychiatric counseling. Others are finding out that their medical insurance applications have been rejected simply because they have been in some form of psychotherapy in the past.
Over 70% of workers in this country who are insured through their employers are enrolled in some form of a managed care plan. These plans usually pay for therapy with the condition that the patient demonstrate a medical necessity for that treatment. Because of this, managed care plans want to know what the diagnosis is, how long the treatment is going to be rendered and what, if any, progress is being made.
Managed care companies state that they understand the need to protect patient's privacy, that they attempt to respect confidentiality of psychiatric information, and are only seeking minimal information regarding diagnosis and treatment in order to be fiscally responsible. They feel they must monitor extensive therapy to ensure that their patients are obtaining cost beneficial treatment. Many in the field of psychiatry believe that this is an unwelcome intrusion by administrators and one that is leading to a negative impact on the field of psychiatry.
Managed care companies often ignore the complexities of human emotions as well as the judgement of professionals who are trained to know what to do next for their patients. There are therapist who believe that managed care companies are much more concerned with reducing cost then they are with providing expert care and furthermore believe that request for information by managed care companies are used as a harassment to them, to discourage patients from seeking reimbursement rather than a tool for determining what the patient actually needs.
Clearly a solution is needed. Privacy is critical, yet health care cost must be kept in perspective.
Recently an innovative Massachusetts law was passed and went into effect in April. This law prevents insurance companies from asking anything but the patient's name, diagnosis, dates of service and types of service for the first $500 of psychotherapy. Beyond that, however, more detailed information may be requested.
In addition, the US Congress is now deliberating over a medical record confidentiality act. This act would give patients the right to see their own medical files and prevent the disclosure of personally identifiable information without the patient's consent. This new law would also create federal penalties for those who violated the standards of confidentiality.
Many managed care companies require therapists who work for them to sign an agreement in advance of employment which would allow the company full access to the therapist files. Many physicians feel as if they are between a rock and a hard place with their patient's in the middle. They do not want to disclose too much information to managed care reviewers, yet at the same time if they do not explain the seriousness of the patient's problem they may not get authorization for appropriate treatment. Because of this, many therapist are warning their patients about the consequences of disclosure, leading many patients to stop their therapy and others to begin paying out of pocket rather than risk an invasion of their privacy.
We need guidelines on this matter and we need it soon. The American Medical Association, with help from psychiatric organizations, need to submit reasonable guidelines which protects both patient confidentiality and privacy as well as the pocket books of managed care organizations.
Surely a compromise can be reached where once again patients and their therapist can explore the limits of their feelings and thoughts in order to regain mental health. The field of psychiatry should demand no less for their patients.
(Frank H. Boehm, MD is a professor of OB/GYN and Director of OB at Vanderbilt Medical Center in Nashville, TN. He can be reached at his web site http://dr-boehm.com. Dr. Boehm resides in Boca).