By Dana C. Ackley, Ph.D.,

Dana C. Ackley, Ph.D., is a Licensed Clinical Psychologist who has practiced in Roanoke for 22 years. He is the author of Breaking Free of Managed Care (Guilford Press, 1997), a book for professionals in search of ways to practice without the compromises demanded by managed care.

Most people believe that what they tell their doctor is private. They certainly want to believe that what they tell their psychologist or counselor is private. If you don’t want to destroy your illusions, don’t read the rest of this article...

A Cautionary Tale

Still here? OK, then, imagine this story:

A man (lets call him Dave) works for a Fortune 500 company. As an executive, he is under a lot of stress, making difficult decisions, winning the cooperation of people in and outside his department, and working far more than 40 hours per week.

His long hours start to interfere with his home life. His wife begins to drift away, and his children learn that misbehavior is the one sure way to get Dad’s attention. He becomes irritable, starts having extra cocktails at night, and has trouble sleeping. He recognizes that he has lost perspective and decides to consult a psychologist.

His employer sponsored health insurance covers psychological services. However, to get it paid for, Dave has to call his HMO’s 800 number to get “authorization and referral.” He finds himself telling a disembodied voice on the other end of the line some of his most troubling feelings. His unprivate record begins as the information he shares is entered into the HMO’s computers.

The HMO representative gives Dave a list of two or three psychologists who serve on its panel. Dave calls one, gets an appointment and makes a visit. But, in order to get the next few visits paid for, the psychologist must make a report back to the HMO. A case reviewer, whom Dave will never meet nor talk with, may or may not decide that Dave needs more visits (perhaps disagreeing with the psychologist’s recommendation.) The information now in his HMOs file will include the most intimate details that Dave has shared in what he thought was the privacy of his psychologist’s office.

In Dave’s case, lets assume that the reviewer gives permission for a few more visits. When those are used and if Dave needs additional visits to achieve his goals, even more highly personal information will have to flow into the HMO’s computer. This process will repeat itself every 6 visits or so.

Lets assume that several visits to the psychologist are helpful. Dave regains perspective and begins working a reasonable schedule. To his initial surprise he is more productive even though he is working fewer hours. He has more time for his family, which leads his children to behave better. Less alcohol escapes from the liquor cabinet into Dave’s glass. His wife again finds him interesting.

Two years later, Dave’s good performance at work is noticed. He is told that he is the number one candidate for a plum promotion. Dave’s hopes soar as he dreams about his new possibilities. Mysteriously, he does not get the promotion, and Dave will never know that when his superiors checked his personnel files, they found that he had seen a psychologist. (A study noted in Time Magazine in 1997 showed that 35% of Fortune 500 companies use health insurance data to make hiring/promotion/termination decisions.) Because his bosses had a poor understanding of what this meant, they denied the promotion. They did not understand that seeing the psychologist was a proactive step. The alternative would have been to engage in denial, worsening the problems. They did not appreciate that Dave’s visits to a psychologist make him a better bet for good performance than his competition. Dave knew enough and had the courage to look at himself and make changes.

Angry over not getting the promotion, Dave quits his job and puts himself to work as a consultant. He has many skills and can easily win clients. Getting himself set up for his new life, he has many details to handle. One is to apply for health insurance. He is staggered by the exorbitant rates he must pay. Why are they so high?

Dave’s visits to the psychologist have been reported to the Medical Information Bureau, which has over 750 insurance companies as members. They pool their data so that they can evaluate the likelihood that applicants might actually use the benefits that their premiums have paid for. Dave never noticed, when he signed up for health insurance through his old employer, that there was, in small print, a place where he signed giving permission for his insurance company to release information to the Medical Insurance Bureau. Of course, the alternative to signing would have been to have turned down the job he was taking.

Insurance companies, like Dave’s former employers, often fail to understand that psychological services increase health and decrease health care expenses in the long run. As a result, they often charge higher premiums to people who have seen a psychologist. The few hundred dollars that Dave saved by using his insurance to pay for his visits to the psychologist were quickly spent on higher health insurance premiums. Then the high premiums continue, so that Dave soon is paying far more in premium expenses than he saved when insurance covered the psychologist’s services. He would have been far better off had he simply paid his psychologist out of pocket. This does not even consider the higher wages sacrificed because his promotion was torpedoed.

Who Else Can Read My Files?

You are probably beginning to see that your medical records are not as private as you may have wanted to believe. As Jay M. Pomerantz, MD., said in Drug Benefit Trends: “The big secret these days is that what patients tell therapists is no longer confidential.” These days, your medical records are open to a long list of people, if you pay for medical care through your health insurance. First they go to the HMO or insurance company so that the claim can be evaluated. Second, in today’s competitive managed care marketplace, it is likely that your HMO today will be bought by another HMO tomorrow, enlarging the number of people with access to your information. Third, your employer is likely to rebid its insurance contract on an annual basis, changing insurance companies when they can find a lower rate. This means that a whole new set of people will have access to your private information.

If you get your health care through one of the large health care organizations that exist these days, then many of the employees in that organization have potential access to your information. While these organizations develop safeguards for privacy, your privacy is only as good as their safeguards.

A 1993 Harris Poll found that more than 25% of Americans reported that health care information about them was inappropriately disclosed. In fact, one of our large, local health care organizations did it to me within the past two months. My experience was the result of staff carelessness, with no serious harm done this time. In other situations, however, disclosures have been intentional and harmful. There was a recent report of someone who, while visiting a family member who was a staff person in a hospital emergency room, downloaded names of HIV patients. Also, a national chain of drug stores was recently caught selling the names of their customers to drug companies for marketing purposes. According to an article in the New York Times, 45% of employees admit to using workplace equipment for unethical purposes.

There’s more. Insurance companies and financial institutions are now allowed to merge. As a result, banks have unprecedented access to both financial and medical information regarding their customers. What might happen to Dave when he goes to get a business line of credit to help him get his business off the ground?

Who else can get your private information? Sometimes government agencies get health information related to public health issues. Researchers sometimes get information, though usually names are removed. Under some circumstances law enforcement agencies are given medical information. Sometimes your records even may go to a managed care company with which you have no involvement. They get them because they have demanded all records from your doctor. They want to know if your doctor is recommending more expensive treatment for people covered under its plan than those not covered. Sometimes insurance companies employ other companies to collect health information from you during the application process. Then that company has your information.

Finally, the 1996 federal Health Insurance Portability and Accountability Act (HIPAA) demands that a national healthcare ID number be created for all citizens. The intended benefit is that the number will be used to organize records to facilitate communication among your health care providers. However, it will also create opportunities for even more people to gain access to your information. In an attempt to ensure privacy, HIPAA also requires that a federal privacy protection law be passed by August 21, 1999 or, if not, then regulations adopted by the U.S. Department of Health and Human Services will apply. In either case, the list of people and organizations who could have potential access to your personal healthcare information is long.

What Can You Do?

You could just not go to the doctor or psychologist. The disadvantages of that solution are huge. You could visit the doctor or psychologist but withhold information you don’t want circulating in cyberspace. The downside here, of course, is that you are likely to withhold the very information most needed to give you the right treatment.

Finally, you can pay for treatment out of pocket. This approach may seem to cost more, though Dave’s story illustrates that this is not always the case, when all factors are considered. Also, there are alternative approaches to health care coverage that can help, which will be discussed shortly. Paying out of pocket offers the most protection of your privacy. There are far fewer people who will have access to your information, usually just you and your doctor. This is particularly true if you select one of the growing number of doctors or psychologists who have begun to wean themselves away from managed care.

In addition to enhanced privacy, self-pay enhances the control you and your doctor have over your treatment. No outside authorizations needed and no artificial limits are placed on the choices you and your doctor can make. The best people to make choices about your health care are you and your doctor. When the money comes out of your pocket, your control is maximized. When the money comes from insurance companies, it is their control that holds sway.

One way many people interested in the privacy and control offered by self pay can save money is to restructure their health insurance coverage. They can buy a policy that has a large deductible, but offers coverage in the event of a truly expensive health care crisis. Routine and smaller ticket items can be paid for through what is saved in lower monthly premiums. The logic of this becomes especially clear when you know that up to 20% of today’s health care costs are administrative, largely related to insurance processes. When you eliminate the middle man, that 20% can be used for your health care, not the salary of insurance company executives.