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John Griffith has been a psychiatrist for 40 years, during which time, like all physicians, he has had to stay abreast of the latest treatments and medications available to his patients. He has also had to put up with the changing business of health care, which, in Griffith's view, is infinitely more difficult than treating the mentally ill.
For example, this summer a managed-care company that Griffith contracts with started using a new patient certification form. Unlike the old form, which required little more than a diagnosis, a brief description of symptoms and a recommended treatment plan, the new form wanted information about his patients' social behavior, the mental and criminal history of their families and any "psychosocial and environmental problems" experienced, such as "interaction with [the] legal system."
While such detail would undoubtedly be helpful to him, Griffith wasn't about to make it available to the managed-care company, at least not without first getting the permission from his patients. Toward that end, Griffith wrote a letter to the company, asking it to explain why such detailed information was required and what it would be used for.
But instead of an answer, the company's "regional professional relations manager" suggested that if Griffith wasn't happy with the new form, he should consider resigning as a core provider for the company.
The response angered Griffith so much that he filed a complaint with the Texas Attorney General's office. The psychiatrist accused the company of demanding information that medical ethics require physicians to keep to themselves. He also suggested that the company was using the expanded form to conduct nonmedical research and might even deny treatment to patients who refused to provide the requested information.
Howard Drescher, a spokesperson for the company, Cigna Behavioral Health, acknowledges that the new form demands a "fair amount of information." He denies the data, which he categorized as "highly protected," is shared with anyone outside the company.
"It goes into our records, but those records are accessible to a limited number of people on a need-to-know and a password basis," Drescher says. "The fundamental purpose is to certify the current condition of the patient in clinical terms."
Griffith doesn't buy that explanation, and, he says, neither do a lot of physicians these days.
"It's like the camel sticking its nose inside the tent," Griffith says. "Every doctor in the country practically has had it happen, and they want the camel to get out of the tent."
Griffith's dispute with Cigna Behavioral Health is one battleground in the war over medical privacy. The principle that a patient's health information cannot be disclosed without permission dates back to the fourth century B.C. and the Hippocratic oath, which states that a physician will never divulge "whatsoever I shall see or hear in the course of my profession holding such things to be holy secrets."
To the extent that a person's medical history has ever been subject to the physician's eyes only, that has certainly not been the case since the American health care system underwent the seismic shift to managed care. Now, by simply signing up for coverage, a person gives HMOs and insurance companies carte blanche to collect whatever information they deem necessary to pay claims.
Nowhere does this accumulation of detail on a patient raise concerns about privacy and confidentiality as in the care of those suffering from mental illness.
"The irony is, the reason they've been able to collect so much information is people actually imagine the Hippocratic oath prevails, and the reason we imagine that is because it's almost intrinsic of human nature that we need privacy to deal with painful things," says Debra Peel, an Austin psychiatrist and legislative chair of the National Coalition of Mental Health Professionals and Consumers. "Not everything is like a broken leg. What people feel about the meaning of getting particular diagnoses is extremely sensitive."
In 1928 Supreme Court Justice Louis Brandeis opined that "the right to be left alone [is] the most comprehensive of rights and the right most valued by civilized men." Evidence suggests people are beginning to realize that when it comes to their health, that right no longer exists. According to a national survey conducted last year by the California Health Care Foundation, one out of six Americans has tried to protect the confidentiality of their medical information, including withholding information from their doctors, paying out-of-pocket for certain procedures and treatments and even avoiding care altogether.
Should the rest of us be as worried? After all, even in the days of paper medical records, patient confidentiality was little more than a myth. Almost any employee in a clinical setting has access to records. Patients visiting a physician, including a psychiatrist, are routinely asked to sign a list at the front desk and then pass the time awaiting their appointment with others seeking treatment. Physicians fax diagnostic data to one another on a daily basis, without considering who might be on the other end.
Typically such practices pose minimal risk to patients, says Paul Handel, a Houston urologist and chairman of the Texas Medical Association's panel on medical economics. "Most of the time, it doesn't make any difference, unless the information falls into the hands of somebody who shouldn't have it," Handel says. "That's a real problem. I have an innate fear that a lot of physicians are so barraged with requests for information that they don't think twice about releasing it."