Transcript Delivery of Integrated Clinical Care for Patients with

Delivery of Integrated
Clinical Care for Patients
with Addictions and Federal
Confidentiality Laws
Richard Saitz MD, MPH
Catherine O’Neill, JD
Eric Goplerud, PhD
Sharon Levy MD, MPH
Agenda
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What are the rules?
Where and when do they apply?
What are the implications?
Agenda
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Scope
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General health settings
Integration of care
Screening and brief intervention
Intro: 10”
Each panelist: 15”
Facilitated audience/panel discussion: 35”
Resources
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CFR 42 Part 2
Legal Action Center. Frequently asked questions (FAQs):
Applying the substance abuse confidentiality regulations
to health information exchange.
Popovits RM. Confidentiality law: time for a change?
Beckerman JZ et al. A delicate balance: behavioral
health, patient privacy, and the need to know.
HIPAA Administrative Simplification.
Letters to (and from) SAMHSA Administrator
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from ASAM, AAAP, AMERSA, AOAA, Patient Protection Coalition,
National Alliance for Medication Assisted Recovery, others…
What is high quality integrated
care?
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Systems with information available
Patient-Centered Medical Homes
Integrated delivery of medical and
addiction care
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Ongoing care beyond an acute episode
Buprenorphine in primary care
Medical services at an addictions program
Screening and brief intervention
CFR 42 Part 2
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Written in 1972
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No integrated care
Rationale: special privacy protection
because of stigma
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to encourage help seeking
to decrease discrimination.
Stigma and discrimination, 2010
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Still here.
Concerns re: poor treatment are real when
clinicians not well-trained in substance use
conditions
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Pain management
Stereotyping
Most generalist clinicians not well-trained
Addictions 2010
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Patients and families seek same high quality of care for
this condition as for others
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IOM 2005: Improving the quality of health care for mental and
substance use conditions
They want their condition to be recognized as a health
condition
But, addiction generally treated separately, and not like
a health condition (even other stigmatized ones)
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Examples:
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Treatment is separate
Records are separate
Societal/general public (and therefore health professional) views
What do the regulations say?
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Applicability
1)Federal assistance
2)Hold yourself out…(next slide)
 Federally assisted, e.g.
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Medicare
VA
Controlled Substances Act registration to prescribe controlled
substances to treat addiction
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e.g. benzodiazepines for withdrawal
e.g. buprenorphine for dependence
NOT naltrexone for dependence
You have IRS tax exempt status
What do the regulations say?
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Applicability
1) Program that HOLDS ITSELF OUT AS A
2) OR identified unit within a general medical
facility that HOLDS ITSELF OUT AS A
3) OR staff whose primary function is AS A…
PROVIDER AND PROVIDE(S) ALCOHOL OR
DRUG DIAGNOSIS, TREATMENT OR
REFERRAL FOR TREATMENT
What do the regulations say?
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Release (and re-disclosure) to health providers
requires specific patient written authorization
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Exceptions:
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Within the VA
Within the Armed Forces
Medical emergency: an immediate threat and need for
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General medical facility, unless…
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immediate treatment
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“holds itself out” or “primary function” then this can include
hospital, ER, doctor’s office, health center…
No discrimination prohibitions or protections
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small fines for release $500, up to $5000
Do the regulations impede quality
care?
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What is the effect of separate treatment on fear
and discrimination, and on equally high quality
care as other conditions?
Patients may not know how restriction of
information can impact diagnosis and treatment
of other conditions>>uninformed choice
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Misdiagnosis (abdominal pain and sweats; medication side
effect)
Duplicate or inappropriate treatments
Medication interactions (e.g. methadone)
Simple solutions?
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Sign a (“global”) release
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Named provider, specific purpose, expiration
date/event
Cannot use for disease management purposes
without specific consent
“Qualified Service Organization” (QSO) exception
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Supposed to be for organizations that provide
services to addiction programs that are incidental to
drug treatment (e.g. billing)
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Not to provide integrated health care
Other conditions
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With other conditions, after listening to
patients we rely on record review for
detail
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not easy for patients to provide
Scenarios
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A federally assisted SBIRT program has a
health educator whose primary function is
to provide diagnosis and treatment or
referral
A primary care physician asks all of her
patients about unhealthy alcohol use
Scenario
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Patient comes to ED after minor auto accident
for evaluation. Hospitalized for observation.
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Health promotion advocate identifies alcohol
dependence.
Patient transferred to inpatient service, different
clinicians. Patient develops severe alcohol
withdrawal.
Seen in the ED doesn’t mean medical
emergency, and therefore not an exception
(unless screening done by someone for whom it
is not primary function)
Scenario
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Buprenorphine
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Medication and counseling in a PC practice
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Is it the physician’s primary function?
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Sounds like a program…SAMHSA has said so
If covered by CFR 42, and patient receives addiction and
medical treatment from the same physician…what happens
to the other medical information?
30 patients
100 patients (PCP panel sizes 500-2000)
How about a nurse care manager—primary function?
Resources
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CFR 42 Part 2
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Frequently asked questions (FAQs): Applying the substance abuse
confidentiality regulations to health information exchange.
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Issue Brief. California Healthcare Foundation, March 2008.
HIPAA Administrative Simplification
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Behav Healthcare, April 2010, pp. 11-13
And www.popovitslaw.com/42CFRupdates
Beckerman JZ et al. A delicate balance: behavioral health, patient
privacy, and the need to know.
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Legal Action Center, for SAMHSA
Popovits RM. Confidentiality law: time for a change?
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see ecfr.gpoaccess.gov
45 CFR 160, 162, 164
Letters to (and from) SAMHSA Administrator
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from ASAM, AAAP, AMERSA, AOAA, Patient Protection coalition, National
Alliance for Medication Assisted Recovery, others…