Group Insurance Health Care and the HIPAA Privacy Rule

HIPAA stands for Health Insurance Portability and Accountability Act. When I hear people talking about HIPAA, they are usually not talking about the original Act. They are talking about the Privacy Rule that was issued as a result of the HIPAA in the form of a Notice of Health Information Practices.

The United States Department of Health & Human Services official Summary of the HIPAA Privacy Rule is 25 pages long, and that is just a summary of the key elements. So as you can imagine, it covers a lot of ground. What I would like to offer you here is a summary of the basics of the Privacy Rule.

When it was enacted in 1996, the Privacy Rule established guidelines for the protection of individuals’s health information. The guidelines are written such that they make sure that an individual’s health records are protected while at the same time allowing needed information to be released in the course of providing health care and protecting the public’s health and well being. In other words, not just anyone can see a person’s health records. But, if you want someone such as a health provider to see your records, you can sign a release giving them access to your records.

So just what is your health information and where does it come from? Your health information is held or transmitted by health plans, health care clearinghouses, and health care providers. These are called covered entities in the wording of the rule.

These guidelines also apply to what are called business associates of any health plans, health care clearinghouses, and health care providers. Business associates are those entities that offer legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services.

So, what does a typical Privacy Notice include?

The type of information collected by your health plan.
A description of what your health record/information includes.
A summary of your health information rights.
The responsibilities of the group health plan.

Let’s look at these one at a time:

Information Collected by Your Health Plan:

The group healthcare plan collects the following types of information in order to provide benefits:

Information that you provide to the plan to enroll in the plan, including personal information such as your address, telephone number, date of birth, and Social Security number.

Plan contributions and account balance information.

The fact that you are or have been enrolled in the plans.

Health-related information received from any of your physicians or other healthcare providers.

Information regarding your health status, including diagnosis and claims payment information.

Changes in plan enrollment (e.g., adding a participant or dropping a participant, adding or dropping a benefit.)

Payment of plan benefits.

Claims adjudication.

Case or medical management.

Other information about you that is necessary for us to provide you with health benefits.

Understanding Your Health Record/Information:

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment.

This information, often referred to as your health or medical record, serves as a:

Basis for planning your care and treatment.

Means of communication among the many health professionals who contribute to your care.

Legal document describing the care you received.

Means by which you or a third-party payer can verify that services billed were actually provided.

Tool in educating health professionals.

Source of data for medical research.

Source of information for public health officials charged with improving the health of the nation.

Source of data for facility planning and marketing.

Tool with which the plan sponsor can assess and continually work to improve the benefits offered by the group healthcare plan. Understanding what is in your record and how your health information is used helps you to:

Ensure its accuracy.

Better understand who, what, when, where, and why others may access your health information.

Make more informed decisions when authorizing disclosure to others.

Your Health Information Rights:

Although your health record is the physical property of the plan, the healthcare practitioner, or the facility that compiled it, the information belongs to you. You have the right to:

Request a restriction on otherwise permitted uses and disclosures of your information for treatment, payment, and healthcare operations purposes and disclosures to family members for care purposes.

Obtain a paper copy of this notice of information practices upon request, even if you agreed to receive the notice electronically.

Inspect and obtain a copy of your health records by making a written request to the plan privacy officer.

Amend your health record by making a written request to the plan privacy officer that includes a reason to support the request.

Obtain an accounting of disclosures of your health information made during the previous six years by making a written request to the plan privacy officer.

Request communications of your health information by alternative means or at alternative locations.

Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

Group Health Plan Responsibilities:

The group healthcare plan is required to:

Maintain the privacy of your health information.

Provide you with this notice as to the planâEUR(TM)s legal duties and privacy practices with respect to information that is collected and maintained about you.

Abide by the terms of this notice.

Notify you if the plan is unable to agree to a requested restriction.

Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. The plan will restrict access to personal information about you only to those individuals who need to know that information to manage the plan and its benefits. The plan will maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your personal information. Under the privacy standards, individuals with access to plan information are required to:

Safeguard and secure the confidential personal financial information and health information as required by law. The plan will only use or disclose your confidential health information without your authorization for purposes of treatment, payment, or healthcare operations. The plan will only disclose your confidential health information to the plan sponsor for plan administration purposes.

Limit the collection, disclosure, and use of participant’s healthcare information to the minimum necessary to administer the plan.

Permit only trained, authorized individuals to have access to confidential information.

Other items that may be addressed include:

Communication with family. Under the plan provisions, the company may disclose to an employee’s family member, guardian, or any other person you identify, health information relevant to that person’s involvement in your obtaining healthcare benefits or payment related to your healthcare benefits.

Notification. The plan may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, general condition, plan benefits, or plan enrollment.

Business associates. There are some services provided to the plan through business associates. Examples include accountants, attorneys, actuaries, medical consultants, and financial consultants, as well as those who provide managed care, quality assurance, claims processing, claims auditing, claims monitoring, rehabilitation, and copy services. When these services are contracted, it may be necessary to disclose your health information to our business associates in order for them to perform the job we have asked them to do. To protect employee’s health information, however, the company will require the business associate to appropriately safeguard this information.

Benefit coordination. The plan may disclose health information to the extent authorized by and to the extent necessary to comply with plan benefit coordination.

Workers compensation. The plan may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Law enforcement. The plan may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Sale of business. If the plan sponsor’s business is being sold, then medical information may be disclosed. The plan reserves the right to change its practices and to make the new provisions effective for all protected health information it maintains. Should the company’s information practices change, it will mail a revised notice to the address supplied by each employee.

The plan will not use or disclose employee’s health information without their authorization, except as described in this notice.

In Summary:

As an employee, you should be aware of your rights and feel confident that your employer is abiding by the guidelines of the Privacy Rule.

As an employer offering group insurance health care benefits, you should make your employees aware of their rights and should give them an avenue to obtain more information or to report a problem.

Health Care Reform – Why Are People So Worked Up?

Why are Americans so worked up about health care reform? Statements such as “don’t touch my Medicare” or “everyone should have access to state of the art health care irrespective of cost” are in my opinion uninformed and visceral responses that indicate a poor understanding of our health care system’s history, its current and future resources and the funding challenges that America faces going forward. While we all wonder how the health care system has reached what some refer to as a crisis stage. Let’s try to take some of the emotion out of the debate by briefly examining how health care in this country emerged and how that has formed our thinking and culture about health care. With that as a foundation let’s look at the pros and cons of the Obama administration health care reform proposals and let’s look at the concepts put forth by the Republicans?

Access to state of the art health care services is something we can all agree would be a good thing for this country. Experiencing a serious illness is one of life’s major challenges and to face it without the means to pay for it is positively frightening. But as we shall see, once we know the facts, we will find that achieving this goal will not be easy without our individual contribution.

These are the themes I will touch on to try to make some sense out of what is happening to American health care and the steps we can personally take to make things better.

A recent history of American health care – what has driven the costs so high?
Key elements of the Obama health care plan
The Republican view of health care – free market competition
Universal access to state of the art health care – a worthy goal but not easy to achieve
what can we do?

First, let’s get a little historical perspective on American health care. This is not intended to be an exhausted look into that history but it will give us an appreciation of how the health care system and our expectations for it developed. What drove costs higher and higher?

To begin, let’s turn to the American civil war. In that war, dated tactics and the carnage inflicted by modern weapons of the era combined to cause ghastly results. Not generally known is that most of the deaths on both sides of that war were not the result of actual combat but to what happened after a battlefield wound was inflicted. To begin with, evacuation of the wounded moved at a snail’s pace and this caused severe delays in treating the wounded. Secondly, many wounds were subjected to wound care, related surgeries and/or amputations of the affected limbs and this often resulted in the onset of massive infection. So you might survive a battle wound only to die at the hands of medical care providers who although well-intentioned, their interventions were often quite lethal. High death tolls can also be ascribed to everyday sicknesses and diseases in a time when no antibiotics existed. In total something like 600,000 deaths occurred from all causes, over 2% of the U.S. population at the time!

Let’s skip to the first half of the 20th century for some additional perspective and to bring us up to more modern times. After the civil war there were steady improvements in American medicine in both the understanding and treatment of certain diseases, new surgical techniques and in physician education and training. But for the most part the best that doctors could offer their patients was a “wait and see” approach. Medicine could handle bone fractures and increasingly attempt risky surgeries (now largely performed in sterile surgical environments) but medicines were not yet available to handle serious illnesses. The majority of deaths remained the result of untreatable conditions such as tuberculosis, pneumonia, scarlet fever and measles and/or related complications. Doctors were increasingly aware of heart and vascular conditions, and cancer but they had almost nothing with which to treat these conditions.

This very basic review of American medical history helps us to understand that until quite recently (around the 1950′s) we had virtually no technologies with which to treat serious or even minor ailments. Here is a critical point we need to understand; “nothing to treat you with means that visits to the doctor if at all were relegated to emergencies so in such a scenario costs are curtailed. The simple fact is that there was little for doctors to offer and therefore virtually nothing to drive health care spending. A second factor holding down costs was that medical treatments that were provided were paid for out-of-pocket, meaning by way of an individuals personal resources. There was no such thing as health insurance and certainly not health insurance paid by an employer. Except for the very destitute who were lucky to find their way into a charity hospital, health care costs were the responsibility of the individual.

What does health care insurance have to do with health care costs? Its impact on health care costs has been, and remains to this day, absolutely enormous. When health insurance for individuals and families emerged as a means for corporations to escape wage freezes and to attract and retain employees after World War II, almost overnight a great pool of money became available to pay for health care. Money, as a result of the availability of billions of dollars from health insurance pools, encouraged an innovative America to increase medical research efforts. More Americans became insured not only through private, employer sponsored health insurance but through increased government funding that created Medicare and Medicaid (1965). In addition funding became available for expanded veterans health care benefits. Finding a cure for almost anything has consequently become very lucrative. This is also the primary reason for the vast array of treatments we have available today.

I do not wish to convey that medical innovations are a bad thing. Think of the tens of millions of lives that have been saved, extended, enhanced and made more productive as a result. But with a funding source grown to its current magnitude (hundreds of billions of dollars annually) upward pressure on health care costs are inevitable. Doctor’s offer and most of us demand and get access to the latest available health care technology in the form of pharmaceuticals, medical devices, diagnostic tools and surgical procedures. So the result is that there is more health care to spend our money on and until very recently most of us were insured and the costs were largely covered by a third-party (government, employers). Add an insatiable and unrealistic public demand for access and treatment and we have the “perfect storm” for higher and higher health care costs. And by and large the storm is only intensifying.

At this point, let’s turn to the key questions that will lead us into a review and hopefully a better understanding of the health care reform proposals in the news today. Is the current trajectory of U.S. health care spending sustainable? Can America maintain its world competitiveness when 16%, heading for 20% of our gross national product is being spent on health care? What are the other industrialized countries spending on health care and is it even close to these numbers? When we add politics and an election year to the debate, information to help us answer these questions become critical. We need to spend some effort in understanding health care and sorting out how we think about it. Properly armed we can more intelligently determine whether certain health care proposals might solve or worsen some of these problems. What can be done about the challenges? How can we as individuals contribute to the solutions?

The Obama health care plan is complex for sure – I have never seen a health care plan that isn’t. But through a variety of programs his plan attempts to deal with a) increasing the number of American that are covered by adequate insurance (almost 50 million are not), and b) managing costs in such a manner that quality and our access to health care is not adversely affected. Republicans seek to achieve these same basic and broad goals, but their approach is proposed as being more market driven than government driven. Let’s look at what the Obama plan does to accomplish the two objectives above. Remember, by the way, that his plan was passed by congress, and begins to seriously kick-in starting in 2014. So this is the direction we are currently taking as we attempt to reform health care.

Through insurance exchanges and an expansion of Medicaid,the Obama plan dramatically expands the number of Americans that will be covered by health insurance.

To cover the cost of this expansion the plan requires everyone to have health insurance with a penalty to be paid if we don’t comply. It will purportedly send money to the states to cover those individuals added to state-based Medicaid programs.

To cover the added costs there were a number of new taxes introduced, one being a 2.5% tax on new medical technologies and another increases taxes on interest and dividend income for wealthier Americans.

The Obama plan also uses concepts such as evidence-based medicine, accountable care organizations, comparative effectiveness research and reduced reimbursement to health care providers (doctors and hospitals) to control costs.

The insurance mandate covered by points 1 and 2 above is a worthy goal and most industrialized countries outside of the U.S. provide “free” (paid for by rather high individual and corporate taxes) health care to most if not all of their citizens. It is important to note, however, that there are a number of restrictions for which many Americans would be culturally unprepared. Here is the primary controversial aspect of the Obama plan, the insurance mandate. The U.S. Supreme Court recently decided to hear arguments as to the constitutionality of the health insurance mandate as a result of a petition by 26 states attorney’s general that congress exceeded its authority under the commerce clause of the U.S. constitution by passing this element of the plan. The problem is that if the Supreme Court should rule against the mandate, it is generally believed that the Obama plan as we know it is doomed. This is because its major goal of providing health insurance to all would be severely limited if not terminated altogether by such a decision.

As you would guess, the taxes covered by point 3 above are rather unpopular with those entities and individuals that have to pay them. Medical device companies, pharmaceutical companies, hospitals, doctors and insurance companies all had to “give up” something that would either create new revenue or would reduce costs within their spheres of control. As an example, Stryker Corporation, a large medical device company, recently announced at least a 1,000 employee reduction in part to cover these new fees. This is being experienced by other medical device companies and pharmaceutical companies as well. The reduction in good paying jobs in these sectors and in the hospital sector may rise as former cost structures will have to be dealt with in order to accommodate the reduced rate of reimbursement to hospitals. Over the next ten years some estimates put the cost reductions to hospitals and physicians at half a trillion dollars and this will flow directly to and affect the companies that supply hospitals and doctors with the latest medical technologies. None of this is to say that efficiencies will not be realized by these changes or that other jobs will in turn be created but this will represent painful change for a while. It helps us to understand that health care reform does have an effect both positive and negative.

Finally, the Obama plan seeks to change the way medical decisions are made. While clinical and basic research underpins almost everything done in medicine today, doctors are creatures of habit like the rest of us and their training and day-to-day experiences dictate to a great extent how they go about diagnosing and treating our conditions. Enter the concept of evidence-based medicine and comparative effectiveness research. Both of these seek to develop and utilize data bases from electronic health records and other sources to give better and more timely information and feedback to physicians as to the outcomes and costs of the treatments they are providing. There is great waste in health care today, estimated at perhaps a third of an over 2 trillion dollar health care spend annually. Imagine the savings that are possible from a reduction in unnecessary test and procedures that do not compare favorably with health care interventions that are better documented as effective. Now the Republicans and others don’t generally like these ideas as they tend to characterize them as “big government control” of your and my health care. But to be fair, regardless of their political persuasions, most people who understand health care at all, know that better data for the purposes described above will be crucial to getting health care efficiencies, patient safety and costs headed in the right direction.

A brief review of how Republicans and more conservative individuals think about health care reform. I believe they would agree that costs must come under control and that more, not fewer Americans should have access to health care regardless of their ability to pay. But the main difference is that these folks see market forces and competition as the way to creating the cost reductions and efficiencies we need. There are a number of ideas with regard to driving more competition among health insurance companies and health care providers (doctors and hospitals) so that the consumer would begin to drive cost down by the choices we make. This works in many sectors of our economy but this formula has shown that improvements are illusive when applied to health care. Primarily the problem is that health care choices are difficult even for those who understand it and are connected. The general population, however, is not so informed and besides we have all been brought up to “go to the doctor” when we feel it is necessary and we also have a cultural heritage that has engendered within most of us the feeling that health care is something that is just there and there really isn’t any reason not to access it for whatever the reason and worse we all feel that there is nothing we can do to affect its costs to insure its availability to those with serious problems.

OK, this article was not intended to be an exhaustive study as I needed to keep it short in an attempt to hold my audience’s attention and to leave some room for discussing what we can do contribute mightily to solving some of the problems. First we must understand that the dollars available for health care are not limitless. Any changes that are put in place to provide better insurance coverage and access to care will cost more. And somehow we have to find the revenues to pay for these changes. At the same time we have to pay less for medical treatments and procedures and do something to restrict the availability of unproven or poorly documented treatments as we are the highest cost health care system in the world and don’t necessarily have the best results in terms of longevity or avoiding chronic diseases much earlier than necessary.

I believe that we need a revolutionary change in the way we think about health care, its availability, its costs and who pays for it. And if you think I am about to say we should arbitrarily and drastically reduce spending on health care you would be wrong. Here it is fellow citizens – health care spending needs to be preserved and protected for those who need it. And to free up these dollars those of us who don’t need it or can delay it or avoid it need to act. First, we need to convince our politicians that this country needs sustained public education with regard to the value of preventive health strategies. This should be a top priority and it has worked to reduce the number of U.S. smokers for example. If prevention were to take hold, it is reasonable to assume that those needing health care for the myriad of life style engendered chronic diseases would decrease dramatically. Millions of Americans are experiencing these diseases far earlier than in decades past and much of this is due to poor life style choices. This change alone would free up plenty of money to handle the health care costs of those in dire need of treatment, whether due to an acute emergency or chronic condition.

Let’s go deeper on the first issue. Most of us refuse do something about implementing basic wellness strategies into our daily lives. We don’t exercise but we offer a lot of excuses. We don’t eat right but we offer a lot of excuses. We smoke and/or we drink alcohol to excess and we offer a lot of excuses as to why we can’t do anything about managing these known to be destructive personal health habits. We don’t take advantage of preventive health check-ups that look at blood pressure, cholesterol readings and body weight but we offer a lot of excuses. In short we neglect these things and the result is that we succumb much earlier than necessary to chronic diseases like heart problems, diabetes and high blood pressure. We wind up accessing doctors for these and more routine matters because “health care is there” and somehow we think we have no responsibility for reducing our demand on it.

It is difficult for us to listen to these truths but easy to blame the sick. Maybe they should take better care of themselves! Well, that might be true or maybe they have a genetic condition and they have become among the unfortunate through absolutely no fault of their own. But the point is that you and I can implement personalized preventive disease measures as a way of dramatically improving health care access for others while reducing its costs. It is far better to be productive by doing something we can control then shifting the blame.

There are a huge number of free web sites available that can steer us to a more healthful life style. A soon as you can, “Google” “preventive health care strategies”, look up your local hospital’s web site and you will find more than enough help to get you started. Finally, there is a lot to think about here and I have tried to outline the challenges but also the very powerful effect we could have on preserving the best of America’s health care system now and into the future. I am anxious to hear from you and until then – take charge and increase your chances for good health while making sure that health care is there when we need it.

Health Anxiety and Solutions

It’s always important to take care of oneself using all the principles of good health. Regular check-ups, proper nutrition and healthful living all enable one to keep on top of their health in a careful yet reasonable way. Often one becomes overly concerned with health issues and caught up in a cycle of health worries. One health issue is reconciled when another immediately pops up to take its place. These worries become all encompassing and exhausting after a while.

Eventually, the individual realizes that this cycle of health anxieties has intruded upon the quality of their life. A dark cloud, always hovering over daily living, this intrusive form of anxiety has to be addressed. One begins by determining why this is occurring, what purpose does it serve and how to interrupt this behavior.

Reason for Health Anxiety

Health worries actually serve a purpose and this purpose is not difficult to detect if one looks deep enough into this pattern of behavior. Often this pattern involves the brain distracting from specific emotions which the individual finds difficult to address.

Many emotions are so overwhelming, such as anger, grief or fear, that the brain looks for ways to distract. Health worries fit the bill because when one worries intensely about their health, there is little room to address an upsetting emotion.

Health worries blanket every other thought and this WORKS. This is the perfect distraction from unsettling emotions. When one worry is reconciled, another takes it place to veil the unaddressed emotion. Each health worry has a strong purpose, as it masks the true upsetting emotion, which is much more difficult to face in the long run.

Solution

- Recognition and acknowledgment of the Health Anxiety habit, one worry quickly following another in a noticeable loop that never ends. Awareness of this cycle is always the first step to reconciliation of the issue.

- Determining if this health worry is a true physical problem by visiting one’s primary physician and ruling out a definite physical cause for the difficulty. Always rule out a physical cause before assuming it is merely health anxiety.

- Noticing that these health worries settle down when you become intensely interested in another topic or swept into a new relationship, job or cause.

- Identify your patterns. Do you experience twinges of symptoms that often jump from one area of the body to another? Do you find yourself overestimating physical intrusions and instantly jump to the conclusion that they signify danger or warrant the attention of an alert?

- Find interests that involve your entire being. Lose yourself in things that allow you little time for inward thinking. True illness does not surface through boredom as do these behaviors. True health problems do not generally follow the same time table as health anxieties do. Health worries are stronger during times of boredom and when one lacks interests. An intelligent mind requires challenges and goals.

- Activity is an important therapeutic tool against health worries. Exercise and movement invigorate and stimulate the mind and body in a positive way. Endorphins are released and Serotonin levels are boosted naturally when activity is a part of a daily routine. Moderate walking, jogging, tennis, swimming and dancing are all helpful activities that bring forth positive results.

- Nutrition is also essential to good health which in itself helps eliminate the strong habit of negative thinking, often concerning health worries. When eating properly, Serotonin levels are naturally boosted and blood sugar levels remain stable. This helps settle down an over-reactive mind, leading to a lessening in health anxieties.

- Talk back to the brain by firmly telling it to stop when health worries enter the mind. Shift into a more positive mode of thinking because you always have a choice in what you think about.

The mind will respond by quieting down as negative thoughts subside. The brain, caught red handed in this behavior is instantly embarrassed causing it to suspend this cycle of negative thought. This is comparative to a child being caught with his hand in the cookie jar. Embarrassment at being caught, stops this intrusive behavior.

- Be aware of “what if” thinking. If the majority of sentences you think begin with “what if” then this is proof of a strong health anxiety habit. Change “what if” thinking to “so what” and watch the cycle break.

Most of all, understand that worry solves nothing. Health worries, in particular will only serve to exhaust and deplete both mind and body. Consciously make a concerted effort to change the way you think and you will succeed in changing your life. You will go from self victimization to freedom from the intrusive habit of fearful worry.