Can We Assure Confidentiality In Health Care Services For Adolescents And Young Adults? The Potential Impact Of The Affordable Care Act Insurance Provisions On A Vital Patient Right

1
Can We Assure Confidentiality In Health Care
Services For Adolescents And Young Adults? The
Potential Impact Of The Affordable Care Act
Insurance Provisions On A Vital Patient Right

• Claire D. Brindis, Dr.P.H.
• Professor of Pediatrics and Health Policy
• National Adolescent and Young Adult Information
  Center and
• The Philip R. Lee Institute for Health Policy
  Studies
• University of California, San Francisco
• September 11, 2013

2
Special Thanks!

• M. Jane Park, MPH, Kathleen Tebb, PhD, Charles E.
  Irwin, Jr., MD, Elizabeth Ozer, PhD, Linda Ha,
  and Jazmyn Scott, MPH
• National Adolescent and Young Adult Health
  Information Center
• Division of Adolescent and Young Adult Medicine
• Department of Pediatrics
• University of California, San Francisco
• Abigail English, JD
• Center for Adolescent Health and the Law
• Trina Anglin, MD, PhD
• Maternal and Child Health Bureau
• Health Resources and Services Administration

3
(No Transcript)
4
Objectives

• To identify specific adolescent and young adult
  health needs.
• To describe the health care systems capacity to
  respond to these needs.
• To identify how expanded health insurance
  provisions, including preventive health services,
  within the Affordable Care Act (ACA) make it
  imperative to address issues of confidentiality
  for adolescent and young adult health care
  visits.

5
Health Issues of Adolescence Young Adulthood

• A unique opportunity to support adolescents to
  become more responsible for their own health
  care, as part of their growing independence and
  transition into young adulthood.
• The major health problems of late adolescence and
  early adulthood are largely preventable.
• Many negative health outcomes are linked to
  behaviors that can be prevented.
• Few youths have serious impairment that
  interferes with daily functioning, BUT
• Those with chronic conditions, including mental
  health disorders, must learn to manage these
  conditions with increasing independence.

6
Motherhood
College
Work
Dropout
Incarceration
Military
Other
Trajectories
7
Critical Health Issues of Adolescence Young
Adulthood Within a Developmental Context

• Increasing independence in habits related to
• diet, physical activity, and sleep.
• how they spend their time and form
  relationships (e.g., more opportunities to become
  engaged in romantic and sexual relationships),
• use alcohol and drugs,
• to work, perform community volunteer service,
  to get into trouble with the law.
• Critical period to prevent chronic conditions of
  adulthood, in areas such as
• Diseases related to tobacco use,
• Obesity,
• Dental caries,
• Hearing loss.

Adapted from the Healthy People 2020 Core
Indicators for Adolescent and Young Adult Health
8
Critical Health Issues of Adolescence Young
Adulthood

• Critical period for emergence of mental health
  concerns, such as
• Major depressive episodes
• Suicide and suicide attempts.
• Substance use, including binge drinking, use of
  marijuana other illicit drugs, and abuse of
  prescription drugs).

9
Critical Health Issues of Adolescence Young
Adulthood

• Violence, including homicide, fighting and
• weapon carrying, and homicide.
• Motor vehicle crashes drinking and driving.
• Reproductive sexual health, prevent sexually
  transmitted diseases, HIV/AIDS, and pregnancy.

10
Changing
Context
for
Young Adulthood
11
Before ACA Health Care Systems Fell Short For
Young Adults

• Among those with a past-year primary care visit,
  less than a third received preventive services
  related to key health issues.
• Young adults have very high rates of ER visits
  only the very young and the elderly have higher
  rates.
• 17 of young adults (ages 18-24) had a past-year
  unmet need for dental health care (2010).

Fortuna et al, 2009, Irwin et al., 2009 CDC/NHIS
2010
12
Percentage of Visits During Which Preventive
Counseling was Provided to Young Adults, 1996 to
2006
All Specialties Primary Care Ob/Gyn
Any 30.6 32.7 33.6
Injury 2.4 3.1 0.8
Smoking 3.1 4.2 3.1
Exercise 8.2 9.4 8.2
Weight reduction 3.0 3.8 3.4
Mental health 4.1 4.2 1.3
STD/HIV 2.7 2.6 7.1
Diet 10.0 12.4 12.4
Adapted from Ambulatory Care Among Young Adults
in the US, Fortuna, et al, 2009
13
Young Adults (19-29) experiencing past-year
access problems due to cost, 2011
Source The Commonwealth Fund Health Insurance
Tracking Survey of US adults, 2011
14
Unmet Needs Mental Health
National Survey on Drug Use and Health, 2010
15
Before ACA Health Care Systems Often Also Fell
Short for Adolescents

• Only 40 of adolescents had a past-year well
  visit.
• Among those, very few receive recommended
  preventive services rates were particularly low
  for Hispanics and females (2001-2004).
• 54 of adolescents received care in a medical
  home (2007). This figure is even lower for some
  populations
• 46 among those with a mental health condition,
  and 35 among those with both a physical health
  condition AND a mental health condition.
• 8.3 of adolescents had a past-year unmet need
  for dental health care (2010).

Irwin et al., 2009 Adams et al., 2013 CDC/NHIS
2010
16
Obama signing Healthcare Reform Bill March 23,
2010
17
The Promise of the ACA

• If fully implemented, the ACA has the potential
  to improve adolescent and young adult health in
  at least three ways
• 1. Increase the number of adolescents and young
  adults with insurance coverage
• 2. Increase access to preventive services among
  those with insurance and
• 3. Improve health care access and information
  more generally.

18
Brief Health Profile of Young Adults
International and Over Time
19
Who will receive preventive care services?

• I am interested in finding out more about how the
  implementation of the Affordable Care Act will
  impact adolescent and young adult males regarding
  preventative services and access to primary care
  services.

20
Preventive Services as Part of the ACA

• No cost sharing in private health plans
• Scope
• USPSTF grade A or B recommended services
• Bright Futures recommended services for
  adolescents
• CDC Advisory Committee on Immunization Practices
  (ACIP) recommended vaccines
• Services recommended in Womens Preventive
  Services Guidelines (IOM)

21
Limits of No Cost Preventive Services as Part
of the ACA

• Preventive Services Coverage and Potential
  Limitations
• Screening
• Diagnosis
• Treatment
• Contraception
• All FDA approved methods
• Exclusion of coverage for some brands
• Religious exemptions accommodations

22
Health Care Reform
23
The Role of Confidentiality in Adolescent and
Young Adult Health
24
The Role of Confidentiality and Consent for
Sensitive Services in Assuring Adolescents and
Young Adults Access and Use of Health Care

• Confidentiality is a basic tenet of adolescent
  health care -- impacts willingness to seek
  medical care, disclose sensitive information, and
  patient ongoing retention.
• While many parents do know about their
  adolescents and young adults use of health
  care, for many, especially those at greatest
  risk, needed care is foregone if confidentiality
  is not assured.
• Time alone with their clinician is recommended
  by health care organizations as it also helps
  adolescents develop skills needed as they
  transition into adulthood.
• Federal and State Laws impact protocols and
  practices within individual health entities.

Source National Resource Council/Institute of
Medicine, 2008.
25
Confidentiality Federal Standards Regarding
Sharing of Health Information - Health Insurance
Portability and Accountability Act of 1996
(HIPAA)

• A major goal of the Privacy Rule is to assure
  that individuals health information is
• Properly protected, while allowing the flow of
  health information needed to provide and promote
  high quality health care and
• Protect the public's health and well being.
• The Rule strikes a balance that permits important
  uses of information, while protecting the privacy
  of people who seek care and healing.
• Source (http//www.hhs.gov/ocr/privacy/hipaa/unde
  rstanding/summary/privacysummary.pdf

26
Confidentiality Federal Standards Regarding
Sharing of Health Information - Health Insurance
Portability and Accountability Act of 1996
(HIPAA)
.

• In most cases, parents are the personal
  representatives for their minor children
• Parents can exercise individual rights, such
  as access to the medical record, on behalf of
  their minor children.
• However, in certain exceptional cases, the
  parent is not considered the personal
  representative.
• In these situations, HIPAA defers to the State
  and other laws to determine the rights of
  parents to access and control the protected
  health information of their minor children.
• Source (http//www.hhs.gov/ocr/privacy/hipaa/unde
  rstanding/summary/privacysummary.pdf

27
HIPAA and the Special Case of Minors

• If State and other law is silent concerning
  parental access to the minors protected health
  information, a covered entity (e.g., provider)
  has discretion to provide or deny a parent access
  to the minors health information, provided the
  decision is made by a licensed health care
  professional in the exercise of professional
  judgment.
• Source http//www.hhs.gov/ocr/privacy/hipaa/under
  standing/summary/privacysummary.pdf

28
State Laws and Minor Consent Confidentiality

• Minor consent laws and confidentiality
  protections vary from state to state starting at
  age 12, covering a range of sensitive services
  (mental health, substance use, reproductive
  health).
• Contraceptive Services
• 25 states and the District of Columbia allow all
  minors (12 and older) to consent to contraceptive
  services
• 21 states allow only certain categories of minors
  to consent to contraceptive services
• 4 states have no relevant policy or state law.

29
Confidentiality and Adolescents andYoung Adults
Emerging Issues

• Privacy concerns likely important to young adults
  in enrollment and provision of care, as well as
  through the insurance claim process
• Sensitive services Sexuality and reproductive
  health,
• mental health, substance abuse, and dating and
• intimate violence
• Other health issues

30
Billing and Insurance Claims Issues for
adolescents, young adults and other patient groups

• Billing insurance claims may jeopardize
  confidentiality
• Eligibility and Enrollment Point of Service
  Enrollment
• Explanation of Benefits (EOBs)
• Electronic Health Records (EHRs) (also often
  known as Electronic Medical Records (EMRs)

31
Challenges to Confidentiality

• Most states do not have clear statutory or
  regulatory directives regarding EOBs.
• Conflicts exist between the provision of state
  insurance laws governing communications that
  occur in insurance claims process and state laws
  that provide confidentiality protections for
  health care information.

32
Examples of reconciling EOBs and
Confidentiality-Focus New York

• New York does not require health plans to send an
  EOB if there is no outstanding balance for the
  patient (e.g., patient pays required copayments
  at the time of service and health plan covers
  balance of the providers fee).
• For sensitive services, EOBs can be sent to
  patients, if patients specify.
• In the case of the ACA, where FDA approved birth
  control methods will be made available without
  co-payment on the part of the patient, this
  approach may be applicable. However, for other
  sensitive services, other protocols may need to
  be established.

33
Examples of reconciling EOBs and
ConfidentialityFocus New York

• New York and other states allow minors to consent
  to reproductive health services, STI, mental
  health, alcohol and drug abuse services, and
  sexual assault treatment.
• Mental Health and other health care providers may
  not disclose confidential information without
  permission of the person who consented to health
  care.
• Enrollment in Medicaid for family planning
  services can be based upon the adolescents own
  income eligibility.
• Medicaid does not send EOBs for sensitive
  services.

34
Electronic Health Records (EHRs)

• Great contribution to improving health care, but
  may make medical records more accessible to
  parents may find notes from previous visits,
  such as family planning and STIs, even if EOBs
  are not required.

35
Navigating Patient Confidentiality A
Clinicians Voice

• Ive been attending our hospitals design
  meetings around utilizing a patient portal for
  our patients. We have been notified by our IT
  team that we cannot filter out certain diagnoses
  or problems from the information that patients,
  or parents, can access. We can filter out
  pregnancy test results and STI results. However,
  all medications will be listed. My question for
  all of you is, if you are utilizing a patient
  portal at your institution, how are you handling
  avoiding inadvertent breaches of confidentiality?
  
• We are planning on having patients obtain sole
  access to their patient portal, once they are 13
  years of age. But, what about the patient that
  presents to our Teen Clinic for birth control at
  age 12? If her parent has access to the patient
  portal, then her mother could see the birth
  control pills listed on her medication list,
  therefore informing the patient that the patient
  may be sexually active.
• Thanks in advance for any information you can
  share with me. Im thankful that my institution
  has invited me to these planning sessions.
  Oftentimes, I am the lone wolf advocating for our
  teen patients confidentiality.

36
California Spotlight Responding to State
Confidentiality Laws Case Example - Kaiser
Permanente

• Organization with a preventive health care focus
  for all ages.
• Family and Patient Friendly balancing the needs
  of parents to ensure the health of their
  children, while also balancing the recognized
  confidentiality needs of adolescents and young
  adults.
• Systems built to reflect the requirements of
  state policy on access and confidentiality.
• Importance of Adolescent Medicine and System
  Champions help make sure systems are legally
  compliant in a way that actually works in real
  clinical life.

37
California Spotlight Responding to State
Confidentiality Laws Case Example - Kaiser
Permanente

• Protocols in place for multiple areas of
  operation
• o        Call Center
• o        Online appointing
• o        Lab
• o        Pharmacy
• o        Injection
• o        Electronic Health Record
• o        Billing
• Ongoing system refinements as laws, protocols,
  and requirements developed.

38
Confidentiality Reconciling Federal and State
Laws

• Several vendors of EHR/EMR systems state they are
  unable to block the creation of Explanations of
  Benefits (EOBs) for confidential care provided to
  youth.
• Mailing these EOBs out to the household would be
  in violation of Colorado state law. Many
  practitioners opt out of entering coding for the
  provision of this type of care which decreases
  the validity of data related to the types of
  services being provided to youth. 
• What, if any, leverage does the federal
  government have with these for-profit entities?

39
Protecting Confidentiality State Policy
Example - California

• California bill (SB 138) prohibits health
  insurers/plans from sending EOBs and other
  insurance communications regarding "sensitive
  services"
• Specifically, if the patient is a dependent on
  anothers policy, and is less than 26 years old,
  all such communications would be barred unless
  the patient authorizes them.
• If the patient is NOT a dependent and under 26,
  there is no automatic barring of sensitive
  communications, but if that patient submits a
  nondisclosure request, the insurer will have to
  honor it.
• Sensitive services" (e.g., prevention,
  counseling, diagnosis, and treatment related to
  sexual and reproductive health, including
  HIV/AIDS, substance use, and mental health) are
  considered Preventive Services under the ACA
  and therefore must be provided without share of
  cost.

40
Planning for the Future
41
Forecasting
42
Prediction is always difficult, especially about
the future Niels Bohr
43
Conclusion

• Adolescents and Young adults populations with
  significant health concerns, high rates of
  uninsured, and relatively low rates of health
  care utilization
• ACA has potential to expand
• Health insurance coverage in private plans
  Medicaid
• Access to important preventive, acute, and
  chronic care services
• Big challenges remain to ensure success in
  meeting ACAs promise for adolescents and young
  adults

44
Challenges to the Success of ACA

• Adolescents and Young adults who
• Do not enroll in health insurance,
• Live in non-Medicaid-expansion states and thus,
  do not have access to ACA standards for
  prevention,
• Dont avail themselves of prevention,
• Need, but do not seek sensitive services, as a
  concern about confidentiality of care.
• Maintaining patient portals that assure
  confidential care provision---how will these be
  sustained after ACA implementation?

45
Selected Sources/Resources

• ACA preventive services URL http//www.healthcare
  .gov/news/factsheets/2010/07/preventive-services-l
  ist.html
• Adams SH, Newacheck PW, Park MJ, Brindis CD,
  Irwin CE, Jr. Medical Home for Adolescents Low
  Attainment Rates for Those with Mental Health
  Problems and Other Vulnerable Groups, Academic
  Pediatrics, 201313(2)113-121.
• Centers for Disease Control and Prevention.
  National Health Interview Survey, 2010. private
  data run. Available at http//www.cdc.gov/nchs/n
  his.htm.
• English A et al. Confidentiality for Individuals
  Insured as Dependents A Review of State Laws and
  Policies. New York Guttmacher Institute and
  Public Health Solutions, 2012, www.guttmacher.org/
  pubs/confidentiality-review.pdf
• English A, Park MJ. The Supreme Court ACA
  Decision What Happens Now for Adolescents and
  Young Adults? Chapel Hill, NC Center for
  Adolescent Health the Law and San Francisco,
  CA National Adolescent and Young Adult Health
  Information Center, 2012, www.nahic.ucsf.edu
• Fortuna RJ, Robbins B, Halterman JS Ambulatory
  care among young adults in the United States. Ann
  Intern Med. 2009151(6)379-385.
• Irwin, CE, Jr., Adams SH, Park MJ, Newacheck,
  P. (2009). Preventive care for adolescents Few
  get visits and fewer get services. Pediatrics,
  123(4), e565-72.
• Kaiser Family Foundation. State Health Facts
  State Decisions for Creating Health Insurance
  Exchanges and Expanding Medicaid as of May 2,
  2013, http//kff.org/health-reform/state-indicator
  /state-decisions-for-creating-health-insurance-exc
  hanges-and-expanding-medicaid/.
• National Resource Council/Institute of Medicine.
  (2008). Adolescent Health Services Missing
  Opportunities. Washington DC National Academies
  Press.
• Substance Abuse and Mental Health Data Archive.
  National Survey on Drug Use and Health NSUDH
  online database. National survey on drug use and
  health, 2010 data. Available at
  http//www.icpsr.umich.edu/icpsrweb/SAMHDA/sdatool
  s/resources
• Tebb, K, Brindis, CD, Giordano, A, Combellick,
  S., Bausch, S, and Diaz A. A shifting Health
  Landscape for Adolescents and Young Adults
  Planning foe the Implementation of Federal Health
  Care Reform in New York. San Francisco, CA
  Philip R. Lee Institute for Health Policy Studies
  and Division of Adolescent Medicine, Department
  of Pediatrics, University of California, San
  Francisco December, 2012. http//healthpolicy.ucs
  f.edu