I used to be a doctor. Next I was a provider. Now, I'm a non-covered entity. I liked being a doctor…I still do. I never liked being a provider. But being a non-covered entity is a secret victory. I'll explain.
As a psychoanalyst and psychiatrist, my work depends entirely on confidentiality and respect for people as individuals. Treatment works only when my patients and I are able to explore very personal feelings and thoughts. If my patients are not confident that what they tell me will stay private, they will withhold their thoughts or abort the treatment. In the mid-1980s, when I began practice, what patients told doctors was kept confidential, protected by a compact dating back more than 2000 years, to Hippocrates. Along came private insurers, Medicare, and HMOs—third parties with a financial stake in medical events. Since they were paying out money, they wanted to know what they were paying for and often began to demand private information before paying. What was personal suddenly became corporate.
To increase profits, insurance companies instituted “managed care” in psychiatry and transferred to shareholders a great deal of the resources that had formerly been spent for health care. Managed care employs many techniques to discourage the use of mental health services. One approach is to have reviewers decide whether patients' problems meet criteria for “medical necessity” before approving payment for “procedures,” such as psychotherapy. To do this they often demand very personal information, compromising confidentiality. This demand for information, because it threatens confidentiality, can lower quality of care just by existing. Who can talk freely when unseen reviewers are eavesdropping? And, unfortunately, too many therapists are willing to go along with this system.
These same insurance companies made me a Provider. I believe they use the word “provider” as a way to address doctors, nurses, therapists of every variety, even syringe suppliers, with the same form letter. Because a provider need not be a doctor, the term also includes the numerous “physician-extenders” who do things that doctors used to do. Many Americans have insurance that obligates them to choose a doctor from a company list or “provider panel.” Even though I don't participate in insurance company provider panels (they rarely allow for confidential, insight-oriented psychotherapy), I have received many a “Dear Provider” letter—impersonal, bureaucratic, and, typically, unsigned.
Then came the Health Insurance Portability and Accountability Act (HIPAA), which made me an Entity. HIPAA was intended to help workers maintain their insurance when they changed jobs. It also directed the executive branch to develop regulations to protect medical privacy. While the rules provide new protection for psychotherapy notes, they also allow large companies (including pharmacies) to use personal health information for all sorts of non-medical (commercial) purposes—without patients' knowledge or consent. (Perhaps you have received a phone call from a company attempting to sell you products for an illness you thought was confidential?) In addition, the rules require hospitals and most doctors to carry out a lot of bureaucratic paperwork to make a display of privacy protection. You've probably signed forms at your doctor's office to satisfy the rule that the office show you its privacy policies.
If I were to send patient information electronically—such as sending a bill to an insurer online—I would become a Covered Entity and would be forced to have my patients sign the useless forms. But, concerned about these electronic transmissions as an additional risk to confidentiality, I choose not to use them. This makes me a Non-Covered Entity. I'd prefer to be a doctor, but as an Entity, I'd much rather be Non-Covered than Covered.
Not everyone feels as I do. My internist now types on a notebook computer as we talk. Although electronic records are lost, stolen, and sold every day he does not believe that the electronic record jeopardizes my privacy. If my records were accidentally or maliciously posted on the Internet, would they even be accurate? The problems listed on my billing slip are not necessarily those I consider important. They seem more oriented to justify to a potential third-party reviewer the substantial amount of time my doctor spends with me than an accurate description of my concerns. Would I tell him of problems about which I felt deeply embarrassed?
Now health care reform is in the wind again, and with it many questions. Will insurance companies still be allowed to skim 20 percent from each health care dollar? Will doctors still be reimbursed huge sums for procedures but pennies for talking with and understanding patients and their families? Can medicine be personal and private? Will people be taken care of by a doctor, a provider, or an entity?
My practice remains personal and private. Most of my patients address me as “Doctor,” but some call me Larry. I'm not particular about this: More important is that the patient be comfortable. If the patient has a strong preference about what to call me, we have the chance to learn from it. The patient's feelings about addressing me may shed light on his or her feelings in other relationships.
Recently, the federal government has required all doctors (including this Provider/Non-Covered Entity) to have a National Provider Identification (NPI) number: It is 10 digits long, so it's not easy to address me by it. But even if you are the bureaucrat who created NPIs, your secret will be secure with me.
Lawrence D. Blum, M.D., is a psychoanalyst and psychiatrist in private practice in Philadelphia and in Cherry Hill, N.J.