Some insurance contracts limit coverage to certain illnesses or certain time periods, therefore insurance companies are entitled to information about patients which is pertinent to these areas. Thus it is necessary in many contracts to demonstrate that an illness did not exist prior to the effective date of the policy. Usually an indication that the patient had an illness which needs treatment is required. To substantiate the type and frequency of treatment given it may be necessary to give some information indicating the general degree of impairment the patient suffers unless treated. This information may be needed too for billing purposes. Finally, the fact that the patient suffers from a psychiatric condition covered by the contract may need to be stated. But in no case should a patient stricken by a condition be penalized because he has added a "burden" to the group. Furthermore, when the cost accounting of a group is made the individual's privacy should not be compromised and all data should be reported in the aggregate. The insurance companies' legitimate right to some information concerning patients is circumscribed. The precise diagnosis and even current "degree of disability" is probably not germane to the policy needs nor helpful to the insurance industry in answering the questions raised, when they follow the general medical model for actuarial purposes. They can usually be replaced by a general category of functional impairment. No information should be given which could in any way be used against the patient. Communications by psychiatrists with an insurance company should be directly with its physician representative, thus subjecting the receiving physician to the same ethical standards of confidentiality the treating physician has. If eligibility to enroll in an insurance program is in question, as it often is in life insurance and some health insurance, the matter should be determined by an examination designed for that purpose, and not by information from the treating psychiatrist.

Any national health insurance program should include strict safeguards of confidentiality built into any data collection or storage system. We must assure that the minimum necessary demographic and health information about the individual be separated from national health statistics. Accessibility to this data must be sharply and carefully limited.

One special sub-category of confidentiality is that of privilege. Here the third party is the court and special legal parameters apply. While it is not necessary here to go into great detail about privilege, we do feel that many of the same principles governing confidentiality also apply to privilege. (For clarification of the distinction between confidentiality and privilege see "Position Statement on Guidelines for Psychiatrists: Problems in Confidentiality", American Journal of Psychiatry, 126:10, 187-193, April, 1970.)

When information is requested it is the psychiatrist's responsibility to explore with the patient the risks of breaking or relinquishing the privilege, and he should discuss the nature of the material which might be divulged. When asked to testify the psychiatrist must be one of the agents protecting the patient's best interests. If information is demanded and legal recourse has been exhausted, only that information specifically required should be revealed and no more. And we should as psychiatrists work for the establishment of privileged statutes which will maximally protect a patient's privacy and the confidentiality of their treatment.

From the foregoing some basic principles can be extracted. These are enumerated following.

DEFINITION OF PURPOSE

To determine the nature of problems threatening confidentiality between patients and physicians, particularly through demands of third party interests.

AREAS OF CONSIDERATION BY THE TASK FORCE

Confidentiality and Insurance Coverage for Psychiatric Patients

The Task Force on Confidentiality as Related to Third Parties (TFC) began conferences with Medical and Claims representatives of the insurance industry to study their legitimate needs for information and to examine with them the nature of psychiatric illness and treatment processes. Efforts were made in an attempt to reach an accord on the following aspects of this problem.

New Code System. One important achievement of the TFC was the formulation of a new code for reporting psychiatric conditions to third party agencies for health insurance claims. The TFC met in May, 1971, with various insurance agency representatives, including a committee of medical directors (Life Insurance Medical Directors of America, LIMDA) and the Health Insurance Council (HIC). As a result, a new reporting system was designed using a specific code aimed at fulfilling insurance agencies' needs while not revealing unnecessary information which could be misused or otherwise be damaging.

This new system of reporting was presented to the Council on Professions and Associations before being sent to all the District Branches in the U. S. and Canada for their examination and comment. Generally favorable and constructive suggestions were made, with the exception of a few that unrealistically advocated sending no information at all. Following discussion by the Council, the Reference Committee and the speaker of the Assembly of District Branches and representatives of the Health Insurance Council arrangements were made and are currently underway for an actual trial in the field. (A copy of the working code system is attached as Appendix B.)

Methods of Reporting to Insurance Companies. Much of the need for information by the industry is for the administration of the insurance contracts. Reimbursement of medical expenses and disability payments, etc. depend on the nature and detail of different insurance contracts. There may be certain exclusions, and the date of onset is also important. For instance, benefits usually are limited to

actual onset during the period of employment. Another factor is the need for certain detailed data for the insurance company's actuarial department in determining risk factors in setting future premiums, and for predicting how much money would be set aside for reserve for claim payments.

Basic information required. It is the opinion of the Task Force that insurance carriers could reasonably expect the provider (the treating psychiatrist, in this case) to supply the following information: 1. Recognition that a psychiatric condition does exist. (In place of diagnosis, the new proposed code system would be used.)

2. Approximate date that patient recognized symptoms and need for treatment, when asked "date of onset". (Note that Task Force is recommending that patients supply this, requiring review by the treating psychiatrist.)

3. Nature of treatment in general terms.

4. Billing which shows frequency, cost of treatment, and whether office, home, or hospital treatment, to support fees charged.

It was agreed by the insurance industry representatives that when they need additional information, the medical director of the insurance company would write specifically to the physician involved asking specific questions and giving the reasons for needing this additional information. The physician would not be in receipt of a form letter mailed by a clerk who has no knowledge of the problem. In addition, it was agreed that the reply to the letter would go directly to the medical director under his safeguarding of confidentiality.

Limiting information given to the employer. The common practice, particularly in employer-linked insurance coverage, of forwarding sensitive information to employers was faced. This has been one of the most embarrassing and sometimes destructive abuses of confidentiality that our Task Force faced. Misuse of this personal and, at times, compromising material could have deep impact on an individual's career, social, or personal life. Awareness of such a danger, has, in many instances, deterred individuals from seeking psychiatric help, even though this was a provision of the plan. This issue was extensively discussed in our May, 1971, workshop with the LIMDA, and, on a number of occasions with the HIC representatives. We met with the Medical Relations Committee of HIC in July, 1973, and this concern was reiterated. In our discussion with representatives of the Health Insurance Council, they agreed to seek methods of quarterly experience reports to employers that would omit any identifying data concerning the employee or employees involved in creating the expenses on the program. The industry indicates they are required to make such reports to employers to justify premium charges. They

were not able to justify having to supply the names of the employees involved. We had adamantly maintained a position that given all the arguments from the insurance industry, employers have no need for and should receive no data that can be identified with a specific known employee. The problem of employer administered programs was discussed. They are a major source of patient information reaching the employer. As a result of our discussions, the AMA and the insurance industry have published agreements to discourage and hopefully to eliminate such programs eventually.

Life insurance examinations limited to non-therapist physicians. The point was stressed with the insurance representatives that, if at all possible, examination and reporting for life insurance eligibility be done by a physician other than the treating psychiatrist. The insurance representatives could understand that such a request for information could jeopardize psychotherapeutic relationship.

Concern with storage of sensitive information within the industry itself. There has been considerable concern and question about insurance data banks, where allegedly confidential information is shared with other companies or organizations without patients' knowledge or consent. Although insurance industry representatives deny that this is a problem, documented cases have been received of instances of information being leaked accidentally or otherwise to patients and their relatives, of questionnaires requesting irrelevant information, and of use of the Retail Credit Bureau to investigate claims. Although HIC has given assurance that the RCB holds such information inviolate, complaints have been received that such investigations have included questioning neighbors about the nature of illness, thereby disclosing that the patient has been in treatment and even hospitalized. Some complaints also indicate that health care. data acquired for claim payment has been shared with other insurance companies for other purposes.

Local Programs. Particular attention needs to be paid to the local administration of specialized insurance operations, such as CHAMPUS, an insurance program for the dependents of service personnel. The Task Force has been concerned with limitations which need to be instituted regarding the information made available to central and clerical personnel and in one instance successfully intervened when a Blue Shield organization attempted to force compliance with a request to photocopy psychiatric records on CHAMPUS claims.

"Consent to Release Information" Statement.

Present forms are not informed consent. The Task Force has had great concern with the blanket release of sensitive information,