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2. Definition of Disease Management (from DMAA.org) . Disease Management is a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant . Disease management:supports the physician or practitioner/patient rel
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1. Disease Management and the HIPAA Privacy Rule
Bradley J. Trudell
WPS Health Insurance
2. 2 Definition of Disease Management (from DMAA.org) Disease Management is a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant . Disease management:
supports the physician or practitioner/patient relationship and plan of care,
emphasizes prevention of exacerbations and complications utilizing evidence-based
practice guidelines and patient empowerment strategies, and
evaluates clinical, humanistic, and economic outcomes on an going basis with the goal of improving overall health.
3. 3 Disease Management Components include: Population Identification processes
Evidence-based practice guidelines
Collaborative practice models to include physician and support-service providers
Patient self-management education (may include primary prevention, behavior modification programs, and compliance/surveillance)
Process and outcomes measurement, evaluation, and management
Routine reporting/feedback loop (may include communication with patient, physician, health plan and ancillary providers, and practice profiling)
Full Service Disease Management Programs must include all 6 components. Programs consisting of fewer components are Disease Management Support Services.
4. 4 Disease Management (DM) is an approach to patient care that seeks to limit preventable events by maximizing patient adherence to prescribed treatments and to health-promoting behaviors. For patients with chronic diseases, the anticipated benefits of DM include:
Superior clinical outcomes
Improved functional capacity and quality of life
Lower health care costs
Reduced need for hospitalization, surgery, or other invasive care
Greater access to care support service
5. 5 The Disease Management Dilemma HIPAAs authors struggled to categorize DM
The dilemma: How to not undercut the benefits of DM reining in the high costs of chronic diseases and improving treatment outcomes by requiring DM companies to obtain patient authorizations
Why? Authorizations would impede DM, since protected health information (PHI) must be received in advance to ID patients who should participate
But under the HIPAA Privacy Rule, DM companies are not providers, so they do not have unfettered access to PHI for treatment, payment, and health care operations
6. 6 DM and the Proposed HIPAA Privacy Rule Under originally proposed rule, DM companies were considered providers and would have had easy access to PHI
DM was included under definition of treatment
But HHS scrapped this approach because DM industry is relatively new
Due to lack of a widely accepted definition of DM, HHS didnt want to create an exception to use and disclosure of PHI w/o patient authorization that could be used by anyone calling themselves DM, including marketers and drug companies
7. 7 DM and the Final HIPAA Privacy Rule Under the Final Privacy Rule, DM is taken out of definition of treatment and isnt mentioned at all in Rule itself
Instead, Rule specifically lists many DM activities under the treatment and health care operations exceptions
Rules Preamble says virtually all DM activities should be protected from authorization requirement under either the treatment or health care operations exceptions
Important victory for DM, because requiring DM companies to get opt-in authorizations would have killed the industry
8. 8 DM and the Final HIPAA Privacy Rule Treatment: DM activities focused on a specific individual fall within treatment, even though DM is no longer mentioned in the treatment definition, and include
Nurse chat
Patient self-management coaching
Drug compliance reminders
Other activities that engage the patient in direct health care improvement
Concern: Under the Rule, its unclear if health plans can use this treatment exception to use internally, or provide PHI to DM organizations, which are business associates of health plans. HHS must clarify.
9. 9 DM and the Final HIPAA Privacy Rule Health Care Operations: DM activities that are population-based fall under health care operations and include
Quality assessment and improvement, including outcomes evaluation and development of clinical guidelines
Population-based activities related to improving health or reducing health care costs
Protocol development
Case management and care coordination
Contacting providers and patients with information on treatment alternatives
Related functions that do not include treatment
Health plans may use internally,or disclose PHI for these activities to DM organizations as their business associates.
10. 10 DM and the Modified Final HIPAA Privacy Rule Aug. 14, 2002 modifications to Privacy Rule clarify that communications regarding DM will generally NOT be considered Marketing
Marketing means to make a communication about a product or service that encouraged recipients of the communication to purchase or use the product or service
Modifications state that care coordination and case management -- core services of DM -- are not Marketing
This distinction will help DM programs, which do not push any particular drug, treatment, or medical equipment, to maintain their credibility
11. 11 Questions/Discussion