MACPAC Discusses Substance Abuse Disorder Confidentiality and Care Integration in Medicaid and CHIP

The Medicaid and CHIP Payment and Access Commission (MACPAC) recently released their June 2018 Report to Congress on Medicaid and CHIP. The report not only includes analysis from the Commission, but also outlines several recommendations for Congress on four broad topics: (1) ensuring more accurate drug rebates; (2) reforming communication among health care providers under Part 2 regulations; (3) continuing to monitor managed long-term services and supports (MLTSS) in state Medicaid programs; and (4) further analysis on the IMD exclusion and opioid care.

In Chapter 2, the first of two June chapters on barriers to substance use disorder (SUD) treatment, the Commission makes two recommendations to support information exchange among health care providers under the federal SUD confidentiality regulations known as “Part 2.” People with SUDs often have serious comorbidities, such as other behavioral health disorders, cardiovascular disease, cancer, hepatitis C, and HIV. Yet federal law and regulations on confidentiality of SUD-related patient records, “Part 2,” can act as a barrier to integrated care.

Part 2 has been criticized as confusing, restrictive, and challenging to implement; according to the Commission, additional guidance, education, and technical assistance to clarify these regulations would be a meaningful step to help providers, payers, and patients understand their legal rights and obligations and opportunities for information sharing that would facilitate integration of care.

In this section from MACPAC, Commissioners and the final report together draw on a review of publicly available information and the views of participants in an expert roundtable that MACPAC convened in November 2017.

Recommendations to Congress

The Commission makes two recommendations to clarify Part 2 to help address this barrier to integrated care:

• The Secretary of Health and Human Services should direct relevant agencies to issue joint subregulatory guidance that addresses Medicaid and CHIP provider and plan needs for clarification of key 42 CFR Part 2 provisions.
• The Secretary should direct a coordinated effort by relevant agencies to provide education and technical assistance on 42 CFR Part 2. Such efforts should target state Medicaid and CHIP programs, health plans, primary care and specialty providers, patients and their families, and other relevant stakeholders.

Key Points

While the chapter provides a more detailed look at the totality of the situation, below are some of the key points made throughout the chapter, leading to the Commission’s recommendations to Congress.

• Disclosure of medical information about substance use disorders (SUDs) can expose individuals to harm, such as criminal prosecution and loss of employment or child custody. Such disclosures risk discouraging individuals from seeking treatment for their SUDs.
• Requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, P.L. 104-191) that govern privacy of most other patient health information are generally less stringent, permitting providers and plans to share information for payment, treatment, and health care operations purposes without patient consent.
• Some stakeholders call for closer alignment of Part 2 with HIPAA. Others suggest that more should be done to improve stakeholder understanding of Part 2 and to develop tools to facilitate consent and disclosure processes.

The Commission also noted that at this time, it does not recommend alignment of Part 2 and HIPAA, but it intends to explore this issue in the future.