Marianne Laouri

Director of Quality Measurement and Research

PacifiCare Health Systems Remarks

My name is Marianne Laouri, and I am Director of Quality Measurement and Research at PacifiCare Health Systems, a network model managed care organization operating health plans in 13 states and Guam, with a membership of more than 4 million lives, including nearly one million Medicare beneficiaries.

I appreciate the opportunity to participate in today's hearing. My comments will focus on the issues of confidentiality and privacy of individual level data. Safeguarding of member enrollment, demographic and medical care related information is of great importance to PacifiCare. PacifiCare supports this Committees' efforts to protect against the unauthorized and inappropriate use of individually identifiable information while promoting efficiency and security of the health information infrastructure.

PacifiCare's efforts to ensure security and confidentiality of member information include:

• Requiring that employees sign a Confidentiality agreement;
• Enforcing a policy that addresses the consequences of improper use of confidential information;
• Allowing access to member and provider level information (demographic and clinical) only to individuals whose job responsibilities require that they use confidential information;
• Maintaining information system controls including warnings on front log-on screens, unique log-on identifiers and passwords, and electronic audit trails.

PacifiCare also enforces the above confidentiality rules with contract employees, consultants and academic collaborators who require access to confidential information.

It is important to bear in mind that managed care organizations, such as PacifiCare, use individually identifiable information for a variety of their core business processes, such as

• utilization review,
• appeals and grievances,
• quality management and improvement, and internal research
• payment of claims

In addition, health plans use individually identifiable data to prepare reports to respond to requests for information from the federal government, state agencies and regulatory bodies, accrediting organizations and employers and purchasers. Examples of such reports include:

• reports on claims payment and processing,
• description of the appeals and grievance process,
• health plan performance data as specified in the Health Employer Data Information Set (i.e., HEDIS), and
• clinical performance measures for individual with certain medical conditions (e.g., diabetes measures from the Foundation for Accountability).

These reports do not contain individual specific information.

Individually identifiable information plays a crucial role in a managed care organization's ability to carry out quality measurement and improvement activities including:

• data collection and analysis both to identify clinical areas or providers needing improvement and to identify the most effective and successful medical management strategies;
• measurement of quality as specified in a nationally accepted clinical practice guideline that the managed care organization adopts and disseminates among its members and providers;
• investigate of individual cases for the purpose of care management; and
• analyses of underuse and overuse to assure appropriate care is delivered to the plan members.

Access to and use of individually identifiable information is critical for trend analysis, care management, provider and member education, as well as for preparation of reports which enable purchasers and consumers to evaluate health plans.

Therefore, PacifiCare encourages this Committee to continue its efforts on promoting efficiency and security of the health information infrastructure. Such efforts will allow managed care organizations and other legitimate users of individually identifiable information to maintain access to this information while safeguarding privacy and confidentiality.

PacifiCare will be happy to provide the Committee with any additional information on the internal security measures and on the uses of individually identifiable data.