Legislators on Capitol Hill are under pressure to pass legislation to ensure the privacy of medical records. Our esteemed political leaders spout grandiose ideals while participating in the largest data collection effort in history. Who is fooling whom? There is no such thing as confidentiality anymore. The battle has already been lost.

The only real way federal legislation can protect patient privacy is to allow records to remain where they were collected. The only real way to ensure any confidentiality is to keep information to yourself. Each person who shares the knowledge poses a threat to privacy. Even children know this.

Psychiatrists are probably better versed than anyone else in the delicate balancing act of protecting patients’ privacy. In residency, I was reminded regularly that even the most casual references in seemingly benign circumstances can lead to damaging breaches.

After a few years this training becomes second nature and sometimes taken for granted. We need to appreciate, however, that once information leaves our offices, neither Washington nor third party payers are competent or even particularly committed to keeping it safe.

Unfortunately, because of the way the insurance system is set up, many psychiatrists have been channeled into compromising confidentiality. Because so many of us feel forced to provide sensitive patient information to payers to justify and be paid for our services, we have begun to underestimate the value of our training and instincts. We are being seduced into believing there is something wrong with keeping patients’ secrets, that it renders us suspicious in some way, that we are taking advantage of our patients’ vulnerabilities.

I contend that we take advantage by allowing access to patient information by anyone but the patient. If the patient does his or her own third-party billing, the therapist never needs to communicate with third-party payers.

I do no third-party billing for my patients. They understand up front that any information provided to third parties must flow through them. In this way, they know what information is requested and decide what they are willing to provide. They quickly discover the games their insurance company plays.

I make money and insurance issues a part of psychotherapy, using these as vehicles to discuss priority setting, accountability, and responsibility. I tell my patients that if they can make their insurance company accountable to them, they can make life accountable to them. I tell them I work for them—not for their insurer.

Because Medicare and Medicaid bureaucracies intrude so heavily on the therapeutic relationship, I have "opted out" of Medicare and do not take Medicaid patients. A few elderly patients have signed private contracts with me, because they appreciate the old-fashioned and individualized treatment I can provide.

In today’s climate my stance may seem extreme, yet it is an absurdly simple method of guaranteeing a patient’s privacy. It is based on a strong belief in the nobility of our profession and our commitment to maintaining appropriate boundaries to create a safe environment.

Psychiatrists have the task of working with and potentially healing human minds; I take this further and assert we have the opportunity to help our patients maximize their potential and develop strengths where they feel weak. This is not something I can justify to an insurer, but my patients can if they feel the therapy is helping them. By doing so, they are strengthened.

My refusal to communicate directly with insurance companies keeps my priorities clear. My practice is amazingly uncomplicated by irrelevant paperwork and phone calls, and I am able to spend my time doing what I was trained to do. My patients are empowered by the arrangement, and so am I. We are able to plan appropriate and highly individualized treatments together, without undue outside interference. My patients know they can trust me and that if I violate their confidence, they can fire me.

I realize not everyone is in a position to take this stance, but other psychiatrists can take steps to minimize third-party victimization of doctors and patients. They can review their managed care contracts and assess which ones are more trouble than they are worth. They can work only with insurers who allow patients to do their own billing. They can opt out of Medicare. There are probably many other small steps practitioners can take to reclaim the boundaries of the therapeutic relationship.

So I sit back and watch the confusion and the vacuous crowing in Washington about patient privacy and don’t buy any of it. Actions speak louder than words. If Washington wants to protect patient privacy, it will make it easier for patients to do their own billing, own their records, and say no to the bureaucratic voyeurs.

There is no real confidentiality anymore, not for the majority, and Washington’s attempt to legislate it is just more illusion. 

Dr. Otto is a private practitioner in Savannah, Ga.