Case History #1

Bill is a 41-year-old African-American man who has applied for admission to an inpatient alcohol treatment facility. Bill’s history of substance abuse goes back 20 years but includes several years of sobriety and active participation in Alcoholics Anonymous. He is in a committed relationship with Harold (36), his partner of 5 years. Bill’s wife died of a drug overdose 3 years ago, and he has custody of his two young children, Melissa (6) and Philip (4). The children live with Bill and Harold in their rented townhouse. Bill’s late wife’s parents have never accepted him and have always blamed Bill for their daughter’s drug problems.

Bill has been teaching seventh grade English for the past 10 years. Only a very few colleagues in the school system know about his sexual orientation and his relationship with Harold. Bill was referred to the treatment facility by the school district’s Employee Assistance Program (EAP); his employer-provided Health Maintenance Organization (HMO)-based health insurance will cover his treatment. He must satisfactorily complete treatment to retain his job. Bill has signed a form consenting to disclosures about his progress in treatment to the district’s EAP.

What legal issues does this case present?

1) Disclosures of treatment information to the district’s EAP: Bill should sign a consent form that complies with 42 CFR Part 2 so that the facility can release information to the district’s EAP about his progress in treatment. The consent form should be limited to disclosure of general assessments of Bill’s progress in treatment. Giving the EAP detailed treatment information would not be appropriate and should not be authorized by the consent form Bill signs. There should be no disclosure of any information about Bill’s sexual orientation or his living arrangements. Public school systems are generally reluctant to employ an openly LGBT person. Disclosure of this information could result in Bill’s losing his job (and his health insurance). Bill should sign a consent form that gives him the option of permitting or prohibiting disclosure of this information (see exhibit 3–1).

2) Disclosures of treatment information to the district’s HMO: The HMO will require information about Bill’s need for treatment in order to make a decision about covering that treatment. It will also demand that the facility update the information periodically. Bill must sign a consent form to permit the program to disclose information to the HMO. Disclosures to the HMO should be as limited as possible, but this may prove difficult. Many managed care organizations require programs to submit detailed information periodically before they will authorize continued treatment (or benefits). Bill has every reason to be concerned that his admission to treatment may trigger a flow of information that might, through school reviews of personnel or HMO records, result in his losing his job. The Federal rules prohibit HMOs from redisclosing information to the district, but there is no assurance that the HMO will refrain from doing so. Therefore, and although this can be difficult, there should be no disclosure of any information to the HMO about Bill’s sexual orientation or his living arrangements. Bill should sign a consent form that gives him the option of permitting or prohibiting disclosure of this information (see exhibit 3–1).

3) Disclosure of information about Bill’s sexual orientation to his in-laws: Disclosure could spark an attempt to challenge Bill’s custody of his children. In many States, the combination of Bill’s sexual orientation and his history of alcohol abuse could be used by relatives to try to wrest custody from him. If Bill’s in-laws do file a court case seeking custody and their attorney issues a subpoena for Bill’s treatment records, the program can, working with Bill’s attorney, ask the court to issue an order restricting the scope of the information the program will be required to provide. For detailed information on dealing with subpoenas and court orders, see Treatment Improvement Protocol 24 A Guide to Substance Abuse Treatment for Primary Care Clinicians (CSAT, 1997a), available from SAMHSA’s NCADI at 800–729–6686.

What policy issue does this case present?

How will Harold be listed on the intake form: as “spouse” and/or next of kin? Facilities may set their own individual policy about how they treat life partners. At the very least, programs should allow clients to sign a consent form specifying whom the program can call in emergencies.