A pediatrician decides a struggling teen with mental illness needs hospitalization to neutralize psychologic demons impacting their personal and social life.
A Workers’ Compensation doctor requests a neck MRI in a powerline worker with growing right arm numbness and weakness to search for potential paralyzing nerve impingement.
An orthopedist orders special testing to determine if an elder patient with right hip pain which limits walking and driving might need surgery to improve their quality of life.
Physicians are rigorously trained to make decisions in the best interest of their patients. Even after medical school and residency, doctors must follow the challenges of evidence-based medicine, standard of care, peer review, and muster the time for “continuing medical education” and certification.
Doctors are not only held accountable by their peers, but also legally as they could be subject to lawsuits. Additionally, state licensing agencies overseeing medical professionals can discipline them should they not practice medicine up to the standards of quality medical decision-making.
However, what if the teen’s pediatrician feels hospitalization is acutely needed for mental illness, but it is denied by the insurance company? What if the Workers’ Comp physician orders an MRI for the powerline worker’s ailing right arm, but it is denied? Or, if special testing to evaluate grandma’s worsening mobility and pain is turned down by the HMO? Who is held accountable?
To justify requests for specific patient care, physicians are forced to have “Peer-to-Peer” phone discussions with doctors employed by insurance companies, Workers’ Comp, and HMOs. Frequently, these conversations result in denial of further care without medical justification. A controversial question arises: Are denials by these company doctors considered a medical decision?
They are not. These decisions are considered “utilization review.” What does this mean? They are making decisions based on controlling costs, which is in the financial interest of the for-profit agencies they serve, but not necessarily in the best interest of the patient. Even though they are licensed doctors practicing medicine, their role in patient care is under the guise of “utilization review”, and therefore not under the scrutiny of state licensing agencies.
What if these physicians deny care because they are incentivized to enhance personal bonuses? More so, what if some are making decisions outside the realm of their medical expertise (e.g. a urologist on a diabetic)? Who holds these physicians accountable for moral transgressions, or lack of judgement?
In California, we have a Medical Board which oversees licensing for all state physicians. If you report a licensed physician for making substandard medical decisions, an investigation ensues. If though the doctor is employed by an insurance company, Workers’ Comp, or HMO and makes denial decisions on their behalf, it is considered “utilization review” and they are not held accountable.
I do not pretend to understand every law and rule governing the Medical Board. But these companies have created legal barriers protecting doctors who might make substandard medical decisions.
Many physicians continue to fight for patient care rights despite frustration and helplessness of ongoing phone calls and paperwork they face. Yet substandard medical care will hamper their efforts as laws are manipulated and oversight is negligible.
Making medical decisions has never been easy. Assuring accountability makes it even harder.
Gene Uzawa Dorio, M.D.