Making Medical Decisions Without Accountability

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.

15 Comments

  • This is a good tip particularly to thopse new to thee blogosphere.
    Brief but very accurate information… Many
    thanks for sharing this one. A must read post!

  • Hosting says:

    Fosfomycin costs $300, and insurance wouldn t cover it. The family was angry at me. I told them they can take the medication, or we can admit her which will subject her to more nosocomial infections and be far more costly. Therein is a classic case of insurance companies making financial decisions but holding the doctors accountable.

  • Zyp Czyk says:

    I thank you, Dr. Dorio, for “speaking truth to power” by spotlighting the current practice of allowing businesses with conflicting financial interests to determine patients’ medical treatment.

    I have long wondered why insurance companies, government agencies, various legislators, self-proclaimed “experts”, and corporate employees in some remote office building are allowed to decide what my medical treatment should be.

    I see this as a prioritization of corporate profits over medical ethics and of inappropriate cost-cutting. For the sake of corporate – not medical – efficiency, impersonal standardization is taking the place of a doctor’s individualized appraisal and guidance of patients.

    These remote “utilization reviewers” don’t know me and don’t want to because their jobs depend on denying me the care I need.

  • Gene says:

    In response to Kiza

    Always ask your doctor why the medical request was denied. Usually, they won’t have an answer. (Keep notes on a yellow legal pad whether you are face-to-face or on the phone.)

    Tell your doctor (or nurse, NP, or PA) you want them to find out: The name of the denying doctor; if they are licensed in California; what their medical license number is; and what is their specialty. If they won’t do this for you, get this same information from your doctor as they are not being your advocate and their acceptance of this denial you construe as substandard care from them also.

    Advise them you want the denying doctors name placed on your Medical Record, and you will be contacting the CA Medical Board to lodge a complaint.

    If the denial came from inside a medical group, like an HMO, your doctor for sure will be very reluctant to do any of this. You must persist and use all recourse to appeal the denial decision, and continue to get names of those doctors (or nurses) involved in the case.

    You must be persistent and assertive in your care, or for the care of your loved one.

    Complaints against California denying doctors can be made to the Medical Board:

    http://www.mbc.ca.gov/Consumers/Complaints/

    As I mentioned in my posting, the Board may call it “utilization.” Don’t give up! We must convince the Medical Board they are the ultimate protectors of our patient care.

    Gene

  • Kiza Hilton says:

    From: Kiza Hilton
    To: Gene Dorio
    Sent: Sun, Feb 5, 2017 1:15 pm
    Subject: Re: Making Medical Decisions Without Accountability

    What should people do when this happens? Should they write to the California State Medical Board? There must be some way to respond to substandard medical care?

    Thank you for your response.

  • Thank you Dr. Dorio. While not all utilization review (UR) doctors are bad apples, I have had reasonable treatments denied by UR doctors to the detriment of my patients.
    Usually we can overturn the denials but not without months of appeals and paper work. These doctors who have never seen the patient and deny the medical care to our patients need to be held accountable for their medical decisions (denial of care to a patient). They need to be held to the same medical standards as the treating doctors. That is the only way we can improve the care to our patients and stop the unnecessary UR denials. The law needs to change.

  • Hooman M. Melamed says:

    Thank you Dr. Dorio. As a spine surgeon I always found this UR so ridiculous and below standard of care. Most of the physicians are not spine surgeons and they give their opinion on a topic that he/she is not an expert. It is absolutely outrageous for them to be getting away w/ this. They absolutely don’t care about pt care rather their own pockets. In my experience these doctors are so horrible and desperate that they need to be hired by the insurance company as they won’t survive in private practice. This is definitely a problem that these insurance companies must be held accountable.

  • Start your own website to expose this fraud.; send your web site’s address to every intern and resident and medical student in our country.

    I’ll help you.

    H

  • Judy penman says:

    Dr Dorio Thank you for your comments you are right on. If it is not medically necessary the HMO in particular will deny anything. How can the regular sick people survive without an advocate, a family member and medicare consultant HICAP specialist. The HMO INDUSTRY IS THE WORST AND IT IS SINGLE PAYER and the government has the control. Too many patients are being sent home to die or have their family take care of them improperly just because they don’t want to pay.

  • Gene says:

    In response to Robbin Day

    Typically, doctors practice under the “standard of care” of their community and state. When they seek further care through testing, procedures, or medication, that is where they must go “Peer to Peer” and their standard abuts against the profit wall of the insurance company, Workers’ Comp, or HMOs.

    HMO doctors are constantly scrutinized by their group using statistics showing whether they are profitable to their organization. When they are not, their contract is not renewed. Within their organization, there is constant monitoring of the medical care they provide, and it must reflect the profit-motive of the organization.

    When the patient costs too much money, medical care is truncated especially in a hospital setting when specialists are not consulted, patients are quickly discharged to a nursing home, or they are placed on end-of-life hospice care (because the HMO doesn’t want to spend the money in situations when survival is possible). This happens far too often with HMO patients.

    Profit.

    Gene

  • Gene says:

    In response to anonymous

    Pass this posting forward. Bring it to the attention of any friends you might have in the media. There are hundreds of thousands of patient stories who have been ripped off by physicians who are contracted by insurance companies, Workers’ Comp, and HMOs not being held accountable.

    Ask your state legislators to look into oversight agencies (like Medical Boards) misinterpreting laws in favor of these companies.

    These doctors (and PAs, NPs, and nurses) making these profit-motive decisions must be held accountable.

    Gene

  • Dr. Dorio, In my opinion physicians should have NO contracts with any 3rd parties. To me the only contracts physicians should have is with their patients. In this way physicians devote themselves solely with their patients best interest.
    If many thousands of physicians adopted this concept the 3rd parties would have to adapt. A system like this would thrive with expanded health savings accounts that could also fund direct care contracts and a high deductible insurance plan.

  • robbin day says:

    What is the protocol in “asking” a doctor or health professional if he/she is practicing under health insurance company guidelines?

  • Thank you Doctor Dorio, I totally agree with this write up. The Utilization Review is such a bogus idea and they should be held accountable for patent decline or health problems most times. I was recently in this situation after a fall and it took 1.5 years to finally approve me for the much needed surgery. Not only did I live through excruciating pain, more damage was done to me and my healing which usually takes a few weeks to couple months took a year, and still; I’m living with pain!! It’s high time something was done about this. If doctors are qualified to make evidence based decisions for patients, I don’t believe that some doctor sitting down thousands of miles away reading a progress note without any physical contact with the patient should determine their care.

  • Anonymous says:

    Thank you. I did not realize this until recently during discussion in the doctor’s lounge. How do you inform the public?

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