Thursday, October 25, 2012

Biased Medical Board Members

The first phase of a lawsuit by physician organization AAPS against the Texas Medical Board ended earlier this month, proving that state medical boards can no longer operate with impunity, not just in my state (Doctor Bites Medical Board), but perhaps nation wide. Conflict of interest and other ethical transgressions among board members may be among the issues raised in the Texas litigation, so I read with interest the description in a recent email about Robert Small, MD, a "Pro-Tem (ad hoc)" psychiatrist member of the Washington Medical Quality Assurance Commission (MQAC) who also reportedly acts as "Behavioral Health Medical Director for health plans administered by Premera Blue Cross and LifeWise Health Plans... [and] Behavioral Health Medical Director for the CHAMPUS/TRICARE program for Washington, Oregon, Northern Idaho and Alaska."

First, even though Dr. Small, as an ad hoc member, may only fill in as needed, I wonder how a physician member of MQAC can represent the viewpoint of and knowledgeably judge the conduct of other physicians without practicing full time. It might reassure me that I do find Dr. Small listed in the usual rating Web sites, but I wonder how much time his insurance company duties leave him for clinical work.

If Dr. Small were acting as an expert witness in, say, a malpractice trial, opposing counsel could easily cross examine him to establish possible bias. But as a voting member of the board I am not sure a defending physician can raise such questions. Besides, given that all physicians either contract with companies like those for which Dr. Small works (or their competitors), or not, I argue that these other relationships always imply potential bias or prejudice, or at least the appearance thereof. Such a board member might, for example, want to minimize evidence against a physician who contracts with one of his companies, or exaggerate that against one who contracts with a competing company, or one, like myself, who contracts with no one other than my patients.

And how would Dr. Small maintain freedom from bias and prejudice in a case involving a subscriber to one of these plans he represents?

I question the ethics of a physician contracting with health plans in general (at least depending on the contract terms), so I believe physician members of MQAC should have no such relationships to skew their decisions. Dr. Small and any other physicians similarly encumbered should resign from medical boards now to be replaced with physicians in full time private practice with no conflicting relationships to payers, perhaps even to their employers. (I may address the question of whether employed physicians are really professionals who should be licensed and sanctioned by medical boards in a later post.)

Thursday, October 18, 2012

PECing Order

Would you know what "PEC Questionnaire" means? I did not. Only in the second (of three) reminder letter did I see the words "pre-existing condition" and realize what this insurance company wanted: an excuse to deny or restrict benefits for an illness their subscriber might already have. Understandably, no insurer wants to take new subscribers who waited until they got sick to purchase insurance. Obamacare seems to promise to solve this problem by making everyone pay. We will see.

Let us look at the questions posed. The first seems reasonable enough, except that the insurer could find all that information in the medical record. (Although I do not provide coding services. Let them look up ICD-9 codes on their own dime.)

I have a problem with question 2. How can I know what prescription medications the patient "was using?" I know what I prescribed, but the insurance company (insco) could ask their subscriber what they used. Ah, but perhaps the insco does not trust the subscriber!

Question 3 crosses the line. Now the insco really seems to want to use me as a detective, and not only do they expect me to name names (which they could also obtain from their subscriber), but they want me to save them the trouble of looking up addresses of the physicians I list.

I appreciate the need to keep premiums low, especially for Regence which is my insco! (Is there a conflict of interest here?) But trust your subscribers and do not try to use me the physician as a snitch. Do you wonder what physicians do with their time? Inscos should work toward accessing this kind of information electronically via the electronic health record (EHR) and leave us docs out of this loop so we can spend time with patients.

Incidentally, Regence never pays me a penny on any claim, so providing this information would not have led to any reimbursement for my patient.

Thursday, October 11, 2012

Prescription Monitoring Programs: Improvements Needed

When I woke up this morning mulling over a complicated case a significant fact occurred to me: When I had first used my state's online prescription monitoring program (PMP) I discovered that two other prescribers had ordered benzodiazepines for this patient with addiction problems without contacting me. I confronted the patient and the prescribers, all of whom agreed to shape up, but now I realize that I have not checked this particular patient's record in a few months, and with the patient facing increasing medical challenges I plan to access the database today.

But I should not have to.

I have written about this program's limitations before here and here, but the problem I have encountered in the case above begs for another technologically easy solution. To state the problem in general terms, busy physicians will never check the PMP often enough to catch everyone's transgressions. It takes too much time. How often must we do this? Monthly? Weekly? Daily?

Two solutions occur to me. First, instead of requiring me to check patients one by one, entering name and birth date each time, the program should allow me to build a list of patients of interest. Every time I access the PMP it would generate a list of all such patients and any prescriptions filled since I last accessed the records. Better yet I could opt for email or text notification for each new prescription, or my electronic health record might alert me. The program could also allow me to opt out of notifications for prescriptions I deem appropriate.

Come to think of it I need to check the PMP for a new patient I examined yesterday. While I'm at it I will check the patient above:

New patient: Negative! I did not use the exclamation point just because the report showed no controlled substance prescriptions, but because this is the first time ever that the PMP actually confirmed finding that patient even though no prescriptions showed up. Maybe they fixed one of those problems I wrote about before! (Or maybe in all prior cases I entered the wrong name or birth date, but let me think positively.)

Complicated patient: No inappropriate prescriptions.

Total time: about 8 minutes, almost enough time to do one of those 15 minute med checks. ;) Imagine how much time it would take to check every patient in a busy practice.

Thursday, October 4, 2012

Physician Heal Thyself

Ask ten health care professionals to describe the statutory threshold for reporting professional impairment or misconduct in their state, and you will get ten different answers. In some states you must report across professional lines, that is, a psychologist, for example, must report an impaired physician.

Until a few weeks ago I assumed I must only report a professional I suspected might pose a danger to patients, but when I called the state physician health program on an unrelated matter I inquired, and the medical director disabused me of that notion. I made a quick call to my professional liability carrier for advice about a physician I had examined a few years ago who did not return and I did not report. The risk management consultant advised me not to report.

A few days ago someone left a message on my voice mail identifying themselves as Dr. ________. Not wanting to put myself or the "doctor" in a bind it occurred to me that I should warn that I might have a duty to report to the health program or the licensing board if I heard evidence of impairment. After all I try to warn all patients of other limitations of confidentiality. The doctor indicated willingness to take chance it, but I had to refer elsewhere when the doctor admitted to having Medicare. You might ask whether I should still report, but all I have at this point is a phone number, and for all I know he could be a "doctor" of divinity rather than a physician. I will not play detective.

What were the legislators thinking when they passed such laws? Did it never occur to them that the law of unintended consequences might intervene? How many physicians, knowing the duty of a treater to report them, eschew getting help and with what consequences?

Workarounds occur to me. One might seek help from a professional licensed in another state, paying cash to avoid a data trail. One might purchase medication out of state as well. Telephones and the Internet could facilitate both.

A physician who fears the consequences might indeed try to "heal thyself" rather than seeking help. Is that what we want?