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Opinion and Commentary from TMA

An Insurance Company Auditor Tried to Destroy My Career

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It’s no secret that in today’s health care market, insurance companies are calling the shots. As a pediatrician in private practice for almost two decades, I’ve seen insurance companies transform into perhaps the single most powerful player in today’s health care landscape – final arbiters whose decisions about which procedures or medications to authorize effectively end up determining the course of patient care.

Niran_Al-AgbaDecisions made by insurers, such as MassHealth, have arguably killed patients. But it was only when I got caught in the crosshairs of an insurance company auditor with a bone to pick that I fully appreciated their power to also destroy physicians’ careers.

My nightmare began around two years ago, when my late father, also a physician with whom I was in practice, and I opened our Silverdale clinic on a Saturday. It was the start of flu season, and we’d just received 100 doses of that year’s flu shot. Anxiety about the flu was running high following the death of a local girl from a particularly virulent strain of the virus a year before, and parents were eager to get their kids immunized as soon as possible.

Under Washington law, adults don’t even need to see their doctors to get flu shots. They can get them at Walgreens, directly from pharmacists. But because children under 9 are more susceptible to rare but life-threatening allergic reactions, they must be immunized by a physician. This meant that, for convenience sake, parents often scheduled their kids’ annual checkup on flu shot day, thus allowing them to condense much of their routine care into a single visit.

That particular Saturday went off without a hitch, with my father and I seeing and immunizing around 60 patients between the two of us over a 12-hour day.

Three months later, a representative from the insurance company requested to see some of the patient charts from that flu clinic as part of an audit. Aimed at rooting out insurance fraud by cross-checking doctors’ records, these audits have become a routine fixture in medical practices today. To incentivize their auditors to ferret out the greatest possible number of irregularities, and thus boost the corporate bottom line, auditors work on commission, being paid a percentage of the funds they recover.

The auditor in charge of my case failed to turn up any irregularities in our documentation. But, still, she issued a stern admonition to my father and me, ordering us not to open our clinic on Saturdays to administer flu shots.

This struck me as an outrageous restriction, considering our clinic is a private entity where we set our own hours and schedule accordingly, and so I called the auditor. But instead of backing down, she ratcheted up her rhetoric, saying she was also forbidding me from examining my patients before immunizing them; clearly a bid to save her employer even more money. I was shocked. Her directive amounted to practicing medicine without a medical license — which is, of course, illegal in the state of Washington and many other states across the nation.

I shot back that immunizing infants and small children is a serious undertaking, requiring proper caution and care, informed her there was no way I would be complying with her mandate. Following this brief exchange, she took it upon herself to report me to the Medical Quality Assurance Board, the government-backed body charged with shielding the public from unqualified or unfit doctors. The accusation levied against me? Not following an insurance company mandate, which, in her opinion, amounted to unprofessional conduct.

It didn’t matter that the charges against me were ludicrous. The potential consequences were only too real, and potentially catastrophic. Had the State Medical Board decided against me, I could have lost my license. I hired a lawyer, sinking more than $8,000 into legal fees. I was cleared by a unanimous committee vote. But other physicians facing similar situations may not be as lucky.

The 18 months of excruciating stress that followed my altercation with the auditor made it patently clear that insurance companies wield far too much power. Bureaucrats are making life-and-death medical decisions without a single minute of medical training, and their auditors are terrorizing physicians by coercing state medical boards to act as their henchman. Unfettered by any consequences for enforcing policies that fly in the face of rules protecting patient safety, insurance companies will continue to harm doctors and patients alike if no one can stop them.

Niran S. Al-Agba is a pediatrician in Sliverdale, Wash., who blogs at MommyDoc

Fix the Broken Windows of the Medical Profession

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  By Suneel Dhand, MD

This story was originally published on www.kevinmd.com and is reprinted with permission.

I am honored to be a member of the medical profession. Being a physician is a great job and a highly rewarding thing to do. One of the aspects that I like most, unlike so many other desk or number jobs, is that you can never go home in this line of work thinking that you haven’t done something good with your day (if you do, there’s something seriously wrong).

The everyday interactions with patients and families ― getting to know them and using one's skills to serve them — are not only deeply rewarding but also very humbling. It’s those positive interactions that sustain me, even on the worst days. I have zero regrets about becoming a physician, something that I’ve also written about previously.

Having said all of this, it’s no secret there’s an epidemic of physician burnout and job dissatisfaction out there. This is for a multitude of reasons, but everything ultimately boils down to a monumental loss of autonomy and independence among doctors, as there’s been a dramatic shift of power and clout away from individual physicians and toward administrators and the business side of health care. Somewhere along the journey, we have lost our direction completely. Unfortunately, in many ways, we have nobody but ourselves to blame collectively because for any large group of respected people to surrender so much autonomy so quickly, a lack of strong leadership must always be a factor.

I am a huge fan of the "broken windows" theory of getting a grip on a problem. In the 1980s and early 1990s, New York was a city in terminal decline. Growing up in England, I knew many people who came back from trips to America telling us about how terrible and dirty the city was. Times Square was basically a no-go area full of aggressive panhandlers. It was a dangerous and scary place. Enter Mayor Giuliani in 1994, and the city underwent a rapid transformation. I understand that some aspects of what Mayor Giuliani did were viewed by (some) as controversial, but not wanting to get into politics, the results were unquestionable. The broken windows theory of turning around New York City went something like this: Heavily target the minor offenses first. Zero tolerance for broken windows, graffiti, and other things such as “squeegee men” who would aggressively approach you when your car was at a red light. So the philosophy goes: Clamp down on the small infringements, and the bigger things will take care of themselves.

The results of this clampdown for New York City were indisputable. By the time I first visited America in 1998 ― New York City being my first stop on a countrywide tour with my family ― Manhattan had become one of the safest and most pleasant places in the country. There was a visible police presence on every street corner, and the city was immaculately clean. Whatever people say — drastic circumstances call for drastic actions. Even today, Manhattan is still one of the safest cities in America, and tourists from all over the world give glowing accounts of their stay in the Big Apple (in fact, low-level crime is actually much lower than in many European cities, including my home city of London). Thank you, Mayor Giuliani.

We all probably have our own personal experiences of how true the broken windows theory is and its everyday applicability. Teaching children good behavior is one such example, when not allowing major bad habits to flourish starts with forbidding the small things first. But let’s get back to health care. For positive change to occur, consider these seven broken windows for physicians:

1. Completely reject the word “provider.” I have written previously about the implications of the now universal use of the word “provider” and have also penned an open letter with the chief executive officer of the American Board of Physician Specialties, William Carbone, to all medical societies and organizations. The word really has taken over, especially evident during the last decade. I am equally shocked by how new residents are being churned out of some of the most prestigious academic centers in the country (my experiences are with the ones in Boston) and are adopting the word so casually, happily describing themselves as “providers” on correspondence, including their social media accounts. The business and marketing world really has done a number on us and has run rings around the medical profession. Unfortunately, physicians are also very naïve as a group in understanding the immense power of words and how not calling ourselves “doctors” or “physicians” anymore is extremely bad for our profession. I personally am okay with many other terms if a more encompassing one is required for certain correspondence, including “clinician” or “practitioner” — but "provider" is deliberately dehumanizing and, also in my view, an insult. If you refuse to use the word and call people out on it, they will stop calling you one. It should be removed from all administrative correspondence including information technology (IT) systems.

2. Insist on a good physician lounge in your hospital. It’s so much more than a physician lounge. It is a marker of professional respect and autonomy. This (very small) job perk has rapidly fallen away. I recently wrote an article on this, which went viral online, being shared more than 20,000 times. That’s because it struck a chord with thousands of physicians who have seen it happen. Lobby for its return in the hospital where you work, and encourage physicians to use it again in their downtime — even for brief meetings.

3. Stand your ground with administrators. As much as hundreds of thousands of employed physicians across the country have a fraught and tense relationship with their administrators. Let’s be realistic: Administrators are very much needed in any organizational structure, and health care desperately needs good ones. However, if you sense that any directive is coming through that will interfere with, or be detrimental to, frontline care, it’s crucial that you sensibly and, of course, diplomatically stand your ground. If you don’t stick up for good health care and your patients, nobody else will.

4. Fix electronic health records. Almost every current study of physician job satisfaction and career burnout lists the burden of cumbersome and clunky electronic medical records at or near the top of the list of everyday frustrations. It’s an issue that is almost invisible to bureaucrats and administrators, but no doctor went to medical school to spend the vast majority of his or her day filling out click boxes and typing out bloated notes for billing purposes. Most electronic medical record systems (I’ve worked with nearly all of them, and in my opinion they all suck) can be optimized in small ways to improve workflow and reduce the “click burden.” What it does require is relentless feedback to your hospital IT department to do so (remember, the main vendor has no motivation whatsoever to improve things because it has a monopoly once the system is installed). Electronic medical records are one of the only examples of technology where the end-user is not the “customer” (imagine how bad the iPhone would be if it worked like that). The companies sell to administrators, so it’s up to physicians to be as vocal as they can.

5. Keep other physician perks. Being a physician is one of the most intense and grueling jobs one can have. Practicing medicine is not for the faint-hearted. Yes, everyone in health care works hard — but no profession should be actively losing things. Are other useful perks like car parking, a nice office, or cleaning services being taken away from you? Well, they shouldn’t. What about the other useful workflow issues, such as the transcription service axed to save costs (now stuck with tremendous inefficiency, with what used to be a thorough, logical note dictated in five minutes now becoming a series of tick boxes, typed sentences, and incoherent computer-generated mishmash)? It may take multiple emails, phone calls, or face-to-face meetings, but you should insist on keeping job perks that a professional of your level of education and intelligence deserves. If the executives in your hospitals have reserved parking spots and secretaries to make their lives easier, there is no way that the physicians should not!

6. Collegiality. No profession is anything without collegiality. It’s one of the reasons why the physician lounge issue is so important. Doctors need to see themselves again as a unified profession — not one that is fragmented where everyone is in their own little corner specialty. Get to know as many specialists as you can, organize social events where all physicians can mingle, and talk to each other about how you can get things done. Along the same lines, the link between primary care and hospital-based specialists has been breached by the fact that primary doctors no longer come to the hospital (even as a hospital medicine doctor myself, I see immense drawbacks to this). We need to restore communication among all physicians, especially primary care physicians.

7. Professional respect. I am all for respecting everyone I work with, and health care is a team-based effort. But when it comes to a clinical situation, the physician is the leader of the team. Period. However, there are lots of ways in which I’ve noticed physicians nowadays being treated much more as “coworkers” rather than as the team leaders they are (and to be fair, physicians also need to step up to the mark). One such example I’ve noticed is that many colleagues in the hospital now immediately address doctors by their first name instead of “doctor.” Now, I’m not someone who minds being called by my first name, and thankfully most people ask first — but I just find it inappropriate when someone in the hospital, who may actually be much younger than me (frequently also including administrators), walks up and calls me off the bat by my first name. Interestingly, I have heard feedback that this actually tends to happen much more to female than male doctors. Every physician has earned the title and deserves to be addressed as such initially in the professional setting. Again, this is not to sound haughty — but most doctors will find anything else a bit uncomfortable and not protocol. The same applies to certain other professionals — university professor, airline pilot, or even military personnel — titles are the norm of introduction until told otherwise.

These are just seven of many relatively low-hanging fruit scenarios in which physicians can, on a daily basis, work toward making sure they retain their professional status. Most of them are free or with minimal associated cost. Remember, we are an ancient and noble profession, and being a doctor is very special. It’s a privilege to use our education and skills to help people get better each and every day. If you want to advocate for the medical profession, deal with low-level stuff, and the rest will start to take care of itself. Of course, there are undoubtedly much bigger things than the seemingly small things noted above: reimbursements, overwhelming bureaucracy, and information technology, to name just a few. They will all have their time and place to be dealt with. But, doctor, start fixing those broken windows first.

Suneel Dhand is an internal medicine physician and author. He is the founder of DocSpeak Communications and cofounder of DocsDox. He blogs at his self-titled site, Suneel Dhand.

Photo Credit: Wikipedia