The doctor who wrote this article is bravely “speaking truth to power” by pointing out 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 addiction “experts”, and
- corporate employees in some remote office building
are allowed to decide what my medical treatment should be.
Dr. Dorio is also questioning this practice which interduces an obvious conflict of interest in determining a patient’s treatment.
In my case, they did not approve payment for many of the CDC-recommended alternative treatments, like acupuncture or Ayurvedic treatments. I truly believed acupuncture would help me, so I spent $1000 over three months before I had to admit the treatment was having no effect at all.
They did not approve payment for visits with a therapist specializing in pain because such experienced professionals charge more than recent graduates. I was so desperate for help beyond merely taking opioids that I paid for 18 months of pain psychology therapy myself.
If these so-called utilization reviews by insurance adjusters are NOT practicing medicine, then why are they allowed to make treatment decisions for me?
Practicing medicine means making medical decisions tailored to my specific symptoms, my individual physiology, and my unique responses.
Is it possible to “practice medicine” at the same time as you are “maximizing shareholder value”? Is it possible to ignore your employer’s financial incentives to “cut costs” by denying “excessively expensive” medical care?
These remote reviewers don’t know me and don’t care to.
They ignore the fact that I am a living, suffering, human being, they deny my existence as a unique individual, and merely use me as a statistic for financial gain.
My pain, my disability, my future – none of these concern them, but money does. As professional corporate employees, they must perform the duties of their position.
Their jobs depend on denying me the medical care I need.
Below is the article from Dr. Dorio:
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?
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.
Author: Gene Uzawa Dorio is an internal medicine physician who blogs at SCV Physician Report.