Guest blogger Jeffrey Segal, M.D., a board-certified neurosurgeon and the founder and president of Medical Justice Services, Inc., says a physician abuses the system—and his fellow doctors.
I think that one thing is not negotiable:You shouldn’t be allowed to work “both sides” at the same time for personal gain.
Introducing ethics into the debate seems obvious enough. But it isn’t.
As long as there has been managed care, there have been medical directors of managed care organizations (MCO). These are physicians who review confidential medical records and, among other things, make determinations of “medical necessity.” This includes determining whether to pay for specific procedures, and if so, how much.
When such records are reviewed, the physician who sends the information to the MCO assumes that the information will remain confidential, and it will be reviewed solely on its own merits.
Imagine the surprise when a physician learned that the Medical Director for one of the larger MCOs in the Northeast was wearing two hats.
By day, he was reviewing confidential charts, as expected.
By night, he was serving as a plaintiff’s expert witness to medical malpractice attorneys.
In this particular case, the same Medical Director who was deciding whether the provider’s patients would be covered for the procedures he performed was simultaneously serving as an expert witness against him.
This was not a mere sideline. It represented a substantial portion of the Medical Director’s income.
One of his depositions recorded the following:
Q. You indicated that in the last five years you have reviewed approximately 250 medical malpractice matters?
Q. And how many have involved health care providers in the state of XXX in the last five years?
A. Maybe 75 percent. You know, as a guess, once again, maybe 75 percent.
Q. Okay. So that would involve 180 to 190 XXX physician files you reviewed in the last five years dealing with medical malpractice matters.
A. If your math is correct I suppose yes.
Further, this Medical Director indicated that his superiors at the MCO were aware of his concurrent legal consulting.
On the one hand, this Medical Director reviewed charts for quality and utilization. Then, he profited by serving as an expert witness against many of the physicians who provide services for the MCO’s insureds. The provider physician was left to wonder whether the Medical Director abused his trust as the keeper of confidential information and passed such information to a plaintiff’s attorney. Whether this happened or not, it clearly created an environment of distrust and, at best, a perceived conflict of interest.
The North Carolina Medical Society recently adopted a Resolution detailing this conflict of interest. Since then, the American Medical Association has written to America’s Health Insurance Plans requesting that Directors for its plans not participate as experts in cases against their provider physicians. Of course, they can, if qualified, serve as experts in other cases.
Remember what we said about ethics? This Medical Director was so prolific because he professed expertise in standard of care matters in many specialties. Interestingly, he had not taken care of a real patient for at least five years. And, he admitted that he could not recall ever seeing one of the two diseases that were the source of the litigation.
Jeffrey Segal, M.D., is a board-certified neurosurgeon and the founder and president of Medical Justice Services, Inc., which offers proactive services designed to deter proponents of frivolous medical malpractice lawsuits.