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Who Is Actually Determining Our Patients' Care?

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I sit on the phone on a weekly, if not daily, basis spending time discussing with a “peer” assigned from the insurance company my patient’s planned care. I am trying to convince the other on the line that what I have planned is medically necessary. Much of my time is often spent educating the other physician about the condition, since it is rare that I have a specialist, and hardly ever a sub-specialist that is in the same field as I am. On the other end of the line, the response is predictable: reciting the insurance company’s criteria for the expected planned care, and how my patient doesn’t fit in the pre-ordained cogs.  

Lately, I have come to realize that the other physician on the line is actually determining the patient’s care. In other words, they have become an active participant in my patient’s care. In doing so, I believe that this other physician should be licensed to practice medicine in my state. That should probably be my first question when they call me: “Could you please give me your medical license number for the state of Texas?” If they do not have that, they are essentially practicing medicine without a medical license, and should be prosecuted, per my State’s law, for that offense.  

In addition, I believe that in determining the care that my patient receives, they should potentially be liable for malpractice proceedings, if any untoward outcome occurs due to the withholding of care as per their determination. This should bring up my second question for the physician on the other end of the line: “Could you please give me your full name and NPI number?” I believe these should be documented in the patient’s chart so that the “peer” can be held responsible if the patient has a bad outcome as a result of the “peer’s” decision with regards to the patient’s care.  

I am not someone who promotes malpractice proceedings against other physicians. Actually, my rule in seeing another patient who has had an unfortunate outcome at the hands of another surgeon is to always compliment something about the care from the other surgeon. It is self-serving for a surgeon to criticize the work of another – it doesn’t make the patient feel good if you criticize the care that they have received. A patient’s surgery is sort of like their baby – you can always find something nice to say about it. I wasn’t there at the time of the surgery, so I do not know what other circumstances were at play.

However, I am there when the “peer” on the other end of the line is participating in my patient’s care.  Let’s face it: I don’t think anyone in medical school graduates hoping to become a medical director for an insurance company. I may be wrong (and please correct me if I am), but in my experience, those who become reviewers for insurance companies are usually physicians who either could not find a residency or job in their chosen field, or those who have failed in practice.

So why are we letting our least experienced, failed physicians determine the care of our patients? By definition, we are now providing our patients the care of our least effectual colleagues. This disgusts me. We should make these individuals take responsibility for their decisions, even if it is under the guise of insurance criteria/guidelines. We, as physicians, need to take back control of our patients care, and not relinquish it to the insurers. The best way to do this is to have the insurers and their employees become liable for the decisions they render. The “peer” must be licensed in the state where the patient is receiving care. The “peer” must also be held responsible by being liable for any untoward results that the patient may encounter, as a result of the decision rendered by the “peer.” Let’s make this happen.

Richard C. Allen, MD, PhD, FACS is an Oculoplastic Surgeon in Houston, TX and a Professor in the Dept. of Ophthalmology at Baylor College of Medicine. He provides care for patients at Alkek Eye Center, Texas Children’s Hospital, MD Anderson Cancer Center, and Ben Taub General Hospital. The views expressed in the article do not necessarily reflect those of Baylor College of Medicine, Alkek Eye Center, Texas Children’s Hospital, MD Anderson Cancer Center, or Ben Taub General Hospital. Dr. Allen has no financial disclosure related to the subject of this article.

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