P. Rucker, D. Armstrong, & D. Burke
Propublica.org
Originally published 15 Dec 23
Here is an excerpt:
Patients and the doctors who treat them don’t get to pick which medical director reviews their case. An anesthesiologist working for an insurer can overrule a patient’s oncologist. In other cases, the medical director might be a doctor like Kasemsap who has left clinical practice after multiple accusations of negligence.
As part of a yearlong series about how health plans refuse to pay for care, ProPublica and The Capitol Forum set out to examine who insurers picked for such important jobs.
Reporters could not find any comprehensive database of doctors working for insurance companies or any public listings by the insurers who employ them. Many health plans also farm out medical reviews to other companies that employ their own doctors. ProPublica and The Capitol Forum identified medical directors through regulatory filings, LinkedIn profiles, lawsuits and interviews with insurance industry insiders. Reporters then checked those names against malpractice databases, state licensing board actions and court filings in 17 states.
Among the findings: The Capitol Forum and ProPublica identified 12 insurance company doctors with either a history of multiple malpractice payments, a single payment in excess of $1 million or a disciplinary action by a state medical board.
One medical director settled malpractice cases with 11 patients, some of whom alleged he bungled their urology surgeries and left them incontinent. Another was reprimanded by a state medical board for behavior that it found to be deceptive and dishonest. A third settled a malpractice case for $1.8 million after failing to identify cancerous cells on a pathology slide, which delayed a diagnosis for a 27-year-old mother of two, who died less than a year after her cancer was finally discovered.
None of this would have been easily visible to patients seeking approvals for care or payment from insurers who relied on these medical directors.
The ethical implications in this article are staggering. Here are some quick points:
Conflicted Care: In a concerning trend, some US insurers are employing doctors with past malpractice settlements to assess whether patients deserve coverage for recommended treatments. So, do these still licensed reviewers actually understand best practices?
Financial Bias: Critics fear these doctors, having faced financial repercussions for past care decisions, might prioritize minimizing payouts over patient needs, potentially leading to denied claims and delayed care. In other words, do the reviewers have an inherent bias against patients, given that former patients complained against them?
Transparency Concerns: The lack of clear disclosure about these doctors' backgrounds raises concerns about transparency and potential conflicts of interest within the healthcare system.
In essence, this is a horrible system to provide high quality medical review.
