Are Physicians Employed by the Employers Insurance Group biased on their Diagnosis?
The Appalachian region located in the Southeastern United States is home to the country’s largest coal mines. Studies show that residents who live close to the Appalachian mountains where the “mountaintops removal (MTR) mines” are located have a higher death rate than average. It is also estimated that the same people are more likely to live in poverty and be exposed to toxic environmental pollutants than any other part of the same region.
One of the major diseases associated with coal mining is the so-called “coal worker’s pneumoconiosis (CWP) or “black lung disease.”
Coal workers’ pneumoconiosis is typically the upshot of continuous inhalation of coal dust by the minors and inhabitants who live in the neighborhood of the Appalachian mountain tops. Deposition of coal dust in the lungs produces irreversible damages through an immunological response called “dust-laden macrophages around bronchioles (coal macules). Initially, a person with the Black Lung Disease may not show any symptoms, but later on in life, it can progress to massive fibrosis or, in layperson terms, lung scarring. That, indeed, can result in impaired lung function. Typically a diagnosis of CWP is made by history and chest x-ray findings. Unfortunately, it is irreversible when a person is diagnosed with Black Lung Disease, and supportive treatment is the only treatment.
Even though signs and symptoms can be subtle initially, if a physician is familiar with the chest x-ray finding of the person with CWP, the diagnosis should not be confounded.
Amid the rising of the Appalacian Black Lung Disease
According to a publication in the American Journal of Nursing, published in April 2019, black lung disease among miners in the United States has significantly increased since the year 2000. The surge was particularly noticeable among victims in central Appalachia. Among Appalachian miners who had worked for over 25 years, the national prevalence of CWP during the most recent five-year period the majority reached 20.6%. That was the highest recorded prevalence in 25 years and surpassed the national average of over 10% if miners worked less than 20 years and the additional 5% for miners who have worked 20 to 24 years.
Do doctors employed by the employer’s insurance group get paid higher to read chest X-rays differently?
The rise in black lung cases among the Appalachians has initiated a new challenge for patients to receive the care they deserve. That is, not every miner who contracts this devastating disease is getting the attention they need. For instance, based on a story published by Medscape Tony Adams, a 48-year-old coal miner whose doctor based on the x-ray ordered by the department of labor found stage I black lung disease. Yet Adams’ claim for medical benefits in 2008 was denied before that on multiple occasions simply because the insurance group that represented his employer hired a different physician as their medical expert. The insurance group’s doctor ruled out any evidence of CWP in Tony’s case. Thus, The judge ruled in favor of the mining company because the doctor employed by the insurance group had a higher credential.
Tony died in 2013 without receiving any benefits or restitution from the employer’s insurance company. After that, an autopsy performed confirmed the diagnosis of CWP, and since, his widowed wife was awarded by two judges even though Tony’s ex-employer appealed the case.
The essence of the publication’s argument is whether the doctors employed by the employer’s insurance company are based on their higher salaries relative to their private counterparts or simply the upshot of variation in clinical judgment. The author sees a pattern in the patient chest x-ray readings suggesting that the physicians working for the employers and their insurance groups might, indeed, have the propensity to skew their diagnosis to the benefit of their employer.
Maybe too overzealous rigid corporate protocol and strategy is to blame
In the corporate world, money is everything. In a highly competitive market, the monopoly is just a matter of convenience for those with the upper hand. Insurance companies are business entities, and just like any other corporation, they are strategically aligned to make profits. Amid increasing coal workers pneumoconiosis, employers insurance companies must assure a profit and lower liability. To them, doubling physician salaries (with certain performance expectations) is still cheaper than paying for the medical costs of their clients like Tony Adams.
To ensure and track the progress of money-making strategy, companies implement protocols and standard operating procedures. Even though they claim that such policies and procedures would not impact physicians' clinical judgment, reality does meddle in the physicians’ way of making the final judgment. Those are either by making them conscious about the negative effect on their human resources records or simply following diagnostic guidelines that force the diagnosing physician not to think outside the corporate box. Either way, there is no excuse for a physician to be biased. Still, in reality, they continue to be that way until we eliminate corporations from being in charge of the healthcare system.
Corporations rely on facets like protocols, standard procedures, guidelines, and key performance indicators (KPI). The latter elements are rarely, if ever, based on physician, patient appraisals. Instead, they have manufactured instructions of the corporate board of directors based on their financial projections.
What Tony Adams went through is the artifact of corporate medicine’s one-size-fits-all scheme.
The corporate entities currently control three healthcare pipelines: Physician reimbursement, Patient drug prices, and Lobbying interests through politicians and the government. All above will affect employed physicians and patients to be obliged to think, eat, live and receive medical care. In the eyes of insurance companies, patients and their physicians must accept what they are given.
In a corporate medicine realm, patients have no say over their medical care. Physicians are losing their independent medical practices simply because they can’t compete with large healthcare systems. The administration made value-based reimbursement protocols that undermine physician autonomy to make a sound clinical judgment and care their patients deserve. High salaries of the employed doctors aren’t necessarily an indicator of them being persuaded by themselves. But instead is their way to attract physicians from private practices under their umbrella, which is much more cost-effective for them than if they have to reimburse an independent doctor.
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