We just went through our Joint Commission site survey and I have a few thoughts after doing this as a medical director. The Joint Commission for the Accreditation of Healthcare...
Independent medical examiners are indispensable for unbiased determination of disability, life insurance eligibility, fitness for employment, and civil litigation. But suddenly, the supply of competent independent medical examiners is in peril.
An independent medical examiner is a healthcare practitioner (most often a physician) who is not involved in a person’s medical care who does a 1-time evaluation of the person to determine the person’s medical diagnoses and severity of impairment. Independent medical examiners do not prescribe medications but may do limited testing (for example, x-rays, pulmonary function tests, EKGs, etc.). Primarily, however, independent medical examiners rely on their history and physical exam as well as past medical records. Generally, the patient’s regular attending physician is not used as an independent medical examiner; there is an inevitable human tendency for physicians involved in the care of a patient to want to be their patient’s advocate, making them often biased about the person’s degree of impairment. Furthermore, the person’s regular physician often does not want to lose that person as a patient, also potentially leading to bias.
I have been an independent medical examiner on many occasions and I also review independent medical examiner reports on a regular basis as part of my role as a member of the Medical Review Board of the State Teachers Retirement System of Ohio and also in my role as an expert witness. 10 years ago, it was relatively easy to find experienced specialists to serve as independent medical examiners. After all, it generally pays better than standard Medicare rates for a one-time consult, there is no responsibility of prescribing medications or treatments, and there is no follow-up care involved (including no urgent calls from sick patients and no follow-up paperwork). The best independent medical examiners are physicians who have experience doing independent medical exams and the very best do a lot of these exams. But almost overnight, the pool of independent medical examiners has been shrinking and it is getting harder and harder to find physicians to do independent medical examinations.
The biggest reason is the internet.
If you get on your favorite search engine and type in the name of just about any physician in the United States, you can pull up all sorts of rating systems – these are equivalent to the Yelp or Tripadvisor of healthcare.
These are notoriously inaccurate. As an example, in “Healthgrades.com” and “vitals.com”, I am listed as a neurologist (my father, James N. Allen, Sr. was a neurologist at Ohio State University but died in 1980). As a pulmonologist, I do not practice any neurology.
Anyone can post a star rating on these websites, including persons who have seen a physician for an independent medical examination. If a physician does an independent medical examination for an insurance company regarding a person who is applying for disability and opines that the person is not disabled, that individual is not going to be very happy. This frequently results in vindictive rating posts.
As a consequence, many independent medical examiners who I know personally as outstanding physicians with impeccable medical judgment have some of the poorest star ratings on the internet. Increasingly, patient satisfaction scores are used by hospitals and medical practices that employ physicians as a measure of quality… and frequently as a basis for salary or bonus determination. Prospective patients searching the internet to pick out a doctor use the ratings to decide which doctor to see (just like they use star ratings to pick out a restaurant to go to for dinner). Additionally, health insurance companies use doctor rating systems in their decision making of which doctors will be included on their insurance plan and what fee rates they negotiate with the doctors.
All of a sudden, it has become hazardous to be an independent medical examiner. Too many negative reviews by vindictive disability applicants who did not get their desired disability because of chronic pain, etc. can be both publically humiliating to the independent medical examiners and can hurt them financially. One negative ratings by a person who did not get what they wanted from the independent medical examiner can be diluted out by 40 or 50 positive ratings from real patients who are getting medical care from that examiner. However, if a physician’s practice involves doing a relatively large number of independent medical examinations (for example, an occupational medicine specialist or a forensic psychiatrist), then their star ratings on the internet can suffer. Just like no chef wants to see his or her restaurant with 1 star on Yelp, no physician wants to see himself or herself with 1 star on healthgrades.com.
Last year, I was on Grand Jury duty here in Columbus. Each day, we would review dozens of cases to determine whether the County Prosecutors should proceed with trials for people arrested for crimes. Few citizens would want to be a Grand Jury member if the accused individuals could all post negative comments about their business, restaurant, or medical practice if the accused knew the names of each juror who voted to prosecute them.
So what is the solution? For fair and unbiased opinions by independent medical examiners, they cannot feel pressured, coerced, or extorted to render an opinion one way or another. However, there is virtually no way for independent medical examiners to be anonymous. Perhaps the best way is for more physicians to be independent medical examiners so that no one physician has a disproportionate percentage of posts by unhappy disability applicants who are denied their disability. But this will require us to train residents and fellows in the nuances of doing independent medical examinations, something that is currently not part of routine training in most residencies and fellowships. But for now, some of the best independent medical examiners are those who don’t Google themselves on the internet.
May 24, 2019