Flawed systems breed dishonesty
So, now that I’ve made the case that honesty in medicine benefits physicians as well as patients, I must include some caveats. Honest medicine gets muddled in situations when we advocate for our patients.
· When requesting prior authorizations for a patient’s medications, we choose our words carefully, as this painful process often requires some exaggeration.
· We also use choice language to expedite referrals for imaging studies or referrals to specialists so that these are approved by insurance companies who are financially motivated to deny, or at least delay, our request (ie, “I am requesting this MRI as I want to make sure my patient doesn’t have a brain tumor”).
These examples are nothing more than a game we have learned to play to navigate what has become an overly complicated and unacceptably unjust healthcare system. If the playing field were leveled substantially, patients and physicians and would benefit considerably. So how can we achieve this?
A solution that works
The eClinicalWorks case that introduced this article is very interesting for a reason other than the discovery of “alleged” deception on the part of the EHR company. As part of the settlement agreement, the US Department of Justice required that eClinicalWorks agree to a “corporate integrity agreement” (CIA) mandating that the EHR vendor “retain an independent software quality oversight organization. This organization will operate as ‘watchdog’ assessing eClinicalWorks quality control and compiling reports for both eClinicalWorks and the US Office of the Inspector General.”
The concept of “independent healthcare oversight” is a long overdue reform that would simplify and improve healthcare delivery, and could be relatively easy to implement.
As we all know, most inappropriate behaviors on the part of healthcare organizations are revealed through “whistleblowers” who put themselves at personal risk when they expose improprieties on the part of such organizations. A whistleblower was responsible for revealing evidence that led to the eClinicalWorks investigation. Although there are policies to protect whistleblowers, these are often insufficient to motivate individuals to step up. If we adopted non–government “watchdog” agencies to oversee medical practices, insurance companies, and pharmaceutical companies, with all stakeholders paying appropriate fees to fund the process, whistleblowers could truly be anonymous and free from retribution.
Today, if you have problems with insurance companies denying claims or denying services, physicians and patients have little recourse other than challenging decisions through the legal system. Independent watch- dog agencies would provide fair and balanced oversight of not only insurance companies, but pharmaceutical companies and hospital organizations as well. Obviously, there would need to be in place a designated nongovernmental organization to oversee these healthcare watchdogs (ie, a watchdog to watch the watchdogs) to ensure that dispositions are fair, as well as to provide a mechanism for appeal.
Physicians and patients would be well advised to advocate for the creation of watchdog organizations, which would need to be initially mandated through legislation. Once implemented, however, I am confident that our healthcare workflows and processes could be simplified and drastically improved.
Until such time that we succeed in overhauling our healthcare system, we can at least continue to practice honest medicine, avoiding these ethical traps, confident that we are following the proper path, all while educating patients that their honesty helps us practice better medicine. We should also make it clear to our legislators and our state medical and pediatric societies that although the government is concerned about paying for healthcare, they all need to help us reform the practice of medicine as well.
If we can achieve this, even in small measure, it would improve patient satisfaction, reduce physician burnout, and, yes, contribute to making pediatric practice great again (see “Make pediatric practice great again!” Contemporary Pediatrics, April 2016).