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Dr Schuman, section editor for Peds v2.0, is clinical assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and editorial advisory board member of Contemporary Pediatrics.
It seems that our healthcare system is overdue for an integrity/honesty overhaul. Let’s review how we can begin the process of restoration at the practice and healthcare system levels.
“One of the nation’s largest vendors of electronic health records (EHR) software, eClinicalWorks (ECW), and certain of its employees will pay a total of $155 million to resolve a False Claims Act lawsuit alleging that ECW misrepresented the capabilities of its software, the Justice Department announced. The settlement also resolves allegations that ECW paid kickbacks to certain customers in exchange for promoting its product.” -US Department of Justice, US Attorney’s Office, District of Vermont; May 17, 2017.
This eClinicalWorks story has led to several conversations among my colleagues regarding the importance of integrity and honesty in medical practice. It seems that our healthcare system is overdue for an integrity/honesty overhaul. Let’s review how we can begin the process of restoration at the practice and healthcare system levels.
Pediatric providers are quite familiar with the rewards of our specialty. We form a unique bond with families as we assist parents in raising their children. In sickness and in health, we are just a phone call or an office visit away. This parent-physician-patient relationship is part professional and part friendship, and this is why I really like doing what I do!
I believe pediatricians are obligated to practice honest and responsible care. We expect no less from our staff and from our patients and their parents as well.
When we treat patients, we involve parents in the decision-making process, and offer our “honest” opinion regarding treatment and diagnostic options. Not surprisingly, when faced with options, parents usually ask me, “If my child were your child, what would you do?” and this frequently leads to a meaningful and often lengthy conversation.
Pediatricians and parents realize that sometimes there are risks and discomforts associated with healthcare choices. Antibiotics can lead to allergic reactions (rarely), blood work is painful (usually), and costs for every additional test add up quickly (always). So, it often comes down to treating our patients as we would like to be treated ourselves-the Golden Rule as applied to Pediatrics-which, in my humble opinion, should guide every medical decision.
There are 3 major problems with the state of pediatrics today.
Physicians are not always treated respectfully and honestly by patients, and we are often treated unfairly by insurance companies and hospitals, and sometimes even by physician organizations that we expect to advocate on our behalf.
Situations such as these are all too common among those practicing in the trenches.
· We pediatricians participate in what most consider one of the noblest of professions, yet there are a few medical providers as well as healthcare organizations (hospitals, insurance companies, vendors) that are sometimes greedy or corrupt.
· Physicians themselves are subject to temptation and lose direction, so we read news stories involving physicians who are accused and eventually convicted for overcharging Medicaid or Medicare.
· We are too familiar with the fact that pharmaceutical companies artificially elevate the price of necessary medications (ie, EpiPens). A change is long overdue, and yes, perhaps it’s time to make some waves!
In the day-to-day practice of clinical pediatrics, we depend on honesty when we interview parents about their children’s symptoms.
· There is nothing wrong when parents admit they didn’t take a temperature, but state the child felt warm to the touch. It is wrong, however, for parents to call to make an appointment and exaggerate symptoms to get booked into an already busy schedule.
· We need to make it expressly clear to our patients that our purpose is to help, not to find fault, and their honesty helps in our triage process. Likewise, our honesty helps prevent the spread of infection between families when we tell them to not bring their child back to daycare until the illness is no longer contagious.
· A parent’s honesty helps us render an accurate diagnosis (such as, “Did you finish the antibiotic I prescribed 2 weeks ago?”). When we err, as we all do, perhaps by prescribing the wrong dose of an antibiotic, or even by misdiagnosing a medical problem, we need to be honest in admitting our mistakes to our patients.
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?
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).