Boston Sunday Globe Magazine: Hippocritical Doctors

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PERSPECTIVE

" Hippocritical " Doctors

When they work for health insurers - and help deny care - physicians are

kicking aside the oath they pledged to uphold.

By ADAM J. WOLFBERG | March 25, 2007

My 5-year-old daughter has mild cerebral palsy that affects the strength and

dexterity of her right hand. With the help of her physical and occupational

therapists, she has made tremendous gains in her ability to accomplish

routine tasks. She swung from the monkey bars for the first time recently and

can

now use her right hand to drink chocolate milk. But in 2005, the prospect of

having her therapy paid for seemed unlikely when my health insurance plan at

the time refused to cover it. I filed an appeal, only to have it rejected

weeks later.

At least two physicians reviewed my appeal before it was denied – physicians

paid by the health plan to review claims when there is a dispute about what

is covered and what is not. While one of these doctors has no expertise with

cerebral palsy, the second one does. In his other job, he cares for children

with severe physical disabilities and is a proponent of therapy for disabled

children. As he wrote to me in an e-mail, “my personal view is that children

with [cerebral palsy] benefit from therapy services.†However, in his review

of my appeal, he wrote a careful explanation justifying why the health plan

should not pay for the therapy. (Although the monkey bars know differently,

the health plan asserted my daughter’s right arm would not improve

significantly in 90 days – a requirement for coverage.)

This doctor and others like him are making money denying care – and they

might as well hang up their white coats. They may believe that their

administrative decisions are medically justifiable. However, it often appears

that they

are hired because their MD degrees lend a patina of legitimacy to

administrative decisions that are based on interpretation of a health plan’s

policies,

not a chart, lab test, or CT scan.

Much has been made in recent years about medical researchers whose science

is tainted by their financial relationships with large pharmaceutical

companies, and about physicians who consult for investment banking firms (and

are

occasionally caught passing along inside information). However, as unethical as

these relationships are, the damage they cause is to society, not to

individual patients.

Individuals are harmed when medical care is withheld. Many of these health

plan doctors, whose job it is to reject claims, end up being paid to violate

the Hippocratic oath they took when they graduated from medical school – to

“

first, do no harm.†The American Medical Association’s position on

physicians

’ behavior outside the exam room is very clear: “Physicians in

administrative and other nonclinical roles must put the needs of patients first

.. . . .

The ethical obligations of physicians are not suspended when a physician

assumes a position that does not directly involve patient care.â€

Some of the doctors on the health plans’ payrolls are young and seeking

administrative experience, while others are mid-career or even retired from

clinical medicine and are drawn to these administrative positions because they

provide a steady paycheck and are an alternative to seeing patients. They

believe that they serve health plan members by making sure patients receive

appropriate care and by providing medical oversight of the plan’s

administrative

decisions – particularly when the decision is to deny care.

A physician who works for the health insurance industry told me that these

doctors view themselves as having “an advocacy role for patient care.â€

Health

plan physicians will argue that without them consumers would have no voice

within the company’s walls. But I say let the businesspeople be the ones to

withhold care in the name of cost savings and profit margins. Physicians are

needed in the clinic and at the bedside, advocating for more care, not less.

A few weeks ago, the large insurance companies in Massachusetts announced

their 2006 profits. Physicians like me may bemoan this drain of resources from

our health care system, and we may even envy the insurance executives’

salaries. But as tempting as it is for physicians to join the health plans’

payrolls, we must not step into roles that place us at odds with those who need

us

most – our patients.

Dr. Adam J. Wolfberg is a Boston obstetrician. Send comments to

_magazine@..._ (mailto:magazine@...) .

© _Copyright_ (http://www.boston.com/help/bostoncom_info/copyright) 2007 The

New York Times Company

© _Copyright_ (http://www.boston.com/help/bostoncom_info/copyright) 2007 The

New York Times Company

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