Patient Safety

Are Health Insurers Practicing Medicine?

Editor’s note: In this guest post, Dr. Niran Al-Agba details how a health insurer interfered with her medical practice and asks the question – Are Health Insurers Practicing Medicine?
By Niran S. Al-Agba, MD (Mom, pediatrician, and Associate Editor at The Deductible)

It’s no secret that in today’s health care market, insurance companies are calling the shots.  

As a pediatrician in private practice for almost two decades, I’ve seen insurance companies transform into perhaps the single most powerful player in today’s health care landscape—final arbiters whose decisions about which procedures or medications to authorize effectively end up determining the course of patient care. Decisions made by insurers, such as MassHealth, have literally killed patients.  But it was only when I got caught in the crosshairs of an insurance company auditor with a bone to pick that I fully appreciated their power to also destroy physicians’ careers.

My own nightmare began around two years ago, when my late father, also a physician with whom I was in practice, and I opened our Silverdale clinic on a Saturday. It was the start of flu season, and we’d just received 100 doses of that year’s flu shot. Anxiety about the flu was running high following the death of a local girl from a particular virulent strain of the virus a year before, and parents were eager to get their kids immunized as soon as possible.

Under Washington law, adults don’t even need to see their doctors to get flu shots. They can get them at Walgreens, directly from pharmacists. But because children under nine are more susceptible to rare but life-threatening allergic reactions, they must be immunized by a physician. This meant that, for convenience sake, parents often scheduled their kids’ annual checkup on flu shot day, thus allowing them to condense much of their routine care into a single visit.

That particular Saturday went off without a hitch, with my father and I seeing and immunizing around 60 patients between the two of us over a 12-hour day.

Three months later, a representative from Regence insurance company requested to see some of the patient charts from that flu clinic as part of an audit. Aimed at rooting out insurance fraud by cross checking doctors’ records, these audits have become a routine fixture in medical practices today. To incentivize their auditors to ferret out the greatest possible number of irregularities, and thus boost the corporate bottom line, auditors work on commission, being paid a percentage of the funds they recover.

The Regence auditor in charge of my case, Anke Menzer-Wallace, failed to turn up any irregularities in our documentation. But, still, Ms. Menzer-Wallace issued a stern admonition to my father and me, ordering us not to open our clinic on Saturdays to administer flu shots.

This struck me as an outrageous restriction, considering our clinic is a private entity where we set our own hours and schedule accordingly, and so I called Ms. Mezner-Wallace. But instead of backing down, she ratcheted up her rhetoric, saying she was also forbidding me from examining my patients before immunizing them—clearly, a bid to save her employer even more money. I was shocked. Ms. Mezner-Wallace’s directive amounted to practicing medicine without a medical license—which is of course illegal in the state of Washington and many other states across the nation.

I shot back that immunizing infants and small children is a serious undertaking, requiring proper caution and care, informed her there was no way I would be complying with her mandate. Following this brief exchange, Ms. Menzer-Wallace took it upon herself to report me to the Medical Quality Assurance Board–the government-backed body charged with shielding the public from unqualified or unfit doctors. The accusation levied against me? Not following an insurance company mandate—which, in her opinion, amounted to unprofessional conduct.

It didn’t matter that the charges against me were ludicrous. The potential consequences were only too real, and potentially catastrophic. Had the State Medical Board decided against me, I could have lost my license. I hired a lawyer, sinking more than $8,000 into legal fees. I was cleared last month by a unanimous committee vote. But other physicians facing similar situations may not be as lucky.

The 18 months of excruciating stress that followed my altercation with Ms. Menzer-Wallace made it patently clear that insurance companies wield far too much power. Bureaucrats are making life-and-death medical decisions without a single minute of medical training, and their auditors are terrorizing physicians, by coercing state medical boards to act as their henchman. Unfettered by any consequences for enforcing policies that fly in the face of rules protecting patient safety, insurance companies will continue to harm doctors and patients alike if no one can stop them.

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Patient Safety

We Must Get Better at Detecting Patient Deterioration ECRI’s 2019 Top 10 Patient Safety Concerns

Editor’s Note: This editorial from the desk of PPAHS’s Executive Director urges clinicians to do better at detecting patient deterioration. Patient monitoring is a combination of the use of technology in the hands of clinicians adequately trained on its use.

By Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health & Safety)

ECRI Institute recently released its “2019 Top 10 Patient Safety Concerns.” In releasing its top 10 patient safety concerns, ECRI said:

This annual top 10 list helps organizations identify looming patient safety challenges and offers suggestions and resources for addressing them.

One of these 10 patient safety concerns in ECRI’s list is – Detecting Changes in a Patient’s Condition.

Why is this important?

Like a canary in a coal mine to detect carbon monoxide and other toxic gases, which alerted miners of potential dangers, being alerted to a change in a patient’s conditions provides the opportunity for clinicians to intervene.

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Patient Safety

Memories of Gina Pugliese – A Relentless Advocate for Patient Safety A Personal Reflection on Why We Must Do More to Improve Patient Safety

Editor’s Note: In this article, Michael Wong, JD (Founder/Executive Director, Physician-Patient Alliance for Health & Safety) remembers Gina Pugliese and remembers how she pushed him to do more for patient safety.

By Michael Wong, JD (Founder/Executive Director, Physician-Patient Alliance for Health & Safety)

It is with great sadness that I learned that Gina Pugliese passed away on March 4, 2019, after a long battle with cancer.

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Patient Safety

Is this the Right Question to Ask – Who’s to Blame for the Opioid Epidemic? From the Desk of PPAHS’s Executive Director

Editor’s note: In this editorial from the desk of the Executive Director of the Physician-Patient Alliance for Health & Safety, Michael Wong, JD discusses the the recent documents disclosed in the State of Massachusetts against Purdue Pharma and asks whether this is right question to ask – “Who’s to Blame for the Opioid Epidemic?”

By Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health & Safety

A lawsuit filed by the state of Massachusetts against Purdue Pharma alleges that the company, the Sackler family (which controls Purdue), and Purdue executives misled doctors and patients about the potential addictive qualities of opioids and, in particular, OxyContin, which Purdue manufactures.

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Patient Safety

Fire Prevention Tips for Patient Healthcare Safety

Editor’s Note: In this guest post, Emily Bartels reminds us of the need to prevent fires in healthcare facilities. She discusses fire prevention tips to improve patient safety.

By Emily Bartels

Fires happen in healthcare facilities at times, but, you can always prevent them from happening.  Here, you’ll learn of the top fire prevention tips for the health and safety of patients in a facility, and what you can do to help rectify any dangers.

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Patient Safety

Are We Doing Enough to Prevent Maternal Death? From the Desk of PPAHS’s Executive Director

Editor’s note: In this editorial from the desk of the Executive Director of the Physician-Patient Alliance for Health & Safety, Michael Wong, JD asks, “Are We Doing Enough to Prevent Maternal Death?”

By Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health & Safety

A US Crisis

The birth of a child is a time to celebrate. As Angela Johnson, a mother of two, writes:

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Opioid Safety, Patient Safety, Respiratory Compromise

3 Recommendations to Implement to Improve Patient Safety During Sedation PPAHS Wishes You a Safe and Happy New Year!

The Physician-Patient Alliance for Health & Safety wishes you a safe and Happy New Year!

To help make 2019 patient safe, please implement the following 3 recommendations to keep your patients safe:

Patients Receiving Opioids Must Be Monitored With Continuous Electronic Monitoring

Much of the public attention has been focused on the harm caused by prescription use and abuse of opioids. However, there is another facet that must be focused on: opioid-induced respiratory depression in clinical settings. This includes patients undergoing moderate and conscious sedation, or recovering from procedures and managing pain using a patient-controlled analgesia (PCA) pump, particularly those during the postoperative period.

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Patient Safety

Most Viewed Clinical Education Podcasts PPAHS’s Top 3 Most Viewed Clinical Education Podcasts in 2018

Merry Christmas and Happy Holidays!

Thank you for making the clinical education podcasts and videos by the Physician-Patient Alliance for Health & Safety some of the most viewed clinical education podcasts on the web! As of December 21, 2018, PPAHS’s clinical education podcasts have been viewed 680,695 times on YouTube.

PPAHS’s top 3 most viewed podcasts and videos in 2018 were:

#1 Most Viewed Clinical Education Podcast in 2018 – Preventing Avoidable Deaths: Monitor for Respiratory Compromise [viewed 78,204 as of December 21, 2018]

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Opioid Safety, Patient Safety, Physician-Patient Relationship

3 Key Patient Safety Initiatives for 2019 PPAHS Presents at the AARC Respiratory Patient Advocacy Summit

At the recent 4th Annual AARC Respiratory Patient Advocacy Summit, Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health & Safety) discussed 3 key patient safety initiatives for PPAHS for 2019.

Key #patientsafety initiatives for 2019 discussed at @aarc_tweets Respiratory‏Patient Advocacy Summit Click To Tweet

Also speaking with Mr. Wong on the panel discussion were:

Tim Myers (Chief Business Officer, AARC) moderated the session.

The 3 key patient safety initiatives for 2019 emphasized by Mr. Wong are:

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Patient Safety, Practices & Tips

3 Tips for Successfully Discharging a Senior Patient from Hospital

According to the Census Bureau, seniors made up 13.3% of the U.S. population in 2011 and will account for at least 20% of the population by 2060. Max Gottlieb discusses 3 tips for successful discharging a senior patient from hospital.

By Max Gottlieb (Senior Planning)

After being discharged from a hospital, seniors and their families not only have to worry about speeding up recovery through post-operation dieting or physical therapy, but they can experience a myriad of issues completely unrelated to physical health. Knowing what to expect when dealing with the American healthcare system, especially when the patient is using Medicare, can ensure that your loved one has the best possible care under your supervision.  

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