Insurance Corrective Action Poses Danger to EBM and Physician Autonomy

Figure: insurance, evidence-based medicine, physician autonomy, Humana, CME, Cincinnati Stroke scale, BE-FAST, National Practitioner Data BankFigureA woman in her 70s presented to our academic emergency department with a 24-hour history of intermittent right-sided numbness. Her Cincinnati Stroke scale score was negative. The care team identified no BE-FAST criteria (Balance loss, Eyesight changes, Facial droop, Arm weakness, Speech difficulty, and Time to act) to prompt a stroke alert. In fact, her neurologic exam was normal. The patient underwent a CT angiogram of the head and neck that revealed no evidence of acute intracranial abnormality. The radiologist commented that we should “consider MRI for further evaluation if concern remains for acute ischemia.” The cause of her paresthesias remained unknown, but her ABCD2 score for transient ischemic attack (TIA) placed her at very low risk (1%) for a disabling stroke. The patient was discharged home with an outpatient referral to neurology. The resident advised her to return to the ED if she had worsening symptoms such as weakness or facial droop. The patient and her family were in agreement with the plan. They would call her primary care provider to set up an appointment for the next day. Instead, when the patient's paresthesias recurred the following day, she called another ambulance and was taken to a hospital across town. With an NIH stroke scale of 1, she was stroke alerted, admitted, and started on aspirin and clopidogrel for subtle findings on MRI. Physical and occupational therapy were consulted, but made no recommendations because she had no appreciable neurologic deficits. She went home two days later having never received thrombolytics or undergone a neurovascular intervention. A week later she reported complete resolution of her symptoms when seen at our orthopedics clinic for an unrelated problem. Months later, I was surprised to receive letters from Humana questioning my management of the patient and threatening to report me to the federal government. In fact, the letters warned, if the level of care I provide my patients failed to improve, Humana might implement other measures to protect their patients from me, including terminating my provider status. I could avoid this fate by complying with a “corrective action plan” designed specifically for me. I needed to complete an hour of continuing medical education on TIAs. Curiously, the letters were from an obstetrician-gynecologist and a cardiologist, members of Humana's Peer Review Committee. The cardiologist declared my actions had “deviated from the standard of care and best clinical practices” and were “unacceptable.” I had failed to call a stroke alert, admit the patient, order an MRI, involve PT and OT, and consult a cardiologist. Not only was Humana imposing a corrective action plan based on a single, dubious example of poor care, they were doing so for a patient I never saw. She was signed over to me at change of shift. ‘Ignorant’ of EBM As always, I had taken assiduous notes at sign-out and referred to them later once her workup was complete. I referenced Johnston's landmark study from 2000 which gave rise to the ABCD2 score when I discussed her disposition with the resident. (JAMA. 2000;284[22]:2901; http://tinyurl.com/7y4zf3kh.) The more recent Canadian TIA score also places this patient at exceedingly low risk. (BMJ. 2021;372:n49; http://tinyurl.com/3syyekkw.) The committee, it seemed, was ignorant of these evidence-based guidelines. I was given one month to comply. The cardiologist threatened to report me to the National Practitioner Data Bank and terminate my provider status, saying that “this non-adverse recommendation of the committee is final and not subject to further review or appeal.” In a bizarre twist, I learned Humana fully exonerated my colleague who actually saw the patient. Readers may be forgiven for never having heard of an insurance company imposing a corrective action plan on a physician because no one else at my hospital had either, including our chief quality officer. My attorneys wrote a letter to Humana requesting an opportunity for us to appeal the decision and meet with the committee virtually to discuss the case. Humana's legal counsel responded that under an internal policy the company was unwilling to share, “only actions that are adverse and lasting longer than thirty days are entitled to a fair hearing.” Humana would, however, conditionally grant my request to meet over Zoom, but I would not be allowed to have legal representation with me. Reluctantly, I agreed. Other conditions emerged over the ensuing weeks. I would be granted 10 minutes to present my case and another 10 to answer questions. I would only be allowed to phone into the meeting while the committee would be linked by video. I would be known as “ER Doctor Number Two,” and the committee members would remain anonymous. I was informed of their subspecialties (critical care medicine, cardiology, general surgery, internal medicine, infectious disease, OB-Gyn, family medicine, and emergency medicine) but nothing about their practice experience. I would be able to submit slides that they would advance as I spoke. Time limits would be strictly enforced. I laid out the facts during my presentation about the patient's risk stratification and favorable outcome. I proposed that instead of doing the CME requirement, a more constructive use of time would be to discuss the case at our Morbidity & Mortality conference where the learning points could be shared and debated more thoroughly before a broader audience. The sole emergency physician on the committee sharply asked if I had heard of the Safer Sign Out tool endorsed by multiple emergency medicine organizations. I had not. The OB-Gyn questioned whether I had scored the duration of the patient's symptoms correctly using the ABCD2 score. I had. (Personal email correspondence with Claiborne Johnston, MD, PhD. June 7, 2023.) Humana notified me a week later that they were rejecting my proposal. I would have to complete the CME requirement or face the consequences. ‘Blame, Shame, and Punish’ Humana's actions are problematic on a number of counts. First, their approach to conducting a quality review is rooted in an outdated philosophy of “blame, shame, and punish” that has been widely discredited. (StatPearls [Internet]. Treasure Island [FL]: StatPearls Publishing: May 2, 2023; http://tinyurl.com/yc7x9frx; Institute of Medicine Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press: 2000; http://tinyurl.com/tvzu3e5a; J Emerg Med. 2018; 54[4]:402.) Moreover, whether a physician provides appropriate care should be based upon clinical outcomes, preferably in aggregate, rather than isolated instances of a perceived error. Second, a committee of specialists with disparate training is ill-equipped to adjudicate the standard of care, a legal principle determined in a court of law based upon the level of care the average physician of the same specialty would provide under similar circumstances. (J Am Acad Psychiatry Law. 2017;45[3]:358; http://tinyurl.com/34htp3uc.) Third, insurance companies should have no jurisdiction in determining the educational needs of physicians. State medical boards, specialty boards, residency credentialing bodies, and hospitals already provide appropriate oversight of physician training and maintenance of certification. Fourth, insurance companies should reward safe, evidence-based practices that are cost-effective, rather than sowing fear among physicians to practice defensive medicine with tests and consultations of questionable value. Fifth, Humana's actions abrogate due process. Insurance companies should not play judge, jury, and prosecution in matters of quality of care, much less deny the defendant legal representation or a right to cross-examination. Finally, the committee's adversarial posture runs contrary to the company's values. To quote a spam recruitment email I recently received from Humana, “Our model is physician-led and value-based, designed with the intent to put you, the healthcare provider, back at the helm of patient care. Your input, expertise, and dedication are the driving force behind this innovative approach.” I could only guess what might happen if I refused to comply with Humana's coercive demands. My gut told me to resist, but I was worried my job might be threatened if Humana followed through on their threat to terminate my provider status. I believed a report to the National Practitioner Data Bank would ultimately be dismissed due to the flimsiness of the case, but I did not want to risk a blemish on an otherwise impeccable record. I was also concerned I might accrue expensive legal fees that would affect my family. Ultimately, I completed the requirement, but I added a statement on the form maintaining that my signature was not an acknowledgement of wrongdoing, error, or misjudgment. I also resolved to share my experience about an insurance company's intrusive overreach with a broader audience of colleagues. We physicians should welcome opportunities to review questionable cases, but we must resist attempts by insurers to define the standard of care or determine the nature of our training. Our practice groups, hospitals, and specialty organizations must be vigilant in upholding the primacy of the doctor-patient relationship, so insurers cannot dictate the terms of the care we provide. We should eliminate clauses from our contracts that enable insurers to take punitive action against physicians for matters of quality of care, whether real or imagined. I still don't know why the cardiologist on Humana's committee believed I needed a heart doctor to help me evaluate the patient's numbness. But apparently, I'm in good company. The doctors across town never asked a cardiologist to see her either. DR. MOAK is an associate professor of emergency medicine at the University of Virginia in Charlottesville with academic interests in trauma, point-of-care ultrasound, evidence-based medicine, and the advancement of Spanish among health care providers. He holds credentials in sonography from the American Registry of Diagnostic Medical Sonographers and has served as the chair of the Society for Academic Emergency Medicine Ultrasound Interest Group. He is also the founder and moderator of Spanish Grand Rounds, a monthly Zoom-based lecture series in Spanish on topics related to emergency medicine (http://tinyurl.com/SpanishGroundRounds).

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