Wednesday, December 10, 2014

Ethics and IMR Transparency

California followed Texas' footsteps with SB 863's independent medical review process. Texas has had this for years, albeit with some significant differences.

One commonality though that was adopted from the Texas IMR process is reviewer anonymity.

In Texas there are multiple review organizations - I believe upwards of 40 or more. California has a single review organization, Maximus, which provides review services for multiple governmental health and disability systems.

Regardless, both states keep the actual reviewing physician anonymous, and in both states there are complaints about anonymity and attempts to lift the veil of secrecy.

Texas State Representative Bill Zedler (R-Arlington) has tried in the past to get legislation through the state House removing reviewer anonymity, and is trying again.
Tx. Rep. Bill Zedler

House Bill 180 would stipulate that once an independent review is complete, a party to the medical dispute that prompted the review “is entitled to the name and professional qualifications of any doctor or other health care practitioner used to perform the independent review” after making a written request to the IRO.

The bill would also require disclosure of the name and professional qualifications of a utilization-review doctor to a patient or the patient’s representative.

"Right now, if you go before a disciplinary committee in the hospital, you know who your peers are that are judging you," Zedler said. "You ought to know who's judging you in these cases, to make sure that it's transparent. Otherwise, we have no idea, when you have certain individuals who can remain anonymous, whether they're making judgments that are consistent."

The arguments in favor of transparency, or conversely, in favor of continuing anonymity, are the same in Texas as they are in California.

Those wishing to maintain the status quo argue that an independent reviewer can't remain independent if people find out who they are and put subsequent pressure on them in various ways: referral deferral, cocktail party conversation, legal threats, etc. This would result in a dearth of reviewers ultimately, the argument goes.

The argument in favor of transparency is that, ultimately, we're in the United States where legal processes should not be secretive, where parties have the right to confront those who make decisions affecting their lives, and that if there is a demonstration of bias or lack of qualification then those should be exposed to protect the public.

I get both arguments, and there is no easy answer.

But ultimately I have to side with transparency at some stage of the IMR process.

In both Texas and California, IMR is the end of the medical dispute resolution process. In both states an IMR might be challenged on issues of bias, discrimination, impropriety, etc. In both states those challenges are impossible unless the identity of the reviewer, in some fashion, is made public at some point in the process.

I don't think it's as simple as simply releasing the identity of the reviewer. There would need to be put into place certain protections that help maintain the integrity of the IMR process, assuming the public wants to continue with IMR, otherwise the system becomes a shambles and the goal of rapid medical dispute resolution gets trashed by lengthy legal interference.

But transparency is necessary to maintain integrity and faith in the process. It should be government's job to regulate IMR, but it is the public's right to know who's making decisions on their behalf and to call attention to the government to investigate and/or discipline those who fail ethical standards.

And then the government needs to take positive corrective action if its investigation uncovers impropriety.

There's a compromise that can work if given the chance.

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