The Independent Medical Examiner |
Many patients have questions regarding an IME
(Independent Medical Exam). These questions usually
come from upset patients who question the process. I
never know what to say, but I recently read an article by
John Gould, who couldn't have described the process any clearer. Some
of the things he said were, and I quote: This is a touchy
subject. The independent medical examiner is a doctor working
on a short- or long-term contract for a worker's compensation
case. In its purest, most legitimate form, this arrangement
provides a second opinion by an alleged expert in a case
in which the response to treatment seems delayed. This review
is to ensure that the patient and the insurance company are
receiving fair and appropriate treatment by the attending
physician. Certainly, this is reasonable. In many cases,
however, it seems that inappropriate treatment, is being
rendered by the insurance company and the independent examiner,
either innocently or otherwise.
Who are the physicians who work as examiners,
and what are they up to? In my experience, they have been orthopedic
fellows, barely out of residency, older orthopedists who have
retired or are phasing down their practice, or young orthopedists
early in their practice, which is often in academics. All need
the money and are aware of the built-in potential for bias:
the more that the reports they provide save the insurance company
money, the more referrals they will receive. It doesn't take
a genius to understand this picture.
My experiences are as follows: Our orthopedic
fellows have made good moonlighting money reviewing these cases.
For these fellows to suggest that some good doctors in our
referral base might not be providing appropriate care, particularly
considering the fellow's lack of experience in managing patients,
could not possibly strengthen our referrals from these individuals.
I forbade this practice among my fellows for both moral -and
practical reasons. I also discouraged young attendings from
spending their time salting away "secret" revenues
and possibly antagonizing private-practice colleagues, rather
than building their practices and participating in academic
pursuits. I questioned these young colleagues' wisdom in passing
judgment in areas where their expertise might well be limited.
This philosophy had, of course, no bearing
on doctors in the community passing judgment on us. Many of
us who thought we were acknowledged in the field to have subspecialist
expertise have experienced the indignity of having a less-experienced
generalist pass judgment on our care, possibly terminating
it and leaving nothing further for the patient. Nonexperts
in complex cases will make decisions on the basis of a single
visit and superficial examination, often negating months of
effort with a quick decision and the flourish of a pen.
I recall the case of a worker receiving
treatment for an anterior cruciate-deficient knee. Rehabilitation
had failed, and the treating sports medicine expert was about
to proceed with a surgical reconstruction. The independent
examiner, unfriendly to the treating physician, declared the
procedure unnecessary, adding that such procedures were rarely
indicated. Clearly, this is an out- dated concept rendered
as an emotional decision. A patient of mine with very clear-cut
signs of a nerve entrapment syndrome, failed conservative treatment,
had negative electrodiagnostic studies, but attained a successful
outcome from surgery. A year later, the opposite extremity
became symptomatic, with the same presentation. In this case,
an examiner reported that surgery was not warranted. Since
we had reached the end of efforts to relieve her symptoms conservatively
and she was unable to work, we had a dilemma. She could not
afford to pay for the surgery herself, and no hospital would
accept her without a guarantee of payment.
I cannot condone the current IME system.
If an insurance company wants another opinion, even multiple
opinions by true experts in the field, so be it. But to denigrate
the care of a competent doctor on the basis of an inexpert
opinion, which has possibly been biased, is truly a scam perpetrated
by companies who do not wish to honor their financial commitments
and by their accomplices, physicians who, perhaps unwittingly,
play the game. This practice needs significant reform.
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