Are Health Insurance Companies Practicing Medicine Without a License?

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.

 

Being a Woman Physician : The Blank Wall of Social and Professional Antagonism #NWPD2019

February 3^rd is designated National Women Physicians Day, in honor of Elizabeth Blackwell, the first woman in the U.S. to earn a medical degree.  Dr. Blackwell said, “a blank wall of social and professional antagonism faces the woman physician.” She was right. Recently, an 85-year old retired surgeon shared that my ‘antagonistic attitude’ is unbecoming; his unsolicited comment reminds me why celebrating this day is important for all women. 

Dr. Mary Edward Walker was a female physician who embodied “antagonism.”  She is the only female recipient of the Congressional Medal of Honor in U.S. history, cited for valor as a surgeon on the Civil War battlefield.  She was also an abolitionist, prisoner of war, suffragist, writer and speaker.  Two years before her death, the Army revoked her award yet she refused to comply.  Her life story is inspiring. 

Mary was raised by progressive, “freethinking” parents, who founded a schoolhouse to ensure their six daughters were as well-educated as their son.  In defiance of convention, her family shared work equally on their farm, encouraged independence and disregarded traditional gender roles.

Mary paid her way through Syracuse Medical College graduating with honors in 1855.  She married Albert Miller, a fellow medical student, yet removed “obey” from her vows and retained her last name, like many female physicians today.  Unfortunately, due to Albert’s philandering – he impregnated two patients – the couple divorced thereafter. 

At the start of the Civil War, she volunteered as a surgeon for the Army, but the Secretary of War refused to commission a woman as anything other than a nurse.  She could have posed as a man, like 400 other women that graced the battlefield, but felt obscuring her gender contradicted her primary goal, which was breaking the gender barrier.

Dr. J.N. Green, the lone surgeon at a temporary infirmary in the U.S. Patent Office, hired her as an assistant surgeon.  After her request for compensation was denied by the U.S Government, she accepted the position without pay.   

Over time, more surgeons began working at the infirmary and Dr. Walker became concerned some were amputating limbs—which was a controversial practice –unnecessarily for practice. The mortality rate for amputations at the knee was 60%, while those done at the hip were more than 80%.  Seeing injustice, Dr. Walker counseled soldiers against amputation when medically appropriate.  Her reputation for being bold, skilled and a friend to the soldiers grew and resulted in families seeking her out to treat their injured sons, brothers and husbands. 

The Army refused to commission Dr. Walker as a surgeon, until Assistant Surgeon General Robert Wood observed her work at the Battle of Chickamauga and broke precedent, offering her a paid position as assistant surgeon with 52^nd Ohio Infantry.  She crossed enemy lines as both spy and surgeon until Confederate troops captured her in 1864.  The notorious “female Yankee surgeon” was imprisoned at Castle Thunder, a Richmond prison known for its brutality.  The maltreatment and starvation she endured would haunt her for the rest of her life, but even after her release via prisoner exchange, she continued seeking a ‘retroactive commission’ as a medical officer. 

The Army Judge Advocate General determined that while there was no precedent to commission a female, a "commendatory acknowledgment" could be issued in lieu of the commission.  Generals William T. Sherman and George H. Thomas provided testimonials of her service and President Abraham Lincoln recommended her for the award shortly before his death for “untiring service on the field of duty.”  On November 11, 1865, President Andrew Johnson bestowed the Medal of Honor upon Dr. Mary Walker, citing her valor on the battlefield during the Civil War as worthy of receiving the nation’s highest civilian honor.  

After the war, she became a writer and speaker supporting the women’s suffrage movement.  In 1917, the Army reevaluated eligibility for the Medal of Honor and rescinded her award.  According to folklore, when federal marshals arrived to reclaim her medal, she met them at the door wearing her medal and brandishing a 12-gauge shotgun.  In defiance, Mary Walker continued wearing the medal every day until her death, at 86, on February 21, 1919, just four months before Congress passed the Nineteenth Amendment, granting women the right to vote.   

Fifty years later, Mrs. Anna Walker, a distant relative, lobbied the Army to reconsider the Medal of Honor revocation.  She said, “Dr. Mary lost the medal simply because she was a hundred years ahead of her time and no one could stomach it.”  Upon the Army’s recommendation, President Carter ordered restoration of the Congressional Medal of Honor to Dr. Mary E. Walker on June 19, 1977.  To this day, she remains the only female recipient of this award in U.S. history.  

May Drs. Walker and Blackwell inspire us to embrace antagonism and change the world.