Revisiting IME Ethics and standards

As founder of MCN and a practicing physician, I am proud of what we do as a company and hold high expectations for ourselves, our consultants and indeed our clients. I write this note with a bit of trepidation, but I have never been known as one to shrink from issues.

What I am addressing is by no means the norm in many or most cases, but there are ethical situations that should not be part of our industry, even at the smallest level. Please review this post in the spirit that it is meant – to improve what we do. Please don’t shoot the messenger. But by all means, feel free to comment on this posting, or privately to me.

It has been almost two years since a major expose in the New York Times regarding certain practices in that region.  For those who wish to read this series, please visit:

http://topics.nytimes.com/top/reference/timestopics/subjects/w/workers_compensation_insurance/index.html this page has all the links. Here are links to the individual articles over 3 days:

http://www.nytimes.com/2009/03/31/nyregion/31comp.html?ref=workerscompensationinsurance

http://www.nytimes.com/2009/04/01/nyregion/01comp.html?ref=workerscompensationinsurance

http://www.nytimes.com/2009/04/02/nyregion/02comp.html?ref=workerscompensationinsurance

To my knowledge the matter to a large degree “blew over” in that I am not aware of any significant regulatory or other outcomes on this issue or sanctions against the company featured, though I have heard that they have changed names.

I believe that it may be time to revisit standards in performance of IMEs, especially in regions of the country where we have observed that certain practices that we regard as improper and indefensible may indeed continue to be practiced by certain consultants and IME companies. Not asking, for example, how it can be that they receive and accept examination reports at price points, length and quality that would not be possible elsewhere in the country.  All clients deserve the highest quality standards from those they rely upon for important services, which in the case of IME’s means unbiased, thorough, evidenced-based assessments performed by engaged and dedicated consultants.

With recent disruption in the industry, including a very large consolidation of a number of smaller companies, it is our hope that those who oversee large numbers of IMEs will endorse some or all of the points we are raising, and take appropriate actions in their own companies to insure integrity in all exams. Likewise all doctors who examinations must perform at the highest medical standards and not allow a lower standard for IME’s.

The basic principle is to do right by clients, claimants and society. And since we facilitate medical examinations, let doctors do their jobs properly and insist that high standards be followed and maintained.

Clients who order exams generally receive quality exams, but they should still ask questions if they see possible issues, and use common sense. Doctors who do exams, whocan’t or won’t practice in a way that treats each claim and claimant as individuals, with respect and dignity, give the process enough time, write original reports where critical thinking is employed, and remember why they entered (or should have entered) the profession, should not do exams. There are certain acts that MCN finds unacceptable. We believe all involved in the business should feel likewise and take appropriate measures to ensure that substandard performance does not occur. In no particular order they include:

Exams that are too brief: We believe that a reasonable rule of thumb is that an IME should take no less than 30 minutes— and often much longer—to perform. We generally schedule an hour in our own facilities, sometimes a bit less, but never more than two an hour, and we question at times whether this is optimal. The time must allow for review of appropriate records, a history from the claimant, a focused and appropriate physical or mental status examination, and an original report. We have observed with our own eyes the extreme of the company cited in one of the articles I liked cited above scheduling 12 exams in an hour, with an expectation of perhaps 4 no shows and therefore approximately 8 exams to be done. This timeframe is simply impossible. Further, I think that it is also impossible to do 4 proper exams in an hour. Attempting to cut corners on time does not work; it leads to claimants who feel rushed and not heard, reports that are shoddy, and conclusions that are inarticulate if not inaccurate.

Use of Boilerplate in substantive content areas: The history, examination and conclusions must be original. Templates can provide a framework to follow or serve as an introduction or disclaimer. But the words used in an exam should be original. Measurements should be real and reflect human variation. Normal findings if quantified should reflect a range of normal. While a 90 degree flexion for example, might be normal, normal flexion will be vary from 90 degrees, while still in a normal range. So the number would be expected to not be 90. Yet I have observed reports where normal variation appears absent. No two exams should ever look the same in language when it comes to the history, examination or conclusions.

Reports that are too brief: I am not prepared to state how long an exam should be, but can state with a high level of comfort that an assessment of a complex injury with records to review, a history to cite and an examination and assessment to record generally ought to be more than 2-3 pages.

Ghost-writing of reports or examination performance: It is the physician’s job, and his/her’s alone, to take the history, review records, perform a substantive examination and issue the final report. And it should be the physician contacted for the exam who completes this work. It may not be delegated. While rare, we have seen instances where this is not followed, despite clear guidelines on the matter. The physician must not sign their name on the work of others. While it may be the practice of a particular physician to delegate certain practice tasks, that is not the standard in IMEs, and certainly not something to be imposed upon an unaware client or IME company.

Ordering unnecessary tests, especially when personal or corporate gain may be involved: It is no secret that society has been looking very carefully at real or perceived conflict of interests in medical services. Fortunately our clients call us and ask for exams and we don’t drive the demand. But we do expect that consultants make a determination as to whether a particular study is needed. Interestingly, when it comes to typical orthopedic type examinations, we find that the common frequency of ordering of studies in situations where testing is not on site is less than 5%. However we have learned that in situations where physician practices or certain IME companies have X-ray equipment on site, the incidence of use increases to approximately 35%. This is a massive variable and suggests that something may be amiss. The only indication for a study should be if it is necessary for a quality report. Often it is not, or prior studies are more than adequate. If a consultant is ordering common films uncritically, or clients see this taking place, questions should be asked. We believe that clients should consider exercising the option of requiring approval for studies, to insert a bit of friction in the process, especially if X-rays appear to be a norm with a particular setting, consultant or company.

Think about the New York Times test: The homily that one should never do something that they would not mind seeing on the front page of the New York Times holds true. And as you can see above, aberrant behavior in our field made the front page two years ago. Or to frame this in another manner, don’t do anything in our businesses or tolerate practices that we would not subject our immediate family members and best friends to. Some of what I have observed over the years would suggest that if this were the case, some people really dislike their friends and families, to allow certain practices to not only take place, but persist.

Some of these practices have been defended on the basis that questionable claims and claimants may justify them. To this I only can shake my head. Yes there are questionable claims and claimants but this in no way justifies lowering our standards of dignity and respect for what we do as physicians and companies.

Other justifications have included the belief that this is what the client wants and that they are price sensitive and therefore a hurried approach, done cheaply and below standard is therefore acceptable. I don’t believe that clients want claimants to be mistreated, and while price may be an issue, clients realistically understand that quality does carry a price and one can’t cut corners in key areas and achieve a defensible and acceptable product. I believe there may be business risk in the long-term if questionable practices are tolerated. Also, the practice of medicine is the province of physicians, and just as a client would not tell a doctor how to provide treatment, the client hopefully should rely upon ethical and trained physicians to be the final arbiter on examination performance and quality.

The consequences of inattention to ethical medical examination practices creates an uneven playing field in the provision of IME’s; those who do quality work and those who don’t. Some IME provider will take a pass on work at a price that could only be provided sub-optimally. Fortunately we at MCN and many of our ethical competitors are blessed with great consultants and clients who value integrity in the work they do and the examinations they expect. We as a company will continue to strive for the highest standards of integrity. We invite all consultants, clients and competing companies to set similar bars of expectation.

In closing, I invite a dialogue, comments, even respectful challenges to these ideas. We also may have missed some additional issue and areas bearing attention. Please raise them.

Brian L. Grant, MD

Chair and Medical Director, MCN