A SECOND OPINION
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Is Administrative Medicine a Real Medical Practice ? by TOM JAMES , MD
Doctors are expected to be able to use evidence-based but humanistic criteria as they provide care to their patients . Images come to mind of the surgeon in the OR , the cardiologist in the cath lab or the internist at the bedside . For many lay people , these are the initial mental images of a doctor . Pre-med students all have their concepts of the kind of physician they hope to become . But my guess is that very few pre-med students ever dream of becoming an insurance doctor . In fact , there are no residency training programs for working in an insurance company or a health plan . The American Medical Association lists the top 10 specialties selected by residents and they are generally all surgical specialties plus pediatrics .
Frequently the physicians working for an insurance company are viewed negatively by doctors who see patients in the office or in the hospital . Antipathy is enhanced by the denial of coverage for services requested by physicians and other health care providers . Since the pandemic , there has been a major shift . Between 70 and 75 % of physicians are no longer self-employed , but receive their pay from some organization . They have now recognized that even the practice of clinical medicine is subject to the influences of the employer — whether hospital system , investor-owned practice management organizations or insurance companies . The lines between administrative medicine and clinical medicine are more than just blurred – they have now become a continuum . It is not uncommon to find practicing physicians who perform consulting services or clinical reviews for insurance companies . On the other hand , there are an increasing number of medical directors / physician reviewers employed by insurance carriers , who also continue to see patients in a part-time role . Having a foot in both clinical practice and within the insurance company allows the physician to understand both roles .
One can well imagine that certain continuum of the application of medical knowledge that stretches between care focused on the individual patient , to the spectrum of population health . It is at this latter end of the continuum that public health policy development represents the application of medical knowledge at a high level . Such medical policies are used in developing regulations , programs and public policies to improve health outcomes for the population . Medical directors within insurance companies find themselves along this spectrum but closer to the policy side . There are a number of similarities with hospital medical directors , even though these physicians may look at medical care from differing perspectives .
The physician employed by an insurance company is most commonly perceived as a doctor who routinely issues “ denial of care ” letters — despite typically only 5 % of prior authorizations actually being denied . Medical review requires the physician to apply nationally recognized guidelines in the review of requested medical services . The insurance companies now require its medical reviewers to be board certified or at least board eligible ; and to use experience-based medical knowledge in applying the case to the guidelines . The lay press may portray doctors in insurance companies as doctors with high malpractice occurrences 1 but rarely offer more than a few anecdotes . National studies on insurance denials as summarized by Experian Health 2 show that the great majority of insurance denials come from “ missing or inaccurate data , authorization process or patient information inadequate or inaccurate .” The current resolution of denied authorizations or denied claims frequently come from “ peer to peer ” conversations . Again , there are no published statistics , but reported experience suggests that when the reviewing physician is given the full facts and the requesting physician is using evidence-based guidelines , then the majority of such requests are approved .
28 LOUISVILLE MEDICINE OPINION