The following is a guest post.
These days, there is a lot of talk about expanding scopes of practice for the group of folks who used to be called “physician extenders” and then “midlevel providers” and more recently “non-physician providers,” many of whom are now getting degrees with the title “doctor” incorporated. While it seems to vary, these folks may include nurses, physician assistants (one day to be called “physician associates” perhaps), pharmacists, and more. Lots of forums are discussing whether folks who are not doctors should be calling themselves “doctor” or whether they should be expanding their scope of practice via legislative rather than educational means. But a recent personal anecdote has made me wonder about a slightly different question: should non-physicians be able to certify “medical necessity”?
Two family members are covered under the same
insurance policy.
He has had a history of knee injury, related surgery,
and subsequent successful rehabilitation. He recently ran a marathon, and now
has new knee pain that has persisted after 8 weeks of conservative therapy at
home. After a long wait for an appointment slot, he finally sees an orthopedic
surgeon with knee expertise. The doctor recommends an MRI to evaluate the
nature of his ongoing pain.
She has chronic back pain that seems to be acting up,
and sees a chiropractor mostly out of convenience, since the office is in the
strip-mall near her home and he can see her anytime as a walk-in. After just two
sessions with the chiropractor, he suggests an MRI, since she isn’t responding
as well as he had expected to the adjustments.
The insurance company immediately approves the
chiropractor’s MRI, but denies the orthopedic surgeon’s. The request was appealed, and again denied, on
the grounds that it was not medically necessary. The insurance company issued a
requirement that the physician first document the patient’s participation in a physical
therapist’s prescribed self-care routine for at least 6 more weeks (recall that
the patient has essentially already done this for 8 weeks, having had formal PT
for the knee in the past, and familiar with the appropriate self-care, but this
did not satisfy the payer). Only after jumping through this hoop may the doctor
meet the standard of “medical necessity” to obtain the MRI.
Lest I be misunderstood, I do
not object to the idea that the chiropractor can order imaging tests. A
chiropractor is an autonomous professional after all, and is a doctor of
chiropractic, just as a dentist is a doctor of dental surgery, and an
optometrist is a doctor of optometry (but that doesn’t qualify him to do eye surgery– a
debate for another time.).
In the modern landscape of myriad
healthcare providers and payers, if a non-physician can certify “medical
necessity,” surely a specialist physician should be able to as well.
Marjorie Stiegler is an
anesthesiologist. She blogs about patient safety and decision-making errors at www.marjoriestieglermd.com.
