Letters to the Editor - April 5, 2004

Editorial was naive in arguing for absolute immunity in peer review - Delays a sign of Medicare breakdown - Serious consequences of making morning-after pill "as available as cough syrup"

Editorial was naive in arguing for absolute immunity in peer review

Regarding "Peer Review: The case for absolute immunity" (Editorial, March 15):

Your editorial expresses great concern that physicians who feel they are victims of bad-faith peer review may retaliate against the hospital and physicians who participated in it. Unfortunately, there is no concern shown for the increasingly common occurrence of a hospital retaliating against a physician whistle-blower via sham peer review.

As physician reimbursements continue to fall, competition increases, and "improper motives" become a reality that is too tempting for some to resist. Likewise, as reimbursements to hospitals decline, hospitals increasingly have a powerful motive to control costs, many of which are affected by physician practices in the hospital (i.e., length of stay, rigid clinical pathways and so on).

If a physician does not follow hospital cost-control initiatives or brings a patient-safety concern to the administration's attention or complains that hospital initiatives are adversely affecting quality of care, that physician is often labeled as a "disruptive physician." Such physicians are then frequently targeted for summary suspension or sham peer review in retaliation. This has a very chilling effect on the willingness of physicians to come forward with quality concerns.

Your editorial naively argues that "discovery of such a dishonest act [bad-faith peer review] would seriously jeopardize their standing among colleagues and in the institutions where they practice." Far from jeopardizing their standing in the hospital, however, a sham peer review against a physician whistle-blower that is conducted at the urging of the hospital administration often enhances the reviewers' standing with the hospital.

The California and Connecticut courts clearly recognized the danger that absolute immunity poses to the accused physician, and they acted properly so as to uphold the few remaining checks and balances in the system that protect physicians who are victims of sham peer review. It is in the interest of patient safety and quality of care to create an environment in which physicians with quality concerns are not afraid of coming forward in the hospital setting in an attempt to correct deficiencies.

Absolute immunity in peer review is equivalent to absolute power over the accused. Absolute power corrupts absolutely.

--L.R. Huntoon, MD, PhD, Jamestown, N.Y.

Editor's note: Dr. Huntoon is editor-in-chief of the Journal of American Physicians and Surgeons and chair of the peer review committee of the Assn. of American Physicians and Surgeons Inc. The AAPS' objective is "the protection of the patient-physician relationship from third-party intrusion."

Delays a sign of Medicare breakdown

Regarding "Medicare enrollment delays leave doctors out in the cold" (Article, Feb. 23): I believe the Medicare system is breaking down in many ways. In the San Francisco Bay area where I practice, an increasing number of physicians are opting out of Medicare, i.e., not treating Medicare patients at all or putting them at the bottom of the waiting list.

Psychiatrists, in particular, are beginning to refuse to treat Medicare patients because of the low reimbursement and very arbitrary, unpredictable denials.

One of my own patients found her depression severely aggravated by the frustration she encountered trying to find out why her services had been denied. I had submitted extensive documentation for medical necessity on multiple occasions for the disputed period of service. I had mailed it certified with return receipt but Medicare kept saying I had not documented the rationale for treatment.

The patient was told by one of the clerks on the phone, "Oh we just throw that away" because they don't have time to collate the information with the original bill. "Medical necessity" has become a ruse for delay in payment or no payment at all. The paperwork is a nightmare for physicians and patients alike.

As I approach 65, I have serious doubts I can count on Medicare at all. Payment turnaround times are often quite long. Colleagues in other specialties tell me that the reimbursement is often lower than the Medicaid rate, which has become something of a joke in our state.

I hope our leaders and legislators consider these factors that are just as critical to the survival of a reasonable health care system as prescription drug coverage.

--Gary S. Nye, MD, Orinda, Calif.

Serious consequences of making morning-after pill "as available as cough syrup"

Regarding "Doctors assess impact of morning-after pill going OTC" (Article, Jan. 19): One of ways the "morning-after pill" works is to not allow the fertilized egg to implant in the uterus. Presumably, most women seeking this medication will do so when they are in the part of their menstrual cycle that they may get pregnant; it is likely this will be the usual way this medication works.

As noted in the referenced article, most advocates for "over-the-counter status" for the "morning-after pill" consider implantation of the fertilized egg in the uterus to be the beginning of pregnancy. If implantation is prevented, a pregnancy is not terminated because, by the above definition, a pregnancy did not occur.

These are word games. That the word abortion is not used does not change the fact that a fertilized egg, with its unique genetic material, is purposely not being allowed to implant in the uterus. Many, if not most, people consider life to begin at conception. With this medication a new life is not given the chance to develop and, by an act of will, is being terminated. Thus, the term abortion, or chemical abortion, is appropriate.

This medication would be more available to victims of sexual assault. However, this probably would be a small segment of women seeking this medication. It is likely that it will be used more often to end inconvenient pregnancies, or those resulting from irresponsible or promiscuous behavior. Such behavior is likely to increase if this measure is adopted. ("What the heck, I can take the morning-after pill.") This medication does nothing to prevent other consequences of this behavior, some of which are fatal. It is unclear what long-term effects inappropriate use of this medication will have. Inappropriate use will certainly occur if this medication becomes "over the counter."

Society must take a long look at the consequences of this medication being as available as cough syrup. Besides moral and ethical questions, there are physical and mental health issues to be considered. If approved, it will be a step backward for society.

--Stephen F. Spontak, MD, Homer Glen, Ill.