". . . there is a dark underbelly in the business . . .
many patients are being profoundly mistreated.
2007 | Celia Milne
While most of the thousands of independent medical
exams conducted each year are professional and impartial, the field is
tarnished by the few substandard assessments that fuel controversy and acrimony
TORONTO | I have seen the worst side of medicine, says
Melissa Felteau, a Thunder Bay, Ont., resident who was in a car accident in
November 1993. It wasnt her ruptured spleen, internal bleeding, broken
ribs, severely damaged left breast and brain injury that broke her spirit, but
rather the gruelling series of province-wide medical assessments her insurer
ordered her to undergo as she fought for medical benefits.
accident, the then 31-year-old Felteau had been working as the director of
public relations at Lakehead Psychiatric Hospital in Thunder Bay. She tried to
go back to work three months after the accident, but was horrified to find that
she had lost her ability to concentrate and plan, as well as some short-term
memory. She stuttered. She could read but not retain information. She could
write, but not string sentences together. It was mortifying; I used to
win awards for my writing, she said. I went from being a highly
functioning executive to being multi-disabled. Yet it was all invisible. You
Five attending medical doctors, including her
neurologist, diagnosed diffuse axonal brain injury. Two neuropsychological
assessments at the time confirmed the diagnosis, and a treatment plan was drawn
Felteaus insurance company, however, ordered her to see
assessors hired by them. So started the nightmare, she told the
Medical Post in an interview at a Toronto hotel. Over the next two years, she
was sent to a psychologist, an orthopedic surgeon, a physiotherapist, a
behavioural therapist, an internist, a psychiatrist, another psychologist, a
psychometrist and a sports medicine doctor.
Felteau said she felt
many of the assessors were patronizing. Its the patient alone in
the room with a medical examiner who has the power to deny or terminate medical
treatment. They sit there and theyre cold, impassionate, skeptical.
Insurance coverage for Felteaus treatment was denied.
Thats when things got ugly. She sued her insurance company for failure to
provide timely and adequate rehabilitation, and so began six more years of
poking and prodding by many more doctors. All in all, she estimates she had 22
independent medical examiners (IMEs) between those ordered by her side and
those for the defence. It ends up being a (confrontation) between the
doctors, while the patient suffers, she said.
you under with assessments. Most patients say, I cant take
this and they give up. Felteau kept on going, but paid a high
By the time her case was settled out of court eight years
after her accident, Felteau said she was traumatized by the IME process. She
developed idiopathic anaphylaxis, and has experienced 17 episodes of
anaphylaxis, which further damaged her neurological system.
have a life-threatening stress reaction, she said. She is now a volunteer
clinical educator at Lakehead University and the University of Ottawa Rehab
Research Group and is studying (with help, to accommodate her still-existing
deficits) for a Masters degree.
We are victims twice, first by
the injury and then by the system.
Felteaus story is not
an isolated one. The Medical Post set out to discover more about the world of
IMEs. (The acronym IME stands for independent medical examinations, but the
E loosely refers to both exams and examiners, so it is possible,
semantically at least, to be an IME, have an IME or do an IME.) We pored over
cases in which IMEs had been used: car accidents, chronic illness,
workers compensation; we called doctors across Canada who either do IMEs
themselves or are knowledgeable about them (not all of them called us back); we
spoke to several lawyers; we attended a medico-legal conference; we met
Felteau, as well as a doctor who runs one of Canadas largest IME
companies, and a representative from the insurance side.
seems, operate on kind of a wild frontier of medicine. While most of the tens
of thousands of independent medical exams conducted each year in Canada are no
doubt professional and impartial, the field is tarnished by the few exams that
are shoddy and substandard. Without exception, our contacts told us there are
some bad eggs in the IME business. Most were quick to add that there are
charlatans in every profession. The differencewe thought as we pursued
this investigationis that with bad IME assessments (unlike, say, bad
audits) patients can get hurt, and theres not much that ethical, caring
physicians can do about it.
Dr. Beverly Tompkins is one such caring
physician. She is medical director of the Burke Institute in Calgary, a clinic
for patients who are highly impaired and disabled with multiple sclerosis and
other chronic diseases. She has dealt again and again with a handful of
insurance-paid doctors who she says give biased assessments.
(With this group) appropriate physical exams are not being done. Doctors
are actually assessing but doing a very poor job. The answer is favourable to
the insurance company time after time after time. They are in conflict with
other physicians who have no vested interest, she said.
Sometimes my treatments are overruled. Their assessments are completely
flawed. It is unacceptable. They say the patients either dont have the
health problem or they can work despite it. Or give them an antidepressant and
theyll be back at work in three to six months.
and then they give a good assessment so that they dont look like they
always give bad ones.
But the end result, she said, is that
many patients are being profoundly mistreated. Some IMEs neglect to
ask meaningful questions to patients or manipulating the wording of the
diagnostic criteria in order to come up with a diagnosis of psychological
problems, she said. In one case, Dr. Tompkins said a doctor giving testimony in
court deliberately changed the wording of the DSM IV in order to boost the
The effect of losing benefits has been devastating
for some of Dr. Tompkinss patients. Many end up in poverty. Stress
makes them much worse; they lose their families; they cant afford food.
This causes not only financial harm but health and psychological consequences.
It is so outrageously horrible.
And Dr. Tompkins can often
predict it. A patient comes in and tells me my insurance company is
sending me to Dr. X for an independent medical examination next week. I
already know what the conclusion is going to be. I dont tell them
theyd better start getting ready to sell their house, but my heart falls
Calgary is not the only city where physicians working
with chronic disease patients complain about IME assessments. It is like
a factory, said Dr. David Saul, a psychiatrist in Toronto who treats
fibromyalgia patients, and has seen dozens of bona fide cases turned down for
benefits. It is easy for the IME doctor to say, I see no objective
evidence. They say, Its all in your head. They crucify
them on the IME. My patients come back and tell me the doctor was demeaning,
condescending. He, too, has seen patients lose their family, their home
and their job and have to go on welfare. They cant go to work, but
they have no income. If they try to go to work, they look like they were faking
The same thing happens to brain injury patients,
said John Kumpf, executive director of the Ontario Brain Injury Association.
It is not malevolence, but ignorance with doctors doing IMEs, he
said. In the past eight and a half years, I have seen IMEs done on
patients with brain injuries that were deplorable in their ignorance. Some were
performed by orthopedic specialists who knew virtually nothing about brain
injury. Others were done by practitioners whose motives would qualify them for
the title of mercenaries. These are the doctors who flatly state there is no
such thing as mild brain injury or who state that unless a person has a loss of
consciousness, a brain injury has not occurred. These doctors violate the first
principle of medical practice: First do no harm.
Post spoke to several leaders in the IME field to gather their perceptions of
the climate in which they work. Dr. Sheldon Levy is the medical director of one
of Canadas oldest and largest IME companies, Riverfront Medical Services,
in Toronto. My concern as a physician is that the proper information is
propagated to the general physician body. A lot of physicians who do this work,
do it well; they add value to the insurance company and they add value to
patients. Thats lost on some of the physicians who are quick to say it is
not right to do IMEs.
The vast majority of Riverfronts
business is conducted without controversy, the run-of-the-mill work of
assessing and quantifying disability. Less than 5% of cases go to arbitration,
mediation or court. And Dr. Levy said he is proud of the work Riverfront does.
The president of Canadas only organized society of independent
medical examiners agreed that IME work is most often done with the highest
level of integrity. We believe strongly in using our knowledge in the
field, training, skills and experience to make impartial assessments,
insisted Dr. Michael Ross, a Toronto psychiatrist and president of the Canadian
Society of Medical Evaluators (CSME). At the core of our values are
evidence-based medicine and the ability to be truly independent and impartial.
Outside bodies may view it differently but these are the core values of what we
How many doctors in Canada do IMEs? CSME represents only a
fraction of them. It has 74 members who are physicians; Dr. Ross estimated the
number of doctors doing IMEs nationally must be in the tens of thousands.
Doctors who do IMEs can spend as much as 100% of their work time on them, or as
little as an occasional assessment. Nobody really knows the scope of the
market. The scope is massive.
There is a large middle layer in
the field: firms that provide a stable of IME doctors for insurers to choose
from. Some of the larger names in Canada are Aim Health Group, Care Point
Medical Centres (formerly the Back Institute), Sibley and Associates, Crawford
and Company, Medisys Health Group Inc., ACT Health Group Corp., ACTIVE Health
Management, Canadian Trauma Consultants and Riverfront.
Though no one
knows exactly how big the IME industry is, or how it is apportioned, the bulk
of IME work is bought and sold through about a dozen facilities, such as
Riverfront, that have a licensed physician in their base office and a roster of
physicians on contract. In addition, there are perhaps 50 companies that simply
broker third-party services, but are not considered health-care facilities.
Dr. Michel Lacerte is one of Canadas most prominent IMEs. He
said he finds the conduct of some of Canadas IME brokers to be
distasteful. He is a physiatrist and associate professor with the
department of physical medicine and rehabilitation at the University of Western
Ontario in London. I have a major concern. They go to the insurance
company and say, I can get IMEs that you would like. They are
volume discounters. The doctor only gets 50%.
He laments the
fact that IME brokers are not regulated and that there are
mercenaries working in the business. He and colleague Dr.
François Sestier, a staff cardiologist at CHUM Hôtel-Dieu in
Montreal, have started a diploma course in medico-legal medicine at the
University of Montreal in an attempt to clean up the IME landscape (see the
Medical Post, Jan. 23).
Indeed, there was a wink-wink, nod-nod tone
to many of the interviews we did about IMEs, as those in the know agreed there
is a dark underbelly in the business. Toronto occupational physician Dr. Gabor
Lantos said: Of course there are cookie-cutter reports and bought
opinions. We all know who they are.
Dr. Ross, CSME president,
said he, too, knows of IME physicians who are not impartial. There are
psychiatrists and psychologists in town I can tell you what it says before I
read it. I wonder why anyone uses these people? Theyre bad apples.
But Dr. Ross doesnt believe their behaviour reflects badly on other IMEs.
They gave themselves a bad name, not the profession.
can be done about the bad eggs? We posed the question to CSMEs Dr. Ross,
and he replied: Even if you know exact numbers, how would you weed them
Dr. Arnold Voth, a specialist in internal medicine in
Edmonton, said that one way to clean up the IME landscape would be to control
the percentage of insurance income doctors can earn. Nobody should be
earning more as an IME than as a doctor seeing patients in the public
system, said Dr. Voth. There should be no additional incentive to
abandon real patients in favour of seeing patients for insurance
companies. IME fees are routinely five to 10 times what an attending
physician earns, he said.
Actual office IMEs are a necessary
part of life, but once you create an entire breed who are making a good living
off it, there is a perverse incentive to be nothing more than a handmaiden to
the insurance companies. As physicians we cant allow that to
Dr. Voth pointed out some Alberta doctors are doing
IMEs outside the areas of medicine in which they are competent. They are
just outside the reach of discipline. To whom are they answerable? How are they
called to account? What is the college doing?
The Medical Post
called two of the countrys collegesin Alberta and Ontarioto
get a sense of how many IMEs have been reprimanded. The statistics do not seem
dramatic. In 2005, for instance, the Alberta College of Physicians and Surgeons
received 35 complaints about third-party doctors, up from 21 in 2001. Of the
35, two resulted in advice on how the doctors could improve their practices and
avoid further complaints, and one resulted in a physician having to formally
acknowledge the issue related to the complaint.
In Ontario there were
a 93 matters relating to third-party reports in 2004 and 67 in 2005. Three
physicians were counseled about recommended changes, one received a written
caution and one received an oral caution. Their names were not available.
Several patients told us they had been mistreated by IME doctors, yet
complaining to the college had yielded few results. In some cases, doctors had
been cautioned repeatedly, but continued to practise as IMEs.
Rocco Gerace, registrar of the College of Physicians and Surgeons of Ontario,
said the college would take a dim view of IMEs providing biased opinions.
A physician has to provide an opinion not in any way based on who
requests the opinion.
The fact that opinions are often
controversial does not worry him. Given a set of circumstances, there may
be opinions that differ. Doctors come at it with different perspectives. That
doesnt mean there is anything wrong. Physiatrists, he said, are
good at attracting controversy because of what they do. Physiatrists have
a disproportionate number of complaints. This reflects, we think, the fact that
they do a number of third-party assessments.
IMEs are tough to
monitor because objectivity is impossible to measure. As Vancouver solicitor
Brad Garside of law firm Paine Edmonds LLP put it, The party or lawyer
whose case is helped by the experts opinion might be apt to consider the
expert to be both correct and objective; the party or lawyer on the other side
whose case is harmed by the opinion might be apt to consider the expert to be
not only wrong but also biased and an advocate for the other side. Im not
sure that it is something that could be objectively quantified.
The Medical Post visited the Toronto offices of the Insurance Bureau of Canada
(IBC) to check out why the insurance industry needs doctors to re-evaluate
patients, especially to assess injuries after auto accidents. Barbara
Sulzenko-Laurie, director of health issues and policy for IBC, has statistics
showing the scale of insurance company payouts.
(auto) injuries . . . Canada-wide, on the private industry side, cost about $4
billion, she said. This number is up dramatically from $3 billion in
Insurance companies certainly dont want to pay benefits
for patients who are malingering, and this is a real threat, reported the IBC.
According to Sulzenko-Laurie, between 15% and 22% of injury claims are
fraudulent (including inflating the severity of an injury), costing the
insurance industry more than $430 million a year.
It is up to
Canadas IMEs to figure out who is faking, but the answer is not always
black and white. For instance, one of the debates raging among IMEs these days
is the exact definition of catastrophic impairment. The stakes are enormous for
insurance companies. If a patient is deemed catastrophically impaired, his or
her maximum medical and rehabilitation costs rise to $1 million in rehab and $1
million in attendant care, with no time limit.
Yet the law, in
Ontario at least, is somewhat open to interpretation. Catastrophic impairment,
according to the Statutory Accident Benefits Schedule, results from (a)
paraplegia or quadriplegia, (b) amputation of both arms or legs, (c) total and
permanent loss of an arm and a leg, (d) total loss of vision, (e) certain brain
injuries, (f) injuries that result in 55% or more impairment of the whole
person, or (g) impairment due to a mental or behavioural disorder. But
heres the rub: Can you combine mental impairment with physical impairment
to get 55%, by adding subsections (f) and (g)?
We believe there
are gamesters trying to increase the number of catastrophic impairments by
interpreting the regulations liberally, said Sulzenko-Laurie. And doctors
are caught in the middle.
Physicians and lawyers who attended the
recent Litigating Catastrophic Disability and Damages medico-legal
conference in Toronto are puzzled. Even Dr. Arthur Ameis, a physiatrist and
medical director of the Multidisciplinary Assessment Centre in Toronto, and one
of Canadas foremost independent medical examiners, was perplexed by the
The problem is were being asked to act
like lawyers and were not lawyers. Weve been slapped on both sides
of our face in some cases. Are you combining (f) and (g)? There is yet to be a
judicial review of how to use (g), he told the audience.
consolation for IMEs, of course, is that they are well paid for their trouble.
Dr. Ameiss clinic charges $3,600 for a basic neuropsychological
assessment, $1,300 for orthopedic, physiatric and neurological assessments and
$1,870 for a psychiatry assessment. Fees are paid by whichever party orders the
independent exam. It is not unusual in any given case to employ many doctors on
both sides for many hours. Dr. Ross told us about a case he was working on as
an IME with 10 or 12 other doctors. Each time a new doctor was added and gave
an opinion, each of the other physicians was asked to provide further comment.
The case was cancelled Monday. Ballpark, Id say doctors
spent 350 hours on it before court occurred. What did those hours cost? The
OMA-recommended minimum for IMEs is $435 an hour, said Dr. Ross. If a
case goes to court, the witness fee is typically $600 to $650 an hour.
The more grave the injury, the more serious the dollars. A bill from
a clinic determining whether a patient suffered catastrophic impairment could
run as high as $40,000, said Sulzenko-Laurie.
For doctors doing
IMEs on behalf of insurance companies, is the incentive that getting the
company off the hook will result in more work?
explained the insurance companies role: They are not allowed to say
to the doctor, This is what we want. Were hiring medical
practitioners who are bound by standards of practice.
Medical Post asked Hugh Brown, a lawyer with Toronto insurance defence firm
Bell Temple, about industry norms. He said that while it used to be common
practice for law firms to tell doctors what they wanted, and even to write the
reports, that is ordinarily not done anymore. Now, it is proper practice
to have a covering letter asking for their opinion on the nature of the injury
sustained and the impact on the patients working life. Can they work with
that type of pain or not? I dont give prior input. Heres the file.
Good, bad or indifferent, I accept the result, said Brown.
Ross has been doing IMEs for more than 15 years and said, There have been
next to no attempts to influence my opinion.
frowned on the idea of interference with an IME physicians opinion.
If there is an attempt to prejudice the witness, there will be punitive
damages. The court can say, this is the award of $100,000 in lost income,
$200,000 in pain and suffering and because the company was a bad bastard, X
number of dollars in punitive damages to claimant and lawyer. There is a strong
incentive for insurance companies not to engage in this type of activity.
The IME also faces the challenges of cross-examination, as Dr.
Darrell Ogilvie Harris noted at the medico-legal conference. He is an
orthopedic surgeon at Toronto Western Hospital who is often called upon to
provide independent exams. Even after doing many of them, he said he still
finds it intimidating to be in court. Im attacked personally.
he said. As doctors, were used to having the final word. I
dont like confrontational situations.
He stressed to the
audience of physicians and lawyers that it is very important for IMEs to have
proper training for the case at hand. They have to be a specialist in the
correct area, have the proper training and practice and carry out useful
examinations. Does this doctor work with quadriplegics or just sit in an
ivory tower pontificating? he asked. Dr. Ogilvie Harris said when he
gives an expert opinion, he will often take the middle ground so that he is not
susceptible to attack.
Dr. Lantos said that what is often up for
debate is whether a patient can go back to work, and that can be a grey zone.
IMEs and treating physicians should be as exact as possible about the
Doctors write notes that say
things like, Patient has been off X weeks and can now go back to light
duties. What are light duties? We dont know. What are modified
duties? A patients resources to find reasonable work after being
ill or injured depends so much on context: union involvement, collective
agreements, how easily they can be transferred, whether they do shift work,
their seniority and geographic considerations, said Dr. Lantos. If
doctors would stick with impairment as opposed to adjudicating disability,
wed avoid 90% of this.
First of all, they suggest operating
IMEs through an independent body outside the insurance industry, and
establishing a registry of qualified health-care providers. They also recommend
a standard fee for IMEs.
Like Dr. Voth, the network takes a dim view
of doctors who only do IMEs and no other clinical work. Doctors cannot spend
more than one-quarter of their time doing IMEs, suggested the network, and must
have an active patient practice. In addition, the IME must be of the same
specialty as the treating doctor, and their practice must be located close to
where the patient lives.
On the industry side, Sulzenko-Laurie
doesnt recommend sweeping changes, but a constant vigilance. The
solution is to just keep working at it. The responsibility to monitor the
system is incessant without end by industry and regulators. We keep tweaking
Despite the bad rap some IMEs get, Dr. Ross said most are
honest, fair and impartial. The headaches that come with this work
surpass most other doctor work, he said. We do it because we are
interested in the diagnosis process. As independent physicians, we have more
data than is usually available. We dont have a waiting room full of
people. Looking at it from an arms length, I can see things others