Toward making IMEs independent : Balancing the source of work

world go around”. The article “Toward making ‘IMEs’ Independent” (pages 9-10) certainly reinforces this phenomenon in the insurance context, highlighting the economic forces at work in independent medical examinations (IMEs). The independence of medical examiners in an insurance context is important because of the power wielded by examiners to recommend that insurance benefits be allowed or terminated. This adjudicative responsibility operates in the context of a significant inequality in ‘bargaining power’ among insurers, who enjoy very large economic resources, and insureds, who by definition suffer disabilities that in many instances render them economically vulnerable. Given the change in public satisfaction between the previous system and the new system described in the article, there is little room to doubt the economic pressures that experts may find themselves under if their livelihood rests on conducting IMEs for insurers. Various systems have been devised to redress this inherent economic imbalance and achieve some degree of fairness in disputed insurance claims. As a lawyer, I must admit to a certain bias in favour of the traditional tort system, which offers an effective method of granting aggrieved parties redress for biased IMEs by subjecting the IME provider’s opinion to open scrutiny. In a trial setting, the IME opinion is tested against an array of witnesses who can testify to postaccident changes in the claimant, as well as the expert opinions of the claimant’s treating physicians and any IME examiners retained by the claimant. The determination of the claimant’s rights is made by the court and binds the insurer. While being criticized as expensive, the strength of the tort system is its strong tradition of judicial independence and an impressive body of jurisprudence in the field of insurance law that recognizes – and seeks to redress – the inequalities between insurers and claimants. In no-fault systems, recourse to the courts is often highly circumscribed or completely eliminated, and administrative processes usually replace the courts. The ability of these bodies to adjudicate disputed claims with fairness and impartiality is highly variable, depending on such factors as the association between the decision-making body and the insurers, and the strength of the insurers’ political lobby to influence the format and operation of the administrative systems. (Where the body that holds the purse strings is also responsible for adjudicating claims, there is inevitably a serious conflict of interest favouring insurers.) Once again, the presence of well-funded corporations on one side and individual claimants on the other creates a dynamic of imbalance. Thus, the economic vulnerability of insurance claimants often carries political consequences as well. In rare but notable instances (such as in Colorado), members of the public have formed a collectivity, which has successfully lobbied for greater fairness in the system. The new program in Colorado attempts to introduce fairness at the first level of adjudication, the IME. Interestingly, the primary method of accountability within the new system is financial. However, the new pro-

claimant.The determination of the claimant's rights is made by the court and binds the insurer.While being criticized as expensive, the strength of the tort system is its strong tradition of judicial independence and an impressive body of jurisprudence in the field of insurance law that recognizesand seeks to redress -the inequalities between insurers and claimants.
In no-fault systems, recourse to the courts is often highly circumscribed or completely eliminated, and administrative processes usually replace the courts.The ability of these bodies to adjudicate disputed claims with fairness and impartiality is highly variable, depending on such factors as the association between the decision-making body and the insurers, and the strength of the insurers' political lobby to influence the format and operation of the administrative systems.(Where the body that holds the purse strings is also responsible for adjudicating claims, there is inevitably a serious conflict of interest favouring insurers.)Once again, the presence of well-funded corporations on one side and individual claimants on the other creates a dynamic of imbalance.Thus, the economic vulnerability of insurance claimants often carries political consequences as well.
In rare but notable instances (such as in Colorado), members of the public have formed a collectivity, which has successfully lobbied for greater fairness in the system.
The new program in Colorado attempts to introduce fairness at the first level of adjudication, the IME.
Interestingly, the primary method of accountability within the new system is financial.However, the new pro-Toward making IMEs independent: Balancing the source of work Faith E Hayman LLB gram goes a long way toward equalizing the previous economic inequalities, by making it most profitable for providers to maintain neutrality, with those providers who are most acceptable to both parties (ie, those who are best at finding the middle ground) being rewarded with the most work.I make two observations pertaining to the new systemone on fairness and the other on funding.
First, the high confirmation rate may reflect a phenomenon of 'rubber stamping' the treating provider's recommendations.In this context, it is important to note that a doctor/patient relationship exists only between the claimant and his or her treating physician, not between the claimant and the IME examiner.Given that the foundation of the doctor/patient relationship is the physician's legal duty to act in the patient's best interest on medical issues, the high rate of endorsement of the treating provider's recommendations is comforting.
Second, there is a surprisingly high percentage (60%) of IME examiners who recommend additional treatment.One would hazard to guess that the significance of this is directly related to the 'same specialty' requirement.For treating IME experts, there may well be an 'I'll scratch your back if you scratch mine' dimension to the IMEs.It is not surprising (although not necessarily appropriate) that insurers have sought to have physiatrists and orthopedic specialists review the treatment recommendations of those specialties who most stand to profit from insurance-funded medical treatment.
Overall, however, it is encouraging to learn of a system that recognizes the financial interests of the respective parties and equalizes them in a practical and economical fashion.A key objective will be to build interdisciplinary collaboration to follow and study a cohort of patients with chronic or subacute pain in order to better understand the needs of and the therapy for this group of patients.The candidate will be expected to develop a research program to study chronic pain as well as fostering an environment for teaching professionals dedicated to the study of pain.
The successful applicant should have 1) familiarity with, and deep commitment to the treatment of chronic pain 2) experience and expertise in working in an interdisciplinary setting that is central to the study and treatment of chronic pain 3) leadership skills and experience in creating a team of health professionals from many disciplines to treat patients with chronic pain, 4) well developed teaching and interpersonal skills, and 5) established research expertise in chronic pain.
The successful applicant will be appointed to the most appropriate University department(s) in the Faculty of Medicine & Dentistry based on the applicant's training and certification.Clinical appointment(s) to the London Hospitals will be negotiated as required.
Interested candidates are asked to submit a CV and letter of application together with names and addresses of three references by April 30, 2001

Hayman
Pain Res Manage Vol 6 No 1 Spring 2001 14 The Faculty of Medicine & Dentistry of The University of Western Ontario and St. Joseph's Health Care London, London, Ontario invite applications/nominations for the newly established Earl Russell Chair/Medical Director of the Interdisciplinary Pain Program.This is a position for a Physician or Dentist with an interest in the study of, and treatment of, chronic pain.This is a unique opportunity for the establishment of an interdisciplinary pain program.The Earl Russell Chair/Medical Director of the Interdisciplinary Pain Program will be a key leader in developing the Interdisciplinary Pain Program in the Faculty of Medicine & Dentistry and at St. Joseph's Health Care London.

to: Dean Carol P. Herbert Faculty of Medicine & Dentistry Health Sciences Addition, Room H112 The University of Western Ontario, London, Ontario N6A 5C1 FAX: (519) 661-3797
This position is subject to budget approval.In accordance with Canadian immigration requirements, Canadian citizens and Permanent Residents of Canada will be considered first for this position.The University of Western Ontario is committed to employment equity, welcomes diversity in the workplace, and encourages applications from all qualified individuals including women, members of visible minorities, aboriginal persons and persons with disabilities.