Candid electronic medical records and medical underwriting don’t mix

Katherine Fullerton, a pediatric emergency physician, makes a nice point. If we want complete and candid electronic medical records, we must protect patients from discrimination based on what such records reveal.

Dr. Katherine Fullerton, a pediatric emergency physician, makes a nice point over at Doctors for America’s Progress Notes. (I am an advisor to DFA.) When insurers practice medical underwriting, physicians are correspondingly wary about writing things down that might come back to harm their patients. As Fullerton notes,

Our EMR and record of past medical problems is a wonderful asset when I’m treating a sick child…. But could this same EMR be a barrier for these children when they become young adults and are trying to obtain their own insurance? Could the adorable 3 year old who is wheezing in room three, have been denied insurance as an adult because I wrote in the medical record that she has asthma? Will the six-year old hemophiliac in room five who is bleeding from a minor abrasion after wrestling with his cousin be denied insurance when he’s reached adulthood?… With the new law, I do not have to worry that my careful history taking will harm their future.

Similar stories could be told in other areas, most obviously in stigmatized matters such as substance use and psychiatric disorders. If we want complete and candid medical records, we must protect patients from discrimination based upon these records. The Affordable Care Act provides these protections, highlighting another good reason not to repeal the new law.

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect,, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

23 thoughts on “Candid electronic medical records and medical underwriting don’t mix”

  1. Trying to understand here- is the kid somehow not going to be a hemophilac as an adult? Obviously not, so why is she worried about hiding it?

  2. Notice that it’s simply assumed that the viewpoint of the customer is the valid one. After all, from the viewpoint of somebody selling insurance, it’s dishonest medical records and underwriting that don’t mix.

    Really, the premise of the post is that people ought to be enabled to obtain insurance fraudulently.

  3. The real point is the obvious solution that has been tumbled to by all the civilized world outside of the USA. Healthcare available to all without regard to medical history and without profits being wrung out of individuals and/or society by paper shuffling corperations. It’s really just that simple.

  4. It’s also yet another indication that “insurance” under PPACA is not really insurance – it is bill paying. Then the question becomes what can society afford and one of priorities. And that’s a question that the left and right have legitimate disagreement about. That’s when PPACA becomes a political issue. You guys won round one, but the reversal and repeal/modification is under way.

  5. Patients are not “customers” except in Hollywood plastic surgeon and dermatologist offices.

    The ONLY way to avoid this problem is to do away with third-party health insurance in favor of universal care for all who need it, when they need it, period. You can go the way of the British, Germans, French, Swiss, or Scandinavians in how you want to pay for it. Take your pick.

  6. This has been around for a long time. Patients seeking mental-health care might have “anxiety reaction” or some similarly limited diagnosis rather than depression or psychosis. Diagnosis and treatment for embarrassing diseases is often sought outside insurance-reimbursed channels. The development of integrated EMRs may make this kind of borderline behavior more difficult, in which case you will see people avoiding certain kinds of medical treatment because of the effect on their insurance status. (There was an interesting example of this in the late 80s and early 90s, when getting an HIV or STD test was considered a red flag, and people pursued alternate means to the point that the Red Cross was explicitly asking people not to donate blood just so that they could get checked for HIV…)

    Brett is, of course, mistaken here because he assumes that the goal of insurance-company underwriting is efficient setting of premiums rather than maximization of revenue in an oligopoly environment.

  7. Btw, Mr. Pollack, you posted a thing about Sebelius and Republican governors a while back – I think that was you? — and I couldn’t comment b/c I was at a workplace computer. But that was a very interesting post. If any of those guys were smart, they would work with her, b/c I think there is a small chance that at some point during the primaries, a chunk of GOP voters will look at their choices – Romney and Palin? — and think, “there’s got to be someone else…” And a GOP guy who could thread that needle in this economy would be something special indeed. I think I hear the POTUS band. (I’m still a Dem though. Just not an enthusiastic one lately.)

  8. Brett assumes that the viewpoint of someone who seeks medical assistance is:
    1. a customer
    2. illegitimate
    res ipsa loquitor you fucking monster.

  9. Yes, I assume somebody seeking to buy something is a “customer”. Yes, I expect, as a default, that if people are to receive things that have cost, they pay for them.

    If you think that makes me a “fucking monster”, that thought makes you somebody whose opinion I don’t care about.

  10. @ KLG

    Not all patients in plastic surgeon and dermatologist’s offices are “customers” in the sense that they’re buying a cosmetic procedure. Dermatologists remove a fair number of skin cancers, and plastic surgeons do some reconstructive work.

  11. Last year I went through chemotherapy for a lymphoma which would, untreated, have killed me in a couple of years. I certainly regarded myself as a “customer”, for all that I really, really wanted the product in question. It was still something I was buying.

  12. Brett, when you go to religious services, are you a congregant/worshipper or a customer? When you and someone you know do favors for one another, are you friends or customers of one another? When you are in a class, are you a student or a customer? When you attend a concert or art exhibit, are you a patron or a customer? And so forth… To never have any role except customer in this great big wonderful multi-faceted world and life — if indeed this is your view, what a poverty of self-concept!

    I for one, am glad to have doctors to whom I am a patient, what a richer relationship than mere customer.

  13. I painted with a broad brush, and for that I apologize. I am well aware of the work of non-cosmetic dermatologists, having had two skin cancers removed from my face in a series of complex snips and cuts and skin grafts with virtually no scars left. My dermatologist was amazing and an artist. Reconstructive plastic surgeons are artists as well as physicians and rank second among their peers behind neurosurgeons in “prestige.” Or did at one time, for good reason. But the “Hollywood” did sort of impart my meaning, no? And my dermatologist? The spouse, also a dermatologist, does the cash-based stuff I was talking about, primarily to men and women of a certain age who are in denial. Real customers they are.

    Brett: Did you shop around for the best price in chemotherapy? Did you not use the really high quality stuff for more of the lesser drugs? Did you insist upon generics? Pay less to a lousy physician than a stellar one because that is what a good customer might do, or at least consider? If not, you are one lousy specimen of Homo economicus.

  14. Yeah, actually I DID insist on generics, to the extent they were available.

    “If not, you are one lousy specimen of Homo economicus.”

    That, or put a really high value on my own life…

  15. Good! Brett, I put a really high value on your life, too. But you didn’t really address the issue of patient as customer. Did you shop around for a doctor or hospital, based on price? Which is what a good customer would do. Did you make sure that your physician was board-certified and that he completed the proper residency? And if you did, how is that consistent with a customer-friendly free market in medicine? After all, when Rand Paul couldn’t or wouldn’t become a board-certified opthamologist he just started his own organization, staffed with family members, if I remember correctly. Now that is the free market in operation! It also allowed him to scarf up lots of Medicare dollars. Smart thinkin’ on his part, too.

  16. KLG, I was a dual major in college, with my second major being human biology. So the moment I got the diagnosis, I was studying up on the sort of lymphoma I’d gotten, and treatment options, and was quite active in my treatment. Can’t expect that of most people, I’ll agree.

    The one thing I got wrong: GET A PORT. By the time you know if you need one, it’s too late to get one.

  17. Excellent. Here’s hoping for a complete recovery! I just finished teaching Hematology; I’ll pass the “port” hint to next year’s class.

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