CRIMINAL CAPITALI$M WORKERS COMP
Study reveals bias among doctors who classify X-rays for coal miner's black lung claims
UIC researchers first to publish data on B-reader financial conflicts of interest
IMAGE: ROBERT COHEN view more
CREDIT: UIC
University of Illinois Chicago researchers are the first to report on the financial conflicts of interest that exist among doctors who review the chest X-rays of coal miners who file workers' compensation claims of totally disabling disease with the U.S. Department of Labor's Federal Black Lung Program.
The UIC researchers found that the determinations of these doctors - who are known as B-readers and who are certified by the National Institute for Occupational Safety and Health, or NIOSH - were strongly associated with the party that hired them.
By analyzing 63,780 radiograph classifications made by 264 physicians in Black Lung Program claims filed during 2000-2013, the researchers found that B-readers who were identified as ever being hired by a coal miner's employer read the images as negative for pneumoconiosis in 84.8% of the records. Pneumoconiosis is the general term for a class of lung diseases caused by the inhalation of dust - coal worker's pneumonoconiosis, or CWP, is commonly known as black lung disease and caused by long-term inhalation of coal dust.
Comparatively, a lower percentage of the records were read as negative for pneumoconiosis by those hired by the Department of Labor or a miner - 63.2% and 51.3% of the records, respectively.
These results are published today in the Annals of the American Thoracic Society.
The authors write that given the clear association between classifications and financial conflicts of interest, a lack of consistency in classifications within and between B-readers and an absence of an objective gold-standard for chest X-ray classifications, substantial improvements in transparency, oversight, and objectivity for black lung claims are clearly needed.
Lee Friedman
UIC's Lee Friedman and Dr. Robert Cohen are senior authors of the study.
"Certainly, we anticipated finding some bias, as there has been anecdotal evidence for some time and the Department of Labor has even taken action since 2013 to avoid such bias. But the degree of bias shown in this data is alarming," said Friedman, associate professor of environmental and occupational health sciences at the UIC School of Public Health. "It begs the question: are those actions enough and are they helping?"
For example, NIOSH has written a rule to institute a panel to review and decertify B-readers who repeatedly provide unreasonably inaccurate classifications of X-rays. However, complaints must be submitted to NIOSH and only after three independent complaint investigations will a B-reader be decertified.
"The system we have today is not being used to its full potential and, even if it were, it still leaves a lot to be desired when it comes to ensuring accurate and judicious outcomes for all parties," said Cohen, clinical professor of environmental and occupational health sciences and director of the Mining Education and Resource Center.
The analysis also found that there were 64 B-readers who classified an absence of pneumoconiosis in 95% of their classifications, with the vast majority (93.3%) of the classifications being made by B-readers who were primarily hired by the employer. The majority of these B-readers - 51 of them - classified films as negative for pneumoconiosis in more than 99% of their classifications.
In contrast, there were 23 B-readers that diagnosed simple pneumoconiosis in 95% of their classifications, with a minority (22%) of the classifications being made by B-readers who were primarily hired by the claimant-miner; 18 of these B-readers diagnosed simple pneumoconiosis in more than 99% of their classifications.
"While there is evidence of bias on both sides, it is clear that the degree of bias is much heavier on the employer side, and this is twofold," Cohen said. "Not only are those hired by an employer much more likely to classify a chest X-ray as negative for black lung disease, but it is also much more likely that an employer will have the resources to hire its own expert - at a much higher fee - in the first place.
"It is clear from this data that this bias is a systemic problem and the most significant offenders are identifiable - the records show a clear pattern of B-reader conflicts of interest," he said.
Better utilizing the current regulations to decertify B-readers with significant bias are among the recommendations the authors of the study present in the paper.
The authors also recommend that all initial contact and payments should be made by USDOL, and the other parties should be prohibited from communicating on a claim until the initial classifications are submitted, limiting coordination between the reader and requester.
Cohen and Friedman say other methods to reduce bias could include growing and diversifying the pool of B-readers; regulating the fees of B-readers who testify on behalf of either party; mandating B-readers to disclose any wholesale relationships and their associated income from related classifications; and, investing in scientific advances that leverage artificial intelligence to classify chest films without bias.
"The technology is there, but we don't have the systems in place to validate or implement a process," Cohen said. "It's a matter of motivation."
"This is really just the tip of the iceberg," Friedman said. "It is very likely that this issue extends beyond the Federal Black Lung Program and is pervasive across workers' compensation systems."
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UIC's Sudeshna De and Kirsten Almberg are coauthors of the paper, which noted no external funding for the research.
Physicians' financial conflicts of interest may play a role in black lung diagnoses
CREDIT: AT
March 23, 2021-- A new study published online in the Annals of the American Thoracic Society examines if the source of physician payment for a medical opinion influences whether the physician finds that a coal miner has black lung disease. The study is the first to look at this relationship in the workers' compensation process.
In "Association Between Financial Conflicts of Interest and ILO Classifications for Black Lung Disease," Lee S. Friedman, PhD, associate professor, School of Public Health, Division of Environmental and Occupational Health Sciences, University of Illinois Chicago and colleagues looked at which party reimbursed B-readers--physicians trained and licensed by the National Institute for Occupational Safety and Health (NIOSH) and approved by the U.S. Department of Labor (USDOL) to evaluate miners' chest X-rays during workers' compensation proceedings--and correlated the payments with diagnoses of black lung disease.
"Our findings demonstrate that B-readers who were ever hired by employers were substantially less likely to classify an absence of coal workers' black lung disease (pneumoconiosis) when they were contracted by the USDOL, compared to later classifications when hired by the employer," said Dr. Friedman. "We did not observe this disparity among physicians ever hired by a miner."
These physicians are hired by the USDOL for the initial evaluation. The miner and/or employer (mine operator), at their own expense, then has the option to request a supplemental evaluation if they feel the initial USDOL-funded classification is incorrect. They may pick any B-reader they choose.
The researchers looked at 63,780 X-ray classifications made by 264 B-reader physicians between 2000 and 2013 for U.S. coal miners' black lung claims. Of these, 7,656 court decisions for the period 2002-2019 were used to evaluate financial conflict of interest for each physician.
"The more frequently a physician is hired by an employer to provide a medical opinion on workers' compensation cases for black lung disease, the more likely that physician will not identify black lung disease on a chest X-ray," said Dr. Friedman. "And the more a physician works with a miner on their claim process, the more likely they will identify black lung disease."
Dr. Friedman noted that many miners cannot afford a supplemental evaluation following the evaluation by the B-reader selected by USDOL, so, often, the only additional classification submitted to the court is from the employer. "While bias is present in both sets of physicians, a vast majority of classifications submitted to these courts are paid for by mine operators. The employers will throw a lot of resources at these cases to discourage miners from filing for compensation by making the process protracted and painful."
One-fifth of all classifications submitted to USDOL were made by physicians who classified 95 percent of their cases in one direction - absence or presence of pneumoconiosis. The average B-reader noted the presence of pneumoconiosis in a third of X-rays. The vast majority of the physicians who classified X-rays in a singular direction were hired by employers and were reporting an absence of pneumoconiosis.
These evaluations are done through the Federal Black Lung Program, which is administered by the USDOL and charged with managing claims by coal miners for workers' compensation for totally disabling coal mine dust disease (black lung disease). Earlier reports raised concerns that financial conflicts of interest may systematically bias physicians when they are classifying chest X-rays for the absence, presence or severity of black lung disease.
Dr. Friedman and his colleagues concluded that their analysis demonstrates the need to reduce subjectivity in the classification of chest X-rays for black lung disease. "There remains a need for empirical analyses specific to the workers' compensation system, which is wholly lacking," they state. "All parties involved deserve a compensation system that is objective and expeditious."
They recommend a series of systematic reforms, as discussed in the paper.
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