Doctor loses coverage over pain prescribing

Being a physician is more than a profession to the Rev. Ronald V. Myers Sr., MD. An ordained Baptist minister (and jazz musician, too), the family physician prefers the job description "medical missionary," and the mission of his Southern Mississippi practice is to provide care to "the poorest of the poor" in the United States.

"I'm their family physician," Dr. Myers said. "I'm also their obstetrician, I'm their gynecologist, their pediatrician, their minister, their pastor and I'm their advocate."

But when some patients started calling him their "pain doctor," his insurer, the Medical Assurance Co. of Mississippi, objected. First it refused to extend his medical liability coverage to a new clinic in Tupelo, Miss., where he planned to take over the patients of a physician whose license is in abeyance. Then it decided not to renew his policy for his four other clinics when it expires April 1.

According to the Mississippi State Board of Medical Licensure, Dr. Myers, 47, has never been sued for malpractice, and he has a license to practice with no limitations.

Mississippi has a reputation for being a highly litigious state, so Michael D. Houpt, MACM's chief executive officer, makes no apologies for being very careful about whom his company will cover. He acknowledged that the company has "rigid guidelines" for underwriting, but then added, "That's why we're still in business."

But Dr. Myers thinks there is more going on than just a conservative business approach. He said MACM is deciding for him which patients he can see.

"It's a sad commentary that malpractice insurance companies are joining the war against doctors and pharmacists by trying to restrict their practice," he said.

Houpt denied this. "That's not true. We insure doctors who practice pain medicine," he said. "We insure doctors in the specialty of pain medicine provided they have the proper training and qualifications to do it."

It is not a secret that Dr. Myers treats pain. He founded the American Pain Institute, which educates the public on pain treatment, lobbies for legislation to insure treatment for chronic pain patients and protects physicians who provide it. Dr Myers' problems with his insurer originated as he prepared to take over the practice of John W. McFadden, MD, a Tupelo pain specialist with a long history of conflicts with the Mississippi State Board of Medical Licensure.

Dr. McFadden's license had been "held in abeyance" since June 2003 after he filed a suit against the board, claiming it wouldn't give him a fair hearing. Dr. McFadden eventually chose to retire, saying he did not want to spend any more money to defend himself against the 27 charges the board had filed against him. They include improper prescribing, improper record keeping and failure to monitor patients.

Dr. Myers said MACM was practicing guilt by association because of his relationship with Dr. McFadden.

Houpt would not comment on specific issues, but Dr. Myers has made public much of the correspondence between him and the company.

In a Nov. 20, 2003, letter to Dr. Myers (provided to AMNews by Dr. Myers), Houpt wrote that MACM would not extend Dr. Myers' liability policy to practice family medicine in Tupelo because of the following concerns:

• The practice would include about 100 pain patients of Dr. McFadden.
• Dr. McFadden apparently still had some involvement in treating patients (described in a Dec. 4, 2003, letter from Houpt to Dr. Myers as "going over the medical histories and medical backgrounds of former patients").
• A physician in solo practice with four clinics in the Mississippi Delta would not be able "to render proper care to patients" in upstate Tupelo, about 180 miles away.

As a primary care physician treating Dr. McFadden's former patients, Dr. Myers said he refers those who require advanced interventions to a specialist, but he is properly trained to provide basic pain management to the rest. Joel Hochman, MD, the executive director of the National Foundation for the Treatment of Pain, agreed.

"Anyone with sufficient continuing medical education can do that kind of work, and every physician should have it," Dr. Hochman said. "The treatment of pain is one of the pillars of medical practice."

In a Dec. 15, 2003, letter to Dr. Myers, Houpt wrote that more specific training is required.

"By your own admission you are not board certified or board eligible in pain medicine, and you have had no special training in the practice of pain medicine," Houpt wrote. "For this reason, it is the recommendation of the management of MACM that your medical professional liability insurance policy ... not be renewed when it expires on April 1, 2004."

Dr. McFadden and Dr. Myers acknowledge that Dr. McFadden was helping Dr. Myers get situated in Tupelo and by handing over charts. Before his license was held in abeyance by the state licensing board, Dr. McFadden said he also gave prescription advice to Dr. Myers.

Michael Goldrich, MD, chair of the AMA Council on Ethical and Judicial Affairs, said that there were ethical and legal boundaries a physician must stay within when he loses his license. "In essence, he can't participate in patient care at all," he said, but added that helping with the transfer of records was "ethically appropriate."

On the third point, Dr. Myers said Tupelo is about a 2½-hour drive from his Tchula, Miss., clinic, and he does not see this as a big deal. His plan is to schedule appointments there two days a week, twice a month, and he is looking for another physician who can cover for him when he's not there.

Until a second physician is found, the clinic would be closed when Dr. Myers is not there. He said that might not be the best situation, but it's better than not having any doctor at all.

"They have nowhere else to go, and nobody will treat them because they are poor and on Medicaid," he said.

Although he hasn't given up fighting MACM, Dr. Myers said he has applied for coverage through the Mississippi Tort Claims Board. In the meantime, he is scheduled to meet with MACM officials March 3, and he is working to shine a spotlight on his case.

"It's one thing to block me in Tupelo, but then to write me a letter telling me they're going to cancel my insurance for all my clinics?" Dr. Myers said. "What kind of message are they sending? I serve in the poorest counties in America and they're saying 'Forget those people.' "