Physicians’ Financial Conflicts of Interest May Play a Role in Black Lung Diagnoses

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.