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Study Shows Bias, Conflicts Of Interest Among Doctors Who Read Black Lung X-rays

Erica Peterson

Doctors hired by coal companies in black lung cases are far less likely to diagnose the disease in X-rays than are independent doctors or those who are hired by coal miners, a new study has concluded, pointing to conflicts of interest in the system that sick miners use to receive assistance.

The doctors who worked for coal companies to read the chest X-rays of miners found an absence of the disease nearly 85% of the time, according to the authors of the study, published Friday by the University of Illinois Chicago School of Public Health’s Division of Environmental and Occupational Health Sciences. In contrast, the doctors whose clients were coal miners found an absence of black lung a little more than 51% of the time.

“The more frequently a physician is hired by the employer/mine-operator to provide a medical opinion related to workers compensation cases for black lung disease, the more likely that physician will not identify black lung disease on a chest X-ray,” the study concluded. “The opposite is true too.”

The study, published in the Annals of the American Thoracic Society, looked at 264 specialists in pulmonology and radiology who reviewed X-rays for more than 37,000 miners from 2000 to 2013. The study examined more than 7,000 court decisions in black lung claims cases from 2002 to 2019 to determine who hired the doctors involved.

The study found that coal companies paid their doctors up to 10 times more compared to doctors hired by miners or their advocates.

“The miners are not paying that much to people reading X-rays on their behalf,” said Robert Cohen, a pulmonologist at the University of Illinois Chicago and one of the study’s authors.

Cohen said that the general market fee for physicians who read X-rays for black lung runs $75 to $100, while those hired by coal companies can be paid as much as $750 to $1,000.

“It’s just what the market will bear,” he said. “Folks that have a lot of money can pay a lot of money to get the readings that they desire.”

Central Appalachia has seen a resurgence of black lung disease in coal miners in recent years, particularly in Kentucky, West Virginia and Virginia. A 2018 federal study found that 1 in 5 Central Appalachian miners had the disease, versus 1 in 10 miners nationwide.

The study Cohen co-wrote illustrates the difficulty facing coal miners in obtaining federal workers’ compensation benefits for black lung disease, and the absence of a “gold standard” for determining who has it. Its authors recommend a series of changes to eliminate conflicts of interest and make the system fairer.

For example, it concludes that the U.S. Department of Labor should have a more active role in making black lung evaluations more objective. The study shows that doctors who have worked only for the department were less biased in their black lung determinations than those who worked for either coal companies or coal miners.

Researchers also recommend giving the National Institute for Occupational Safety and Health, which certifies the doctors who review black lung cases, more power to weed out those who are proved to be consistently biased or inaccurate in their assessments.

In an unattributed statement from NIOSH, the agency said it has a process in place to decertify doctors who submit inaccurate classifications in black lung cases. The agency declined to say how many doctors it had decertified. 

Additionally, Cohen said doctors should be required to disclose how much they were paid to review black lung cases.

NIOSH does not have the authority to regulate the compensation of doctors in black lung cases, the agency said.

A bill introduced in 2015 by members of Congress from Appalachian coal states attempted to address the issue, in part by establishing a pilot program to create an independent medical review panel for black lung cases. It did not become law.

“It’s a tough, adversarial system, and it’s hard to legislate it,” Cohen said. “But we really have to pay attention to that and in every way that we can make it as level a playing field as possible.”

Wes Addington directs the Appalachian Citizens’ Law Center in Whitesburg, Kentucky, which works with coal miners seeking black lung claims. Addington said the study affirms what he and his colleagues see in the claims process. 

“This type of bias has real world implications for deserving miners and their survivors,” he said. “That sort of bias that could knock miners out of not only what's a fairly meager monetary benefit per month, but also health insurance to treat their conditions.”

ReSource reporter Katie Myers at partner station WMMT contributed to this story.

Jeff Young is managing editor of the Ohio Valley ReSource, a journalism collaboration led by Louisville Public Media.

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