License denials soar as NMC scrutinizes medical evaluationsJul 26, 2012 05:24 PM
Dr. Laura Gillis, medical director at the National Maritime Center, says her first duty is to be an advocate for public safety.
As the National Maritime Center (NMC) staffed up its expanded medical division over the past two years, the number of mariners who fail their medical evaluations has more than tripled.
In 2009, only 466 mariners, or 0.6 percent, failed their medical review. In 2010, the number of medical denials had risen to 650, or 1.1 percent. In 2011, the number of medical denials reached 1,676, or 2.6 percent of the total applicant pool.
When the new rules creating the larger Medical Evaluation Division went into effect in 2008, the NMC brass initially said they didn’t expect any increase in denial rates. Later, upon closer scrutiny of the process, the leadership recognized that the earlier licensing reviews had not always paid enough attention to medical fitness, even under the rules in effect at the time.
Now that a team of physicians, physician assistants and other health-care professionals is checking each application, the process has become more thorough and consistent, U.S. Coast Guard officials said.
After high-profile fatal accidents and oil spills in recent years, policymakers and the public have become less tolerant of risky and careless vessel operations. According to the regulations, the NMC’s duty to Americans is to ensure that no commercial mariner is permitted to operate a vessel if there is “an inordinate risk of sudden incapacitation or debilitating complication.”
The NMC, in Martinsburg, W.Va., now analyzes objective data to ensure that all mariners are fit for service, said Dr. Laura Gillis, the center’s medical director.
“No longer are you a patient advocate, so to speak,” said Gillis, a specialist in occupational medicine. “You are an advocate for public safety. You are making an evaluation of whether someone is safe to work in a safety-sensitive position. ... You went from a system where there was really no medical oversight at all, and now we ask for additional information and tests.”
The higher failure rate in medical reviews coincided with a gradual improvement in overall processing time for credential issuance. In early 2009, it took more than 90 days, on average, for the NMC to process a license application, including requests for missing information, exams and mailing. Industry and labor groups complained that the NMC was ill-prepared for its newly centralized licensing task.
Three years later, the average time is down to 35 to 40 days, including all follow-ups. An application with all completed documentation has just a 12-day average processing time, according to NMC statistics.
“We’re getting it done in less than 40 days, and that’s a pretty big change,” said Capt. Anthony Lloyd, the NMC’s commanding officer since 2010.
Paul McElroy, a Florida-based consultant who helps mariners prepare their license applications, confirmed that the Coast Guard has taken dramatic steps to improve the NMC’s processing systems and train its employees.
“I am seeing excellent turnaround — about 15 days from the date an application is mailed,” McElroy said. “The mariner cannot complain about turnaround time if they provide the necessary data in the proper format.”
Lloyd and Gillis said part of the reason for the improvement is that mariners and their employers understand the new system better than they did when the guidelines were first published in the Navigation and Vessel Inspection Circular of 2008. That same year, license processing was centralized at the NMC. Previously, the work was done at 17 Regional Examination Centers (RECs). Lloyd noted recent improvement in industry outreach and communication with applicants.
The NMC — including the RECs — has 270 government employees and less than 130 contractors. The call center is up to 24 employees and 23 agents. Twenty of the call center personnel have over 24 months experience in the job. Six months ago, the NMC introduced a complaints process and a new “NMC Online Survey” to gauge mariners’ opinions on the quality of the service.
The Medical Evaluation Division has grown to 35 people, including three doctors, 14 physician assistants and several certified medical assistants. A new medical help desk for mariners and their physicians is staffed by a certified medical assistant and a retired chief corpsman.
The remaining bottleneck in the system isn’t at the NMC but at Coast Guard headquarters in Washington — where appeals of medical denials are processed. If the initial medical reviewer issues a denial, the mariner is allowed to contact the NMC directly and ask for a reconsideration. If the mariner is dissatisfied with the result of the NMC’s reconsideration, he may file an appeal, which is handled at the Mariner Credentialing Program Policy Division of the Coast Guard’s Office of Commercial Vessel Compliance.
It is taking the policy division an average of 140 days to process the appeals, said Luke Harden, the division’s chief. Only one physician is available there.
“The number of appeals is more than the Coast Guard anticipated,” Harden said. “Appeals were going to be a collateral (duty), but it has turned out that appeals are our primary function. ... Clearly we’d like to have the appeals done quicker. There is a backlog.”
The 140 days includes the wait for additional information from the mariner and/or the mariner’s personal physician, Harden said.
Even though the appeals process can be long and arduous, mariners often get the results they’re looking for. McElroy said his clients have found that process to be slow but fair. The Coast Guard ends up siding with the mariner the majority of the time.
“I recently won two appeals — one for a charter boat captain (who had been) denied renewal because he takes over-the-counter Dramamine for motion sickness. I appealed to Coast Guard headquarters on the grounds that they allow their own boat operators to use Scopolamine, which is a very potent prescription-only drug,” McElroy said.
“I also won a case for a private yacht captain who takes Percocet for back pain after returning home from a rough day on the water,” he said. “The medical staff at the NMC didn’t seem to realize that the small amount of codeine in the medication dissipates in the body in less than 24 hours.”
Many of the successful appeals don’t necessarily negate the findings of the NMC reviewers, Gillis said.
“A lot of those appeals have reached that point because we have failed to get the information from the mariner,” Gillis said. In many cases, the information finally arrives during the appeals process.
Harden said the Office of Commercial Vessel Compliance has sided with the mariner in 54 percent of the appeals, based either on new information or the existing NMC file. Eight percent are partially granted, e.g., with an alternative credential. Thirty-four percent are denied. Four percent had other outcomes.
Harden’s office handled a total of 240 appeals in 2011. Medical appeals are about 85 percent of the total, he said. As of May 15, 128 medical appeals were pending, of which 91 were awaiting additional information. There also can be medical reasons to hold up the process.
“If the mariner is taking medication that’s not allowed, and he’s trying to wean himself off, we give him time to wean himself off, and that delays the appeal, and that causes the backlog of appeals,” Harden said.
As a result of the recent Coast Guard Authorization legislation, Harden’s office is allowed to extend a mariner’s credential for up to 12 months if it is in danger of expiring during the lengthy appeals process.
Mariner advocates have complained that a personal physician who sees the patient regularly is in a better position to determine fitness than a federal employee reading a file in West Virginia. Older mariners become frustrated when they receive denials, even though they were approved five years ago with the same ailments and medications. Hometown physicians have even questioned the need for certain tests. Sometimes it takes a while for the patient to get an appointment to undergo the additional test, and the test may cost money.
“If it is in the standards of care, theoretically it should be covered by health insurance,” Gillis said. “You’re trying not to be a cost burden on the mariner, but you’re still trying to protect public safety.”
The industry is hoping that the medical-review process will be clarified further as a result of the recently created Merchant Mariner Medical Advisory Committee. The panel consists of 10 medical professionals and four mariners. It held its second meeting in May and accepted tasks, including a review of the top 10 problematic medical conditions, a proposed designated medical examiner program and the upcoming Coast Guard rule-making on Standards of Training, Certification and Watchkeeping. The next meeting is in September.
Among the top reasons for denials are coronary artery disease, uncontrolled diabetes and sleep disorders, seizures and chronic use of narcotics, benzodiazepines and sedative-hypnotic medications.
NMC requests for additional information — known as “A.I.” letters — can be an eye-opener for mariners who are unaware of the health risks of the prescriptions they get from their own physicians.
“I am seeing a problem with the ‘pill mill’ doctors who prescribe a medication for every ailment to mask the symptoms,” said McElroy. “Some doctors I have dealt with poo-poo the NMC’s position on sleep, pain and anxiety medications — pill-pushers all.”
The NMC is looking carefully now at each mariner’s prescriptions, the quantities taken and the interactions with other drugs.
“With folks in safety-sensitive positions, there is obviously concern about taking medications and whether the mariner is physically suited,” Gillis said. “More than one mariner has gone into rehab after receiving one of our A.I. letters.”