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Internal medicine physician and psychiatrist Muhamad Aly Rifai discusses the KevinMD article “The role of social credit scores in the enforcement of health care regulations.” They explore the expansion of predictive algorithms like Prescription Drug Monitoring Programs (PDMP) in health care, the emergence of social credit scores as tools for assessing physician trustworthiness, the risks of systemic bias and reputational damage, and potential solutions to ensure fair and just enforcement practices. Muhamad offers actionable takeaways for health care providers navigating these evolving regulations and emphasizes the importance of ethical standards in data-driven environments.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Muhamad Aly Rifai, internal medicine physician and psychiatrist. Today we’re going to talk about the KevinMD article that he co-wrote, “The role of social credit scores in the enforcement of health care regulations.”

Muhamad Aly Rifai: Thank you for having me today to talk about this important and lively as well as a timely topic—to talk about the social credit scores and the surveillance in the enforcement of health care regulations. All right.

Kevin Pho: So for those who didn’t get a chance to read it, what’s this one about?

Muhamad Aly Rifai: So, the article talks about the enforcement of health care regulations through monitoring and through artificial intelligence and social credit scores. One of the main tools for monitoring is the prescription drug monitoring programs that got implemented at state level throughout the U.S.

What happened recently—just in the last week—the Drug Enforcement Agency, through rulemaking, and the Drug Enforcement Agency Administrator on her way out, proposed a national Prescription Drug Monitoring Program. There is actually an open comment period that’s currently open, where physicians as well as other interested parties are allowed to make comments about that.

The implementation of a national prescription drug monitoring program is going to be a significant tool for the government to monitor everything that’s going on in terms of controlled substances prescriptions, but it carries significant implications in terms of what’s going to happen for physicians, the enforcement of controlled substances regulations, as well as what’s going to happen in terms of prosecution of innocent physicians who practice on a daily basis.

Kevin Pho: So, before going forward, tell us the intent of prescription drug monitoring programs in the first place.

Muhamad Aly Rifai: So, the intent of the prescription drug monitoring program initially was to be able to monitor prescriptions that are entered into the database through pharmacies as well as through physicians, and to ensure that, for example, physicians are adhering to certain levels of dosing for their patients, as well as ensuring there is no diversion—that patients are not shopping from pharmacies, not filling a prescription multiple times from different pharmacies—and to ensure communication between pharmacies.

However, that program, which was very well-intentioned, got switched and got tooled specifically toward, for example, targeting red flags. One of the red flags, for example, is that a patient is going to multiple pharmacies. But we know now, for example, with multiple controlled substances, that there’s actually shortages of controlled substances and that many of my patients—up to almost 90 percent—will have to call multiple pharmacies to be able to obtain their controlled substances, namely, for example, medications for attention deficit hyperactivity disorder because of a shortage.

So a red flag that was established several years ago as a red flag for diversion is now actually a normal pattern because of medication shortages. And so these patients are innocent in terms of any issues related to diversion; they just have to call multiple pharmacies to obtain their medications. This is how a prescription drug monitoring program could be misused by government authorities to prosecute patients and physicians in the health care arena.

Kevin Pho: All right. So your article brings up social credit scores. Tell us exactly what they are and how they’re being used in the enforcement of health care regulations.

Muhamad Aly Rifai: So the social credit scores address basically the available information about a person on the World Wide Web—specifically, the information that’s known about somebody. Unfortunately, part of what’s going on in health care litigation, as well as in health care enforcement of regulations, is that the government sometimes resorts to sullying the credit score—the social credit score—of a person.

For example, calling them names or using inflammatory language in press releases such as “stealing from Medicare” or “prescribing to underprivileged populations.” Sometimes we’ve seen individuals who are beyond reproach in the prosecution of a pain physician, Dr. Rajendra Bothra in Detroit. Dr. Bothra was a philanthropist; he actually worked with Mother Teresa, and he was working with the Pope. However, the government sullied his reputation and kept him in prison for three and a half years while prosecuting him for health care violations and controlled-substance-abuse violations, only for him to be found not guilty at trial of more than 50 charges.

We see how the government can resort sometimes to sullying somebody’s social credit score and reputation in an attempt to try to convince them that they should plea or should negotiate, while in reality they’re not guilty of the crimes they’re being accused of.

Kevin Pho: So, “social credit score” is another variation of a physician’s online reputation. Is that fair to say?

Muhamad Aly Rifai: Absolutely. Absolutely, yes.

Kevin Pho: So, in terms of actionable steps health care clinicians can make to protect their social credit—online reputation—against potentially unfair charges from the government or another regulatory body, what are some things they can do?

Muhamad Aly Rifai: They have to stay knowledgeable, and they have to know the regulations. For example, I cited another fellow physician from Puerto Rico, Dr. Reyes-Vizcarrando. Now, this exemplary physician worked in a rural hospital in Puerto Rico, and he contracted with this hospital to provide emergency medicine services. In his contract, the hospital agreed for him to bill for his services, so the physician would be able to retain the payments for his services. Then, the hospital would get paid for any additional services that they provided for the patients.

However, the hospital proceeded to bill on behalf of the physician, and so what ended up happening is, for the same services that the physician provided, the hospital billed for it and the physician billed for it. The hospital billed for it without any authorization from the physician. This physician ended up being indicted by the federal government, and he endured three and a half years of being called a thief and being called someone who violated Medicare regulations, only for the prosecutor to find on the eve of the trial that there was no authorization for the hospital to bill on behalf of this physician, and that the physician acted honorably and appropriately within the Medicare guidelines. The case was dismissed on the eve of the trial after three and a half years of prosecution and bad publicity.

So even a physician who’s doing the best they can do—everything right—could still be subject to litigation and unfortunate prosecution from the federal government. So people have to be up to date on their social credit score. They need to know what’s out there. Doing an audit of your social credit score—doing a Google search about yourself and seeing what information is out there—and sometimes trying to remediate some of that information with positive publicity, with articles, with publications, with positive news, can drown the negative publicity. Also, trying to fight that negative publicity with legal action sometimes is very, very successful.

Kevin Pho: Give us an example of a way or a success story where a physician fought back against negative publicity using lawyers, using some of the tactics that you describe. What would that look like in practice?

Muhamad Aly Rifai: Sure. I’ll actually give you a personal story. I did talk in this story about how I was prosecuted by the federal government and how I prevailed at trial. For example, the federal government persisted in keeping a press release about the prosecution, and only after I fought back—invoking multiple federal statutes and letters from attorneys and actually a complaint to the Inspector General for the Department of Justice—did the federal government publish an update. The United States Attorney’s Office published an update to their press release saying that I was found not guilty and that their case was baseless.

So people need to fight back. People need to correct the information that’s out there about themselves. In the case of Dr. Bothra, he was prosecuted with several other physicians also who are fighting back. They are speaking about the injustices that happened to them. Dr. Bothra himself, a philanthropist and basically a person who was beyond reproach—he was an icon in the Detroit community—is actually writing a memoir about what happened to him, as a lesson to other physicians to stand their ground and to sometimes resist accusations.

There are other physicians also who have been falsely accused by patients with accusations that have sullied their reputation, and they fought back. Some physicians even resort to the action of suing the patients who are sullying their reputation and winning those lawsuits and receiving damages, because the statements that were made by either the patients or other hospitals are not true, and they affected their social credit score—their reputation. So we need to invoke laws and defend our reputation as physicians and be able to fight back.

Kevin Pho: Now, getting prosecuted or indicted by the federal government certainly is one thing, but getting a bad patient review certainly is, I would say, on a lesser end of the spectrum. Are you recommending physicians hire PR firms and lawyers whenever anything negative is said about them online?

Muhamad Aly Rifai: You have to decide. People in different specialties have different tolerance levels in terms of their ability to, what we call, “have a thick skin” for patient reviews. Some physician specialties, they don’t care that there are patient reviews about them—for example, their Google reviews are a score of one or two. Some physicians, that doesn’t matter to them. For other physicians, it’s very important to have a score of four-and-a-half or five, and they’re very, very active in terms of managing their Google reviews, which we know sometimes may not be very accurate and sometimes artificial based on only getting reviews from positive patients and not getting reviews from people who felt slighted.

It all depends on the specialty, but there are physicians who’ve been successful in getting bad reviews removed or employing litigation to fight back from bad reviews that they felt were derogatory about them.

Kevin Pho: One of the things that you also mentioned are some systemic biases when it comes to the physician’s social credit score. Talk more about that.

Muhamad Aly Rifai: Sure. So these are the biases that we see in our community. I talked in the article about some of the biases that we’ve seen with prosecution—specifically, a prosecution of minority physicians. For example, in my prosecution, the care that I provided was for two individuals that the government may perceive as dispensable or undesirable people in rural Pennsylvania who were elderly and who were poor, where I provided psychiatric services to them. The perception was that nobody is going to argue with a prosecution like that.

Or the prosecution of Dr. Bothra, who provided services in the underserved areas of Detroit—a Hispanic, African American, underserved population. They had 25,000 patients, and nobody cared when the federal government upended their practice and their practice was closed. The government also made derogatory remarks about some physicians—for instance, about an African American physician who was described as a thug or that he owned expensive things or that he owned a big mansion, while his property was just a regular-sized house for a physician, and his wife was also a physician.

So sometimes using negative information toward physicians can be very derogatory. A very recent case, also, that I would talk about undergoing right now in Texas is the case of Dr. Itam Haim, who is a surgeon who was accused by the federal government with criminal HIPAA violation for comments that he made and whistleblowing that he did about gender care—gender-affirming care—that was provided by the Texas Children’s Hospital. The case is currently slated to go to trial next month in February. He spoke about and defended himself; however, he was faced with a gag order from the judge—the government requested a gag order because they perceived that he was accusing them of being corrupt and that their whole prosecution of him was inappropriate.

So we’ll see what’s going to happen with that case, but he has a gag order and he’s not able to speak up, and he has a very active Twitter feed where he talks about his case. I encourage all physicians to talk. It’s your First Amendment right, and you need to protect your reputation and your credit score.

Kevin Pho: We’re talking to Muhamad Aly Rifai, internal medicine physician and psychiatrist. Today’s KevinMD article that he co-wrote is titled, “The role of social credit scores in the enforcement of health care regulations.” Muhamad, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Muhamad Aly Rifai: As physicians, our reputation and our social credit score are valuable things that we worked very hard throughout our life to create. And so I urge all fellow physicians to protect those very dearly and to use laws and regulations that protect your reputation and your social credit score, and for you to be able to effectively provide good care to your patients.

Kevin Pho: Muhamad, thank you so much for sharing again your perspective and insight, and thanks again for coming back to the show.

Muhamad Aly Rifai: Thank you.