Study finds that US doctors must deceive insurers to provide quality health care

By Helen Halyard
18 April 2000

In a new survey published in the April 12 issue of the Journal of the American Medical Association ( JAMA), 39 percent of doctors questioned admitted to stretching the truth and even lying to administer treatment needed by patients.

The report—“Physician Manipulation of Reimbursement Rules for Patients—Between a Rock and Hard Place”—is based on a random survey mailed to 1,124 practicing physicians in 1998. The objective of the survey was to determine the frequency with which physicians manipulate reimbursement rules and to examine the underlying reasons they do so.

The answers given by the 720 doctors who responded point to the increasing difficulties a large number of American families have in obtaining quality health care. While 47 million Americans have no medical coverage at all, the report reveals that even those who are insured do not receive proper care. The lead author of the study, Dr. Matthew Wynia, assistant vice-president of the Institute of Ethics, said this is the first time such statistics have been published.

Doctors who responded to the survey did so anonymously, with a large percentage answering yes when asked if they had “sometimes,” “often” or “very often” exaggerated the severity of a patient's condition, changed a patient's official billing diagnosis or reported signs or symptoms that a patient did not actually have to help secure coverage for needed treatment or services.

Known as “gaming the system,” more than half of the doctors surveyed said they had used these tactics more often now than five years ago because of the growing number of managed health care companies that severely limit the type of treatment a patient can receive in order to increase their revenues. A quarter of the doctors servicing state-funded Medicaid patients said they were forced to use such measures in order to provide badly needed care.

Furthermore, doctors expressed their frustration over the limitations imposed on their ability to provide needed care, and explained that they saw their actions as a form of patient advocacy and professional obligation. The report points out that many doctors are engaging in such practices despite a well-publicized crackdown on insurance fraud and abuse.

Many doctors explained that they are simply turning the tables on insurance companies that engage in “gaming the patient.” Managed care providers routinely deny coverage requested by doctors, but eventually approve the service upon appeal, knowing that time and other constraints will prevent a number of appeals from being pursued.

The JAMA survey observes, “The root causes of this problem are tensions that are structural, largely unavoidable, and likely to become increasingly intense. These tensions reflect an underlying uncertainty as to whether health care is best viewed in a market-based contractual model or a profession-based fiduciary model, when both models have ethical and legal strengths.... American society is strongly leaning toward a market-oriented emphasis on value for money and free choice in health care.”

What is exposed by the report is a health care system in America that is becoming more and more divided between those who are able to pay for decent care and those who are forced to rely on managed care plans that do not serve their medical needs.

For the full text of the JAMA report see:
http://jama.ama-assn.org/issues/v283n14/full/joc91752.htm

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