Some doctors feel they must "game the system"

Instead of turning to deception, physicians should work for health plan changes that would make this practice unnecessary, say the authors of a new study.

By Vida Foubister, amednews staff. May 1, 2000.

What exactly is medically necessary care?

The answer to that question is the crux of the current debate between doctors and health plans about what services their patients should receive.

Shades of truth

Patients want all possibly beneficial care, and their physicians are eager to provide it. But insurers are not paid to provide all of these services.

This disconnect has put physicians in an untenable position, and many are choosing to sidestep the issue and take matters into their own hands.

An article published in the April 12 Journal of the American Medical Association found that 39% of 720 physicians surveyed in 1998 had sometimes or more often deceived a third-party payer to secure coverage for needed care. In addition, a surprisingly large percentage, 28.5%, went further, saying that they believe it is necessary to "game the system" to provide patients with high-quality care.

The authors, who include three members of the AMA's academically independent Institute for Ethics, say these findings suggest that the health care system is broken.

"There's something wrong with a system where this many [patients and physicians] think the rules shouldn't apply to them," said Matthew Wynia, MD, MPH, the institute's assistant vice president.

This isn't the first study to show physicians are more ready to advocate for their patients -- even if that involves some degree of deception -- than they are to follow health plan rules restricting care. It also isn't something that's new to managed care.

Change the system

Instead of taking the expedient route and exaggerating the need for medical care, doctors have an obligation to work for changes in the system, said Charles M. Cutler, MD, chief medical officer at the American Assn. of Health Plans.

"If they feel that health plan policies are inappropriate, there are ways to challenge those."

The authors of the JAMA study are advocating for more dialogue between physicians, health plans and patients. They also believe that more user-friendly utilization review procedures might encourage patients and physicians to use "legitimate advocacy channels."

Dr. Cutler, however, says that health plans already have those mechanisms in place.

When questions about medical necessity for a service that isn't specifically excluded arise, "in the majority of those instances there is a dialogue between the physician and the health plan," he said.

Sometimes, however, what doctors determine to be necessary care just is not covered.

"For a physician to misrepresent what's being done to get those services is not an appropriate approach," Dr. Cutler said.

Dr. Wynia agrees. But right now the public's sympathies lie more with the physicians -- in spite of the fact that they're the ones breaking the rules.

"The mistrust of health plans right now is so great that this data is being seen as an indictment of plans," he said.

ADDITIONAL INFORMATION:

Shades of truth

Physicians said they had sometimes or more often:

Exaggerated the severity of a patient's condition to avoid early hospital discharge (28%).
Changed a patient's billing diagnosis to secure coverage for needed care (24%).
Recorded symptoms that a patient did not have to obtain necessary care (10%).

Doctors also said that:

Today it is necessary to game the system to provide high-quality care (28.5%).
Gaming the system is unethical (84.7%).
Their patients ask them to deceive third-party payers (37%).

Source: Matthew Wynia, MD, MPH, et al., "Physician Manipulation of Reimbursement Rules for Patients: Between a rock and a hard place," Journal of the American Medical Association, April 12