Study: MDs misrepresent symptoms for payment
With very ill patient, lying may feel ethical
If you’re a physician and you have ever (or often) misrepresented patients’ symptoms to make sure their treatment and your services are covered by insurance, you’re not alone.
According to Rachel Werner, MD, PhD, a staff physician at the Philadelphia Veterans Affairs Medical Center and assistant professor of internal medicine at the University of Pennsylvania, a study she helped conduct last year indicates 11% of physicians support misrepresenting patient symptoms to facilitate coverage. Patient support of gaming the insurance process was even greater — 26% of patients surveyed say they like the idea.
Werner’s study found that physicians feel compelled to lie to insurance providers if their patients’ conditions are very serious and if they believe the appeals process will be overly long or unsuccessful.
"Physicians were more likely to misrepresent patients’ symptoms if the disease was more serious," she explains, "for example, cardiovascular disease vs. their back hurts.
"And if they were told the appeals process would take a long time — hours, as opposed to minutes — and if the likelihood of success in appeals was low," Werner adds.
Tension’ within medical community
Werner says it’s her belief that the practice of gaming the insurance system arose in the 1980s and 1990s, when health maintenance organization (HMO) plans imposed limits on the use of medical interventions in an effort to control costs. Physicians found themselves with patients whose care was not going to be reimbursed, and looked for ways to get insurance to pay.
That situation has eased in recent years, she says, in part because HMOs "got a bad rap" for the limits on paying for care.
"It’s much less prevalent now, but even though HMOs backed off, health care costs continue to rise, so my speculation is that insurers will put more restrictions on what they’ll pay for," Werner says.
She says the study found that physicians felt forced to take action to ensure needed care for their patients, and that misgivings about manipulating facts regarding their patients’ symptoms were outweighed by the benefits of coverage and the avoidance of lengthy waits while denials were appealed.
"Even physicians who agree that there need to be restrictions on costs don’t necessarily apply that thought to individual patients," Werner says. "Obviously, there’s a tension for them between doing the best thing for their patients and their responsibility to the insurers."
Bad perception of the health care system?
Timm Glover, MDiv, vice president of mission and leadership at Middle Tennessee Medical Center in Murfreesboro, says he thinks the findings in Werner’s study say more about perceptions doctors and patients have about the health care system than they do about the honesty of doctors.
"I think the power of this study lies in what are some of the popular perceptions among consumers and providers," he says. "It demonstrates the landscape of health care that has so impacted the relationship between provider and patient."
Glover says a significant fact pointed to by the study "is how many players there are in the health care relationship."
"At a time when medicine is pushing for patient-centered medicine and shared decision making, we’re all in the room with you," he says.
Glover says he suspects that physicians more often don’t misstate patient symptoms, but instead work within the system — working with insurers’ medical review panels to get approval or referring the patient to a specialist for a diagnosis that is covered.
"I think physicians lean the other way, that they maintain their ethics and reputations with third-party payers, and still get the care their patients need," he adds.
Glover, as a hospital administrator, says he sees value in Werner’s study in identifying pressures that are created by today’s third-party payer system.
"Health care is the only industry in which when technology develops, costs go up, not down," he says. "One of the exciting forces playing in health care is evidence-driven medicine, and as technology advances, we can get that more and more in real time.
"That’s a win-win for everyone, because we will be utilizing treatments and other approaches that we know really work, and that’s always the best route to cost savings."
Glover says he finds that when physicians err in coding, it’s usually to their own detriment.
"When they should be coding for better reimbursement, what happens is usually the opposite," he says.
2000 study: Some MDs say gaming is ethical
In a study published in 2000 by Matthew Wynia, MD, MHP, of the American Medical Association’s Institute of Ethics, in the Journal of the American Medical Association, 28.5% of physicians agreed with the statement, "Today it is necessary to game the system to provide high-quality care," and 15.3% agreed with the statement, "In general, it is ethical to game the system for your patients’ benefit."
The 2000 study found that physicians reported three ways of manipulating reimbursement rules: exaggerating the severity of patients’ conditions to help avoid early hospital discharge was the most commonly used method (28%), changing official diagnosis codes was second (24%), and recording signs or symptoms that the patients did not have was the third method (10%).
Wynia, too, theorized that the practice of manipulating information to ensure patient coverage is likely to increase.
"It’s a difficult situation," says Werner. "Doctors have a hard time balancing what’s best for their patients and the restrictions of the third-party system."
Resources
- Wynia M, et al. Physician manipulation of reimbursement rules for patients: Between a rock and a hard place. JAMA 2000; 283:1,858-1,865.
- Werner R, et al. Lying to insurance companies: The desire to deceive among physicians and the public. Am J Bioethics 2004; 4:53-59.
Sources
- Timm Glover, MDiv, Vice President, Mission and Leadership, Middle Tennessee Medical Center, Murfreesboro. Phone: (615) 396-4100.
- Rachel Werner, MD, PhD, Staff Physician, Philadelphia Veterans Affairs Medical Center; Assistant Professor, Internal Medicine, University of Pennsylvania, Philadelphia. E-mail: [email protected].
- Matthew Wynia, MD, MPH, Institute for Ethics, American Medical Association, 515 N State St, Chicago, IL 60610. E-mail: [email protected].
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