Doctors in Study Back Lying to Aid HMO Patients
Increasingly squeezed by cost-cutting guidelines of health maintenance organizations and other insurers, many physicians say they are willing to exaggerate the severity of patients’ illnesses to achieve coverage that is not otherwise available, researchers said Sunday at an American Medical Assn. conference at UCLA.
As many as 58% of physicians responding to a survey said they would be willing to submit “deliberately deceptive documentation” to an insurance company to ensure that a patient receives a needed heart bypass operation or other care for a life-threatening situation. But at the other extreme, only 2.5% would do so for a “nose job,” said Dr. Daniel P. Sulmasy of the New York Medical College in Valhalla.
Only a quarter said they would never exaggerate claims.
Physicians in areas with a higher percentage of health maintenance organizations were more likely to support such deceptions than those in areas where conventional insurance predominated, according to the study, which is to be published today in the Archives of Internal Medicine.
Physicians are almost daily being subjected to a “moral stress test” that forces them either “to violate their oath to provide the best care for patients or to act dishonestly,” Sulmasy said.
The study follows on the heels of a July report from the Kaiser Family Foundation, which said that more than half of physicians surveyed had patients whose health was seriously impacted by coverage refusals. Many of those physicians also said they had exaggerated claims to obtain coverage for such patients. The AMA’s Institute for Ethics is preparing a similar study that experts said will echo the results presented Sunday.
“The AMA does not sanction fraud and abuse,” said Dr. Yank D. Coble Jr., an AMA trustee. But he lamented the fact that treatment decisions are increasingly being removed from physicians’ hands, necessitating such conflicts of interest.
“We need to remove the doctor from the position of being both the patient’s advocate and the cost controller,” Sulmasy said. “Those two roles are almost always in direct conflict.”
Sulmasy, a medical ethicist, was careful to distinguish such claim exaggerations from Medicare and insurance fraud, which are conducted to line the pockets of physicians. Those are “egregiously wrong,” he said. Even writing a letter to an airline to provide an excuse for missing a scheduled flight is wrong if the patient was not really sick, he added.
The difference in the cases in question, he said, are that the patient’s health is at stake and denial of payment could have an adverse impact.
Such manipulation of claims forms, often called “gaming the system,” is not new. In the early 1980s, Medicare would not pay for routine mammograms for women over 50, although physicians knew they were clearly beneficial. Many doctors would thus claim a diagnosis of “fibrocystic disease” or something similar so that Medicare would pay, Sulmasy said.
Today, deception is more likely to involve care for a mental health problem such as depression because of restrictions in coverage. Referrals to a psychiatrist are often difficult to obtain, he said, and insurers typically will not pay for antidepressant drugs prescribed by a general practitioner.
A physician thus might focus on a particular symptom, such as sleep disorders, and prescribe an appropriate drug that happens to be effective against depression.
In the current study, Sulmasy, Dr. Victor G. Freeman of Inova Health Systems in Fairfax, Va., and their colleagues surveyed 169 internists in eight cities across the country. The team presented them with six hypothetical scenarios and asked if they thought a colleague should submit deceptive insurance claim forms to obtain coverage.
In one scenario, a 55-year-old woman needing a coronary artery bypass was refused coverage because the condition was preexisting and her condition was stable. The hypothetical patient was unable to pay herself. The insurer would pay, however, if she developed progressive chest pain or other symptoms indicating that the condition was deteriorating.
A full 57.7% of the internists said their colleague should submit forms claiming the pain or other justification for the bypass. For the other five scenarios, the proportion in favor of lying was:
* 56.2% for opening a blocked blood vessel in the leg.
* 47.5% for intravenous pain medication and nutrition for a terminal patient suffering nausea.
* 34.8% for mammography.
* 32.1% for a psychiatric referral.
* 2.5% for cosmetic rhinoplasty (a nose job).
Just over a quarter of the physicians did not support deception in any of the scenarios, and 13.6% supported it in all the scenarios except rhinoplasty.
Some who did not support deception said physicians should serve as an advocate on the patient’s behalf in an attempt to change the insurer’s decision. But many doctors suffer from “appeal fatigue” from fighting too many such cases, Sulmasy said. “It’s easier to give up or to fudge the billing sheet.”
But fudging “is hardly the optimal solution,” he added. In the long term, it adds to everybody’s costs and will lead to more bureaucratic scrutiny. “What we need is a better system of cost containment,” he said.
