In a stunning communal confession, nearly 40 percent of physicians queried in a random survey admitted that, in the last year, they deceived insurance companies to help patients get needed care.
The deceptions included exaggerating the severity of patients' conditions; changing billing diagnoses; and reporting signs or symptoms that patients did not actually have.The tactics came to light after researchers mailed surveys to 1,124 practicing U.S. physicians in 1998; of those, 720 replied and 39 percent said they "sometimes" employed one or more of these deceptive practices to secure insurance coverage for their patients.
"As a physician, I can tell you that this is a widespread practice, but it is not part of any systematic effort to defraud insurance companies," said one of the study's co-authors, Dr. Ira B. Wilson, a New England Medical Center internist and assistant professor of medicine at Tufts University School of Medicine.
The study appears in the current Journal of the American Medical Association.
The most startling aspect of the results is that they document, possibly for the first time, what doctors are doing in their day-to-day practices, said Wilson. Within the profession, fudging insurance company forms to ensure that patients are reimbursed is anything but a secret. It is simply the "daily struggle" doctors face, said Wilson, in an age when cost-cutting is king. Indeed, the authors predict that: "As pressures to control health-care costs increase, it is likely that manipulating reimbursement systems will increase in parallel."
In statistical models comparing the physicians who used manipulative practices to those who "rarely" or "never" did, the researchers found that the manipulators believe that "gaming the system" is necessary to provide high-quality care in today's marketplace; receive more requests from patients to deceive insurers; feel pressed for time during patient visits; and have more than 25 percent of patients covered by Medicaid. The authors say the latter could be due to physicians' desire to benefit patients, themselves or both, as Medicaid reimbursement rates are often lower than those of commercial payers.
However, the authors point out that their findings suggest that financial self-interest was not a major motivating factor for doctors who fudged reimbursement forms. In the most common situations, such as getting patients into the hospital, doctors were not in a position to profit from their actions.
In fact, the authors write, physicians who experienced recent financial losses in their practices did not report altering insurance forms at any greater rate than others.
HMO officials said the study showed people are getting benefits for which they have not paid.
"The people who pay for that are everybody else who's paying for the premiums," Dr. Charles M. Cutler, chief medical officer for the American Association of Health Plans, told the Associated Press. Cutler said the practice, if continued, would cause health-care costs to rise even faster.
But Wilson said he does not believe the study is about "good guys and bad guys." "This is not a story about physicians and big bad insurance companies. It's a story about how all of the actors -- the patients, physicians and payers -- need to move closer together and have an open and agreed upon social dialogue" about what criteria should be used to ensure fair access to care, be it tests, medications, or hospitalization.
How might this be accomplished? Insurance companies, for example, might stop their unstated, but widely believed practice of rationing care by routinely denying coverage for certain procedures but then paying for them after doctors file appeals "knowing that time and other constraints will prevent some appeals," wrote the authors.
"For the most part, doctors are not reimbursed for their time," said Dr. Matthew K. Wynia, the study's lead author and assistant vice president of the Institute for Ethics, an independent research arm of the American Medical Association, which funded the study. "Many physicians tell me, 'there's no way I could appeal everything I think ought to be appealed; I'd spend all day on the phone.' "
Patients could contribute to solving the problem by putting less pressure on doctors to perform tests or prescribe drugs that doctors feel are unnecessary, said Wynia. Yet blaming patients is the last thing Wynia and Wilson said they want to do.
Ideally, utilization review systems by insurers should be "more user friendly, quicker, more patient friendly and less punitive to physicians," said Wynia. Physicians are often marked as "troublemakers" by insurers, and can be fired, if they continually appeal the companies' decisions.
When pressed about how their study might be used to change the system so doctors don't have to be reduced to cheating, both authors indicated that there must be some kind of formal process or forum in which doctors and patients are more fully involved in the an insurer's decision-making process. "If patients and physicians were involved in those decisions at the outset, there might be a better buy-in," said Wynia.
And patients and doctors would be more likely to "buy in" if they were privy to the process that went into deciding why a particular insurance company, for example, will pay for eight tablets of Viagra a month, said Wynia. "What's the process and the rationale? If patients and doctors can turn to a rationale and accept it, that's fine. If they say we need to appeal this; there should be a legitimate process of appeal."