Many physicians are so frustrated by managed-care plan denials of patient care that almost half the respondents in a recent survey admitted exaggerating patients' conditions to get treatments approved.
The Harvard School of Public Health conducted the survey of 1,053 physicians and 768 nurses. Almost nine of 10 doctors reported that a patient they treated had been denied coverage for some type of care they recommended-usually a specific prescription drug-in the past two years. Doctors said they believed the denials had harmed their patients' health.
Two-thirds of the physicians said they had tried to intervene with health plans on their patients' behalf.
Specialists were more critical of managed care than were primary-care physicians. Seventy percent of specialists reported that managed care had affected their patients negatively, compared with only 58% of primary-care physicians.
Mental health providers reported the most denials (65%) that seriously affected patients' health. They had trouble getting approval to admit substance abuse patients into residential treatment programs or to prescribe the proper medications.
The American Association of Health Plans rebutted the findings, pointing out that the study did not provide the number of denials as a percentage of the patient base. "Even very infrequent coverage denials can produce a high percentage of physicians reporting some type of denial," the AAHP said in a written statement.
In many cases, initial denials result from insufficient information from doctors, the AAHP said. Denials are often reversed when more information is provided.
The survey also failed to account for cases in which recommended care may be inappropriate, unnecessary or unsupported by scientific evidence, the HMO lobby said.
However, the study specified some denials and their harmful effects. For example, a doctor reported that a patient with an irregular mammogram had to wait six months for a breast biopsy, which resulted in breast cancer.
To help protect patients in managed-care plans, all 50 states have enacted some kind of legislation, according to a report by the National Conference of State Legislatures. For example, 47 states have banned gag clauses, and 36 states mandate coverage without preauthorization for emergency-care services such as screening and stabilization.
In a report about managed-care quality released this week, the National Committee for Quality Assurance said that health plans that routinely disclose their Health Plan Employer Data and Information Set, or HEDIS, scores perform better clinically than those that don't. This year, 410 health plans permitted their scores to be released, up sharply from 292 last year.