Physician advocates said it's a sign of larger systemic problems. Managed-care leaders called it a breach in physicians' ethics. And while most doctors said they don't do it, almost 40% of physicians in a new national survey admitted to deceiving health insurers to obtain treatment coverage they've deemed necessary for their patients.
The doctors were asked if they used any of three tactics to game the system by working around utilization review to benefit patients. The tactics were exaggerating a condition's severity, changing the billing diagnosis and reporting nonexistent signs or symptoms.
The study, conducted via mail by Matthew Wynia, M.D., assistant vice president of the American Medical Association's Institute for Ethics, Chicago, was based on answers from 720 practicing physicians in 1998. The results appeared in the April 12 issue of the Journal of the American Medical Association.
The AMA is on a crusade against the managed-care industry, fighting for antitrust relief to allow collective bargaining for physicians, joining class-action suits against insurers and pushing for patient-protection legislation that would allow enrollees to sue HMOs for malpractice.
The journal's editor said JAMA does not speak for the AMA.
"The AMA has no idea what we're publishing until it is in print," said Catherine DeAngelis, M.D., editor of JAMA. "This has nothing to do with AMA policy. If it was the exact opposite, we would still publish this study, which is very good. We have total and absolute editorial freedom."
A belief that gaming the system is necessary to get patients high-quality care topped the list of factors that influenced the doctors' decision. And those who felt this necessity were significantly more likely than those who didn't to believe their reporting manipulations are ethically acceptable. The majority of respondents, however--even those who said it was necessary--did not feel gaming is an ethical practice.
Stephen Fatum, a healthcare attorney with the Chicago office of Barnes & Thornburg, said the study results are symptomatic of a broken system. Physicians face the dilemma, he said, of working with managed-care rules they didn't help create. He questioned the insurance industry's procedures for determining what is medically necessary.
"What is the level of training of the people at the utilization-review firms who make the decisions?" asked Fatum, whose practice focuses on legal and strategic matters affecting physicians and physician organizations. "Some could say (managed-care plans) are gaming the system by using people who are unqualified, replacing those who are (the physicians)."
Donald Young, M.D., medical director and chief operating officer for the Health Insurance Association of America, disagreed.
"This study said a lot of doctors knew what they were doing. So it's not a matter of education," said Young, the former executive director of the Prospective Payment Assessment Commission, which advised Congress on Medicare payment policies. "It's a matter of physicians examining themselves and adhering to ethical standards in their treatment practices as well as their billing practices."