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Health Care Reform:

Health Insurance & Affordable Care Act

Doctors Willing to Deceive Health Plans for Patients

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Suggesting a possible link with increasingly aggressive managed care cost-control practices, more than half of these physicians said they gamed the system more frequently than they had five years earlier. Yet 61% of physicians said that they rarely or never manipulated payment rules.

Additional survey questions revealed that doctors' willingness to manipulate health plan rules was strongly linked to their belief that such behavior was necessary to provide high-quality care. Almost 29% of the survey's physicians thought it necessary to game the system to provide high-quality care. Nevertheless, just over 15% of the physicians in the survey said that they believed it was ethical to do so.

"They are being asked to do something that they believe is unethical in order to do a good job," Wynia tells WebMD.

But Young disagrees, saying "there is no question in the research literature that 20% or more of health care services are unnecessary. Doctors are doing whatever they can to lash out against managed care."

Of the doctors surveyed, 37% reported that patients had requested that they deceive their health plan, a factor that Wynia says correlated strongly with physicians who reported that they gamed the system. And doctors who said that they had insufficient time with their patients also were more likely to engage in deceptive practices.

Young notes that this deception by doctors brings "potential harm" to patients. "If you put something on a medical record, a diagnosis that is not accurate, the individual then could have that diagnosis carried with them," he tells WebMD. "If you put down diabetes when in fact they don't have diabetes ? it may interfere with their getting life insurance."

While doctors may be deceptive, they do not necessarily deceive for greed. "Physicians with potentially greater financial stakes in manipulating reimbursement rules did not report doing so more often," the authors write.

The problem isn't likely to get better anytime soon, as cost-control pressures are certain to only intensify in the health system, the study notes. But the survey "may stimulate more scrutiny of physicians and physician claims," says Young. "This just lays out that there is substantial fraud going on out there."

"There is a fundamental conflict here and neither society nor doctors have a clue as to how to answer it," Georgetown University law professor Gregg Bloche, MD, JD, tells WebMD. "The conflict is between ? the notion that physicians have a duty of undivided loyalty to patients, and the 20th and 21st century reality that health care is much too expensive to be paid for by individual folks out-of-pocket."

 

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