Reports From The Field-Managed care

Plan contracts force docs to manipulate rules

Study finds nearly 40% fudge bills

Health plan utilization rules appear to be forcing a large minority of physicians to employ strategic tactics to obtain coverage for patient services, according to a recent study report in The Journal of the American Medical Association.

Researchers mailed surveys to a random sample of 1,124 practicing physicians in 1998. Seven hundred and twenty physicians responded, for a response rate of 64%. Physicians were asked how often they had used one of three tactics in the past year to obtain reimbursement for patient services:

• exaggerating the severity of patients' conditions;

• changing patients' billing diagnoses;

• reporting signs or symptoms that patients did not have to help the patients secure coverage of needed care.

Thirty-nine percent of physicians reported using at least one of the listed tactics "sometimes" or more often in the past year. In multivariate models comparing that 39% to physicians who reported "never" or "rarely" using any of the listed tactics, researchers uncovered that physicians who use the tactics often are more likely to:

• believe that "gaming the system" is necessary to provide high-quality care;

• have received requests from patients to deceive insurers;

• feel pressed for time during patients' visits;

• have more than 25% of their patients covered by Medicaid.

In addition, of those physicians who reported using the tactics often, 54% reported doing so more often now than five years ago.

Researchers concluded that unless novel strategies are employed to address this issue, great utilization restrictions in the health care system are likely to increase physicians' use of "covert advocacy" tactics to obtain coverage for their patients.

[See: Wynia MK, Cummins DS, VanGeest JB, Wilson IB. Physician manipulation of reimbursement rules for patients. JAMA 2000; 283:1,858-1,865.]