Physician manipulation of reimbursement rules for patients - Between a rock and a hard place

Context Health plan utilization review rules are intended to enforce insura nce contracts and can alter and constrain the services that physicians prov ide to their patients. Physicians can manipulate these rules, but how often they do so is unknown. Objective To determine the frequency with which physicians manipulate reimb ursement rules to obtain coverage for services they perceive as necessary, and the physician attitudes and personal and practice characteristics assoc iated with these manipulations. Design, Setting, and Participants A random national sample of 1124 practici ng physicians was surveyed by mail in 1998; the response rate was 64% (n = 720). Main Outcome Measure Use of 3 different tactics "sometimes" or more often i n the last year: (1) exaggerating the severity of patients' conditions; (2) changing patients' billing diagnoses; and/or (3) reporting signs or sympto ms that patients did not have to help the patients secure coverage for need ed care. Results Thirty-nine percent of physicians reported using at least 1 tactic "sometimes" or more often in the last year. In multivariate models comparin g these physicians with physicians who "never" or "rarely" used any of thes e tactics, physicians using these tactics were more likely to (1) believe t hat "gaming the system" is necessary to provide high-quality care today (od ds ratio [OR], 3.67; 95% confidence interval [CI], 2.54-5.29); (2) have rec eived requests from patients to deceive insurers (OR, 2.44; 95% CI, 1.72-3. 45); (3) feel pressed for time during patient visits (OR, 1.69; 95% CI, 1.2 1-2.37); and (4) have more than 25% of their patients covered by Medicaid ( OR, 1.60; 95% CI, 1.08-2.38). Notably, greater worry about prosecution for fraud did not affect physicians' use of these tactics (P =.34). Of those re porting using these tactics, 54% reported doing so more often now than 5 ye ars ago. Conclusions A sizable minority of physicians report manipulating reimbursem ent rules so patients can receive care that physicians perceive is necessar y. Unless novel strategies are developed to address this, greater utilizati on restrictions in the health care system are likely to increase physicians ' use of such manipulative "covert advocacy" tactics.