brand logo

Am Fam Physician. 2000;61(5):1455-1456

Physicians have been under increasing pressure from managed care organizations to cut health care costs. As the managed care organizations impose stricter control on access to medical treatments, physicians face new ethical dilemmas. Anecdotal evidence suggests that some physicians have chosen to “game” the system in order to obtain care for their patients. The full extent of the deception of third-party payers is unknown. Freeman and associates studied physicians' willingness to deceive insurance companies in order to secure care for their patients.

A cross-sectional mailed survey was used to evaluate physician willingness to use deception in six vignettes with scenarios ranging in clinical severity: coronary bypass surgery, arterial revascularization, intravenous pain medication and nutrition, screening mammography, emergent psychiatric referral and cosmetic rhinoplasty. In each vignette, physicians were presented with a scenario in which a colleague was considering deceiving a third-party payer to secure treatment for a patient. The physicians were asked whether the colleague should deceive the third-party payer, and then they were asked how they, their colleagues and society would rate the deceptive behavior on a five-point Likert scale: 1 (clearly justified) to 5 (clearly unjustified).

The primary outcome was physicians' sanctioning of a colleague's deception of the third-party payers. Of 602 randomly selected physicians, 169 responses were used in the analysis. The respondents were predominantly women (52.7 percent) and white (81.7 percent), with a mean age of 41.6 years. A total of 40.8 percent practiced at academic medical centers.

Most physicians sanctioned deception to obtain authorization for coronary bypass surgery (57.7 percent) and arterial revascularization (56.2 percent). Many physicians also approved of deception to obtain mammography (34.8 percent), intravenous pain medication (47.5 percent) and psychiatric referral (32.1 percent). Few physicians supported deception for cosmetic rhinoplasty (2.5 percent). Physicians practicing in areas of high managed care penetration were more likely to sanction deception in all areas. Sanctioning the use of deception was associated with the clinical severity of the vignettes. More than 26 percent of physicians did not support deception in any vignettes, while 13.6 percent sanctioned deception in all vignettes except cosmetic rhinoplasty.

Most of the responders believed their primary professional responsibility was to practice as a patient advocate. They believed that working within the rules and restrictions of third-party payers was important as long as those rules did not significantly compromise patients' interests.

Results of this study demonstrated that many physicians sanctioned the use of deception to obtain medical care for patients when a third-party payer denied authorization. Sanctioning of deception varied by the clinical severity of the patient's condition. Physicians showed greater support for deception in life-threatening situations than in urgent care needs and in cases of palliative and diagnostic care than in cosmetic care.

The authors conclude that the obligation to abide by insurance companies' stipulations for patient care often conflict with physicians' obligation to act as patient advocates. Although using deception as a solution may solve the problem in the short-term, the long-term loss of integrity is a concern to physicians. Solutions to avoid subterfuge involve broadening the appeals processes and having open dialog between physicians, patients and third-party payers.

Continue Reading

More in AFP

Copyright © 2000 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.