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Fam Pract Manag. 2000;7(5):25-27

Physicians sidestep health plan rules to help patients receive care

A “sizeable minority” of physicians say they have manipulated information given to insurance plans to ensure that their patients receive the care they deem necessary, according to a study published in the April 12 Journal of the American Medical Association.

Thirty-nine percent of the 720 physicians participating in the study said they had used at least one of the following tactics “sometimes” or more often in the last year: exaggerating the severity of patients' conditions to help them avoid early hospital discharge (28 percent), changing patients' official billing diagnoses (24 percent), or recording signs or symptoms patients do not actually have to help them secure coverage for needed care (10 percent).

Physicians who used these tactics were more likely to agree that “gaming the system” is necessary to provide high-quality care today and were more likely to have received such requests from patients. “These physicians may see manipulation of reimbursement rules as an indirect, or covert, form of patient advocacy and even a professional obligation,” wrote the authors.

They speculate that increased utilization restrictions by health plans may lead to greater numbers of physicians manipulating health plan rules.

What are you paying your office manager?

Source: Special report: 1999 salary survey, Part B News, Jan. 3, 2000.

HMO accused of using flawed data for reimbursements

The AMA and the Medical Society of the State of New York recently filed a class-action lawsuit against UnitedHealth Group (previously United HealthCare), alleging that the Minnesota-based insurer uses faulty data to reduce reimbursements to doctors and plan members nationwide. Metropolitan Life Insurance Co. was also named in the suit.

In determining physician reimbursements, health plans typically factor in the “reasonable and customary” rate, which is based on the amount charged by similarly trained physicians for comparable services within a specific geographic area. According to the AMA, the data used by UnitedHealth Group to determine these rates are flawed and underestimate actual medical charges.

Donald Palmisano, MD, JD, an AMA trustee, commented in the March 16 Wall Street Journal that “the case calls into question the entire payment mechanism that the insurance companies have used for years in paying physicians.”

UnitedHealth Group has not yet issued a statement, but Chip Kahn, president of the Health Insurance Association of America said the lawsuit simply “seeks more money for doctors.”

Patients may not be revealing drug complications

Many doctors may never know that their patients have suffered adverse reactions to prescription drugs. A study conducted by Brigham and Women's Hospital, Boston, of over 2,000 outpatients found that while 18 percent of patients had experienced a drug complication, only 3 percent of their charts included documentation of the complication. “Clearly, some disconnect in patient-physician needs to be bridged,” said Tejal K. Gandhi, MD, MPH, lead author of the study.

Gandhi speculates that patients may not be telling their doctors of the drug complications because shorter office visits don't allow them to raise all of their concerns.

The drugs most commonly associated with adverse events were antibiotics, antidepressants and non-steroidal anti-inflammatory agents. On chart review, 13 percent of the adverse events were found to be avoidable because the patient had a previously documented allergy to the drug.

Physician computer use

While most physicians have access to computers and the Internet, relatively few are optimizing this technology within their practices, according to a Harris Interactive survey of 769 physicians.

83%Access the Internet from their homes.
51%Access the Internet from their personal office areas.
34%Access the Internet in their clinical work areas.
32%Work in practices with Web sites.
28%Use computers to access patient information.
52%Use computers to receive laboratory test results.


After buying back its assets from MedPartners practice management company, one Southern California multispecialty group is landing on its feet. Talbert Medical Group says it has met key benchmarks in its first six months of independence by focusing on strengthening community ties, improving patient service and building a stable network of physicians.

Patients' rights

Family physicians from across the country descended on Capitol Hill last month urging Congress to enact a patients' bill of rights. The physicians presented stethoscopes and calculators, representing health care run by physicians vs. accountants, to each member of the congressional conference committee charged with creating a compromise bill.

Seniors' medical expenses

On average, senior citizens spend 19 percent of their total income on out-of-pocket medical expenses each year, according to a recent study published in the Journal of Gerontology. The poorest elderly are the most vulnerable demographic group, paying out 32 percent of their income; the wealthiest elderly spend 9 percent of their income on medical care.


Sixty-five percent of boys in 5th through 12th grade want their physicians to discuss drugs with them, and 75 percent of 11- to 17-year-olds would trust a doctor “a lot” on issues such as drugs and sex, according to a recent report by Children Now, a child advocacy group. But some physicians aren't reaching out to teen patients. In one study, while 61 percent of family physicians said they like working with teen patients, only 34 percent of internists and 31 percent of pediatricians agreed.

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