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Between a Rock and a Hard Place

Matthew K. Wynia, MD, MPH; Deborah S. Cummins, PhD; Jonathan B. VanGeest, PhD; Ira B. Wilson, MD, MSc

JAMA. 2000;283:1858-1865.

Context  Health plan utilization review rules are intended to enforce insurance contracts and can alter and constrain the services that physicians provide 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 reimbursement rules to obtain coverage for services they perceive as necessary, and the physician attitudes and personal and practice characteristics associated with these manipulations.

Design, Setting, and Participants  A random national sample of 1124 practicing 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 in the last year: (1) exaggerating the severity of patients' conditions; (2) changing patients' billing diagnoses; and/or (3) reporting signs or symptoms that patients did not have to help the patients secure coverage for needed care.

Results  Thirty-nine percent of physicians reported using at least 1 tactic "sometimes" or more often in the last year. In multivariate models comparing these physicians with physicians who "never" or "rarely" used any of these tactics, physicians using these tactics were more likely to (1) believe that "gaming the system" is necessary to provide high-quality care today (odds ratio [OR], 3.67; 95% confidence interval [CI], 2.54-5.29); (2) have received 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, 1.21-2.37); 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 reporting using these tactics, 54% reported doing so more often now than 5 years ago.

Conclusions  A sizable minority of physicians report manipulating reimbursement rules so patients can receive care that physicians perceive is necessary. Unless novel strategies are developed to address this, greater utilization restrictions in the health care system are likely to increase physicians' use of such manipulative "covert advocacy" tactics.

Author Affiliations: Institute for Ethics, American Medical Association, Chicago, Ill (Drs Wynia, Cummins, and VanGeest); and the Division of Clinical Care Research, New England Medical Center, Boston, Mass (Dr Wilson).

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