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To the Editor: Dr Wynia and colleagues¹ found that physicians sometimes manipulate reimbursement rules to benefit patients, themselves, or both. When reimbursement rules are bent, the physician always benefits.

Under fee-for-service arrangements, common manipulations include unnecessary hospitalizations and additional hospital days, higher levels of coding of services, or alleging nonexistent pathology to justify cosmetic procedures. Each of these actions increases income for the physician.

Under the capitation model of managed care, physician practices are frequently monitored using risk-adjusted outcomes. Manipulating the rules for reimbursement subverts such monitoring and often results in more favorable profiling of the physician.

Patients need to understand what services they are entitled to under their policy. The public and professional tension between rationing care and rationalizing care does not justify fraud. A physician who would lie for a patient would likely lie to a patient.

Lawrence W. O'Neal, MD
St Louis, Mo

1. Wynia MK, Cummins DS, VanGeest JB, Wilson IB. Physician manipulation of reimbursement rules for patients: between a rock and a hard place. JAMA. 2000;283:1858-1865. FREE FULL TEXT

To the Editor: Even . . . [Full Text of this Article]

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