A new survey presented last week at the American College of Rheumatology (ACR) conference reveals that doctors sometimes lie to insurance companies to get patients the care they require.

In the survey, published in the October issue of Arthritis and Rheumatism, physicians reported “embellishing” symptoms to get approval for medications, testing, and physical therapy.

A practice first brought to light in the 1990s continues, said Dr. Daniel Sulmasy, and is the product of a broken healthcare system.

“There are those who might think, 'How horrible, these doctors are lying,' and others may say, 'How wonderful, the doctors are being advocates and Robin Hood and redistributing money,'” said Sulmasy, associate director of the MacLean Center for Clinical Medical Ethics at The University of Chicago Medicine. “The real question is, 'What's wrong with our healthcare system that makes doctors think they need to lie to get patients services?”

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More than half of the rheumatologists who responded to the survey said they grapple with the high cost of treatment for their patients. Of 5,500 surveys e-mailed to the ACR's membership, 771 doctors replied.

An 'Unfair' Environment 

"The delivery of medical care takes place in a particular social context, and when this context includes conditions that are unfair, healthcare practitioners may be forced to struggle with ethical conflicts, making trade-offs that may go unrecognized or are not adequately discussed,” the study's lead author, Dr. C. Ronald MacKenzie said in a news release.

MacKenzie, a rheumatologist at Hospital for Special Surgery in New York City, added, “While an optimal or fair system would mitigate these impediments to care, our survey of ACR members suggests that this is often not the case.”

Sulmasy co-authored a study published in 1999 in JAMA Internal Medicine called “Lying for Patients: Physician Deception of Third-Party Payers.”

Lying When It's Needed Most

In Sulmasy's study, more than 150 board-certified internists answered survey questions about when they might lie to get patients the help they needed. More than half said they would do it to get a patient heart surgery. Just fewer than half said it would be necessary for intravenous pain medication or nutrition.

About a third said it would be OK in the case of a mammography or an emergency psychiatric referral. Only 2.5 percent said they would fib for a patient who wanted a nose job.

That the practice of, for example, changing insurance billing codes to get around the rules continues today is no surprise to Sulmasy. He said the current healthcare environment requires doctors to get pre-authorizations for tests and treatments and to prescribe medications other than those they believe are best for the patient.

“These mechanisms are put in place for a good reason, to try and contain healthcare costs. But they really are blunt instruments and time-consuming and annoying for physicians, and those are what feed the temptation to change coding,” Sulmasy said. 

Is the Environment Changing?

Dr. Victor Freeman co-authored the 1999 study with Sulmasy. Freeman, who now works for a company that develops technology aimed at helping doctors do better clinical documentation, said he is also not surprised that doctors still sometimes lie for their patients.

“The fundamental problem is that the American form of fee-for-service reimbursement continually drives up the utilization and, in the turn, the societal costs of medicines, procedures, and services,” he told Healthline. “If you make more [money] by doing more, you will do more.”

In response, state and federal governments and managed care providers pile on loads of red tape. “The result is that physicians find themselves in what I called the Pinocchio Dilemma – they are either 'puppets,' doing what payers require, or 'liars,' embellishing documentation to get around payer restrictions,” Freeman said.

For example, a doctor may have a patient with a simple urinary tract infection, but upcode the bill to say the patient has urosepsis (bacteria in the blood) in order to get a higher rate of reimbursement for the same treatment.

Sulmasy noted that 25 percent of a hospital's budget goes to administrative costs, partly because of the complexities of billing and payments.

Sulmasy believes the Affordable Care Act (ACA) may make things worse in terms of regulation. He believes the country would be well-served by a single-payer healthcare system like Canada's, similar to the Medicare program serving the elderly in the U.S. 

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Will Healthcare Reform Help?

Freeman, who was at Georgetown University Medical Center during the 1999 study, now serves as regional medical director for J.A. Thomas and Associates in Atlanta, a division of Nuance. He believes health care reform is a step in the right direction to address the issue of lying physicians.

He's a proponent of the Accountable Care Organization model, where a single payment is made to a group of providers who work together in one geographic region. The group shares monetary bonuses when patient outcomes improve and costs are contained.

Freeman also believes the ACA will drive physicians into more group-centered environments. This will give them better access to electronic health record technology and promote efficiency, he argues.

“While these new models do not eliminate ethical issues, they do align incentives to promote more cost-effective use of healthcare resources to achieve better patient outcomes,” he said. “Care provider accountability shifts from often overbearing payer oversight toward delivering healthcare that not only meets the standards of local community colleagues but also advances the health status of individual patients and the community.” 

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