Researchers find some physicians more willing to misrepresent patient information to avoid the "hassle factor" of appeals process

ANN ARBOR, MI -- Imagine you go see your doctor because you've been suffering from severe chest pain. Your physician diagnoses you with coronary heart disease and puts you on the maximum amount of medication to help ease your pain. But your pain doesn't go away. Your next option is bypass surgery, but your insurance company won't pay for it unless your symptoms get worse. What to do next is the one of the biggest dilemmas facing doctors today.

In a paper published today in the Archives of Internal Medicine, University of Michigan Health System researchers found some physicians are willing to misrepresent clinical information to insurance companies in order for their patients to receive the medical treatment they feel is necessary.

Senior author of the paper, Peter A. Ubel, M.D., associate professor of internal medicine in the University of Michigan Medical School and research investigator at the Ann Arbor Veterans Administration Medical Center, says he's not surprised.

"In an effort to control health care costs, many insurance companies have developed mechanisms to limit physicians' ability to order expensive tests or treatments," says Ubel. "If the HMO says 'no', doctors can appeal, but often, it is a long and burdensome process. So in some cases, physicians lie about their patient's condition."

Using a random survey of 890 physicians with similar scenarios, the study found 11 percent of doctors said they would misrepresent the patient's condition to obtain HMO approval for surgery or additional procedures. Seventy-seven percent said they would appeal the decision, while 12 percent said they would accept it. But when hassle of the appeals process increased, so did the number of physicians willing to misrepresent patient information.

"The 'hassle factor' had a big influence over the doctors' actions," notes Ubel, director of the Program for Improving Health Care Decisions or PIHCD, a new program funded jointly by the
U-M and Ann Arbor's Veterans Administration Medical Center. "In fact, when physicians were told the appeal process would be 50 percent successful, 13 percent reported they would misrepresent, as opposed to 9 percent with a 95 percent success rate."

The study also found time and the severity of the patient's illness directly related to a physician's willingness to deceive an insurance company. If an appeal was estimated to take 10 minutes, 9 percent of doctors would misrepresent data. If the appeal was estimated to take 60 minutes it jumps up to 14 percent. In the case of severity, 16 percent would lie if the case was more severe as opposed to only 7 percent if the case was less severe.

"It's important not to see this as an us-versus-them issue," says Ubel. "We ought to see it as how to find the best way to give people appropriate care, while restraining the use of expensive tests that brings small benefits. The more it is seen as us-versus-them, the more doctors will begin playing by their own rules. If that happens, it is everyone's problem."

Other authors on the study are Rachel M. Werner, M.D., at University of Pennsylvania, G. Caleb Alexander, M.D., University of Chicago, and Angela Fagerlin, Ph.D., University of Michigan Medical School.

---University of Michigan

Back to The Science of Mental Health