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Datawatch

Do Physicians Not Offer Useful Services Because Of Coverage Restrictions?

Abstract

 
Ethically, physicians should discuss all medically appropriate services with patients, but coverage restrictions can make these discussions difficult. In a national survey of physicians, we asked how often physicians elected not to offer their patients useful services because of health plan coverage rules. During the course of a year, 31 percent reported having sometimes not offered their patients useful services because of perceived coverage restrictions. Among these, 35 percent reported doing so more often in the most recent year than they did five years ago. It can be frustrating for doctors to discuss uncovered services with their patients, but open communication is necessary for shared decision making and to improve coverage decisions.

How physicians respond to coverage restrictions is a matter of ethical and policy significance, and physicians have several options for addressing coverage refusals. For instance, some physicians report manipulation of health plans’ reimbursement rules to help their patients obtain needed care.⁵ Dubbed "gaming the system," this is an option that some physicians use even though it violates professional ethical standards and, in the extreme, can constitute fraud.⁶ Physicians also might appeal for coverage, although doing so can be time-consuming, and some physicians report fears of deselection over appeals.⁷ Additional options include recommending out-of-pocket payment for uncovered services, using less expensive or covered alternatives, or, where possible, providing uncovered services for free. Some physicians also report recommending that patients switch insurers.⁸

One option, however, carries special ethical and legal hazards: not offering services that would not be covered by patients’ insurance, despite their usefulness. This tactic could avoid unpleasant and potentially time-consuming confrontations with patients and their insurers, although it also might deny patients relevant information and therefore present a liability risk for the physician. Not discussing useful care because of coverage rules is strongly discouraged in codes of medical ethics.⁹ In the late 1990s considerable attention was paid to the possible existence of "gag clauses" in physician–health plan contracts, which legally prohibited physicians from discussing uncovered services with their patients. These clauses greatly troubled the profession, the public, and lawmakers, and federal and state legislation was proposed to make them illegal.¹⁰ Apart from these contractual clauses, little attention has been given to whether physicians might not offer useful services to patients because of coverage restrictions. In this study we use data from a national survey of physicians to explore this question.

Study Methods

Top Study Methods Study Results Discussion Editor's Notes NOTES

 
Physician sampling. A self-administered survey was mailed in 1998 to a random sample of physicians from the American Medical Association (AMA) Masterfile, which includes all licensed U.S. physicians. The sample consisted of 1,124 eligible physicians, of whom 720 (64 percent) responded.

Data collection. Data collection methods have been previously reported in detail.¹¹ The survey was supported by the AMA Institute for Ethics and conducted by the National Opinion Research Center at the University of Chicago. Information provided by respondents was kept strictly confidential. An independent institutional review board (Western IRB, in Olympia, Washington) approved the study protocol.

Variables. Questionnaire items were developed from the literature, from a 1996 pilot survey of 134 physicians attending a scientific meeting, and from a focus group of practicing physicians. Several items have been shown to have good test-retest reliability.¹² The dependent variable in our analysis was an item asking, "How often, in the last year, have you decided not to offer a useful service to patients because of health plan coverage rules?" We used the term "useful" rather than "medically necessary" because ethical standards call on physicians to discuss all medically useful, or appropriate, options with their patients and not to allow coverage considerations to affect initial counseling regarding treatment options.

Independent variables included demographic characteristics, practice characteristics, and specific attitudes about and experience with payers and patients. Demographic characteristics included number of years in practice, physicians’ country of origin, practice region, urban or rural practice, specialty, and gender. Practice characteristics included number of managed care contracts; fraction of income at risk based on patient care costs; percentage of income from capitation, salary, or fee-for-service; recent income gains or losses; fraction of patients covered by Medicare or Medicaid; employment type; and number of patient visits per week and per clinical session.

Physicians’ attitudes were assessed through a series of items posed as agree-disagree statements, using a five-point Likert scale. Each of these items was collapsed for analysis into three categories: those who agreed (including agree or strongly agree), those who disagreed (including disagree or strongly disagree), and those who were not sure. Items addressed time pressures faced by physicians, perceived hassles of utilization review, overall satisfaction with medical practice, and physicians’ sense of responsibility for cost control. One item asked physicians to report how often, if ever, patients asked them to mislead insurers to help them obtain uncovered services. Finally, although this is a cross-sectional survey, we assessed the longitudinal trend by asking those physicians who reported having not offered useful services also to report whether they did so more often, less often, or as often in the past year compared with five years ago.

Statistical analysis. For multivariable modeling, we decided a priori to dichotomize the dependent variable such that those answering "never" and "rarely" would be compared with those answering "sometimes," "often," or "very often." Continuous independent variables were dichotomized at cutpoints based on their distributions and clinical importance. For categorical variables with "agree," "disagree," and "not sure" categories, the "disagree" category was used as the comparison group. One categorical variable ("How often have your patients requested that you in some way deceive their third-party payer to help them secure coverage for a service?") had five response options ranging from "never" to "very often." This variable was dichotomized by collapsing the "never" and "rarely" categories and the "sometimes," "often," and "very often" categories. Bivariate relationships between the dependent variable and independent variables were then assessed using t-tests for continuous variables and Chi-square tests for ordered variables. Variables with bivariate relationships to the dependent variables of p < .2 were entered into a straight-entry logistic regression model.

Study Results

Top Study Methods Study Results Discussion Editor's Notes NOTES

 
Respondent characteristics. Physicians who completed the questionnaire have been described in earlier reports and did not differ from nonrespondents on available demographic variables.¹³ The sample did not differ from national statistics on key demographics (specialty, sex, age), although it did contain a larger-than-expected proportion of foreign-born physicians (40 percent versus 27 percent).¹⁴ Foreign-born physicians, however, were not more likely to have responded to the survey and were statistically similar to American-born physicians on all demographic, practice, and attitudinal factors except for the dependent variable.

Frequency and trend. Overall, 31 percent of physicians reported not offering useful care to patients because of health plan coverage rules at least "sometimes" in the past year (Exhibit 1). In contrast, 69 percent reported "rarely" or "never" using this tactic. Among physicians who reported not offering useful services in the past year, 35 percent reported doing so more often than they did five years ago.

View larger version (23K): [in this window] [in a new window]   Exhibit 1 Frequency And Trend Of Physicians Not Offering Useful Services To Patients Because Of Coverage Restrictions, 1998 SOURCE: Authors’ analysis. NOTE: Right-side graph represents a subset of left-side graph.

Discussion

Top Study Methods Study Results Discussion Editor's Notes NOTES

 
Medical decisions today often reflect an increasing attention to patient autonomy, following an idealized model of shared decision making. This model has many potential benefits and has been widely endorsed by clinicians, policy-makers, and ethicists.¹⁵ But for patients to share effectively in medical decisions, they need enough information to participate.¹⁶ Ethical standards state that patients have a right to "be informed of all pertinent medical information," and "physicians have an obligation to assure the disclosure of medically appropriate treatment alternatives, regardless of cost."¹⁷ Yet, as one health care expert has related anecdotally, "A lot of doctors are nervous about describing medically indicated... care that isn’t covered."¹⁸ This study, for the first time, offers an empirical basis for this concern. In this national survey almost one in three U.S. physicians reported not offering useful services to some patients because of coverage restrictions. Moreover, 35 percent of these physicians reported using this tactic more often in 1998–99 than they had five years earlier, which suggests a rising trend.

Strongest rationales. Ethical concerns. The strongest correlate of not offering useful but uncovered services was having experienced patients’ requests to "game the system." Perhaps when uncovered services are discussed, some patients put pressure on physicians to manipulate health plan rules.¹⁹ Since the great majority of physicians (85 percent) do not believe that gaming the system for patients is ethical, some physicians might elect not to offer useful but uncovered services in the hope of avoiding these tense situations.²⁰

Larger volumes of poor patients. Physicians with larger volumes of Medicaid patients were also more likely to report not offering useful care because of coverage restrictions. When a physician is faced with an impoverished patient, choosing not to offer uncovered services might be an understandable, even compassionate, response; after all, why offer a useful medical service to someone who cannot afford it? This reasoning, although reflecting sympathy, is also paternalistic and sometimes incorrect. In addition, African Americans are five times more likely than whites are to be covered by Medicaid.²¹ Given increasing concerns about racial disparities in health care, it would be of great concern if these data reflect physicians’ systematically electing not to offer some services to minority patients.²² In a 1999 survey, 56 percent of the public believed that health disparities arise in part because "most doctors assume that people from minority groups do not have enough insurance or money to pay for the care they get."²³ Although we did not collect data on patients’ race or ethnicity, our physician data lend some credence to this general concern, and future work should address this possibility.

Being American-born. Surprisingly, a physician’s being American-born was one of the few factors statistically associated with not offering useful but uncovered services, although weakly so. Perhaps some foreign-born physicians are more comfortable with restrictions on care and asking patients to accept these restrictions, while American-born physicians and their patients might expect insurance coverage to be broad and deep.

Financial pressures. Finally, financial pressures on physicians might also play a role. Among those physicians (18 percent) with more than 25 percent of income at risk for the costs of patient care, there was a trend toward not offering patients useful but uncovered services. Perhaps limiting certain strong financial incentives might improve patient-physician communication around uncovered services.

Limitations. This study has several important limitations. First, we could not independently confirm reported acts of not offering care to patients. If there were a systematic reporting bias, we believe that it would be in the direction of under-reporting, as embarrassment, perceptions of legal risk, and social desirability would all negatively influence reports on such a sensitive issue. We also could not confirm whether physicians were correct in their assumptions regarding insurance coverage. Utilization review is declining among health plans.²⁴ Some physicians might believe restrictions exist where they do not. If so, then we might have captured some events that do not reflect current coverage restrictions.

Perhaps the most important limitation is that although the items were tested in a focus group and in pretesting, we cannot be certain about each respondent’s interpretation of the questions. Physicians might interpret the term "useful" to mean "medically necessary," "medically appropriate," or "medically acceptable," to name a few possibilities. We used this broad terminology intentionally, to capture physicians’ sense of withholding what they considered to be useful information, and because physicians are ethically obliged to discuss all such options regardless of coverage issues. Yet this breadth has important implications for the careful interpretation of our findings. There are countless examples of potentially useful, but discretionary, services: uncovered medications for which acceptable alternatives exist; services of marginal or unlikely benefit; nonmedical services, such as transportation or food vouchers; and so on. Future research should aim to disentangle these issues. Given the legal and ethical risks involved, it seems less likely that physicians would elect to not offer services that clearly save lives or alleviate significant morbidity; ethically, most will see a difference between not offering an uncovered service that is lifesaving versus one that might result in a slight improvement in symptoms.

Policy implications. In the late 1990s there was widespread concern over managed care "gag clauses," which might have prevented physicians, by contract, from discussing uncovered services with patients. Physicians, patients, and policy-makers bristled at this overt intrusion. Many states passed legislative bans on gag clauses, federal legislation was considered, and health plans largely dropped these clauses from physicians’ contracts.²⁵

This study unfortunately raises these issues anew. In short, some physicians appear effectively to be "gagged" by coverage restrictions. This finding has important ethical and policy implications. We fear that public knowledge of these findings might inadvertently create patient mistrust of the profession. On the other hand, professional understanding of this issue is vitally important and should serve as a catalyst for action. We hope that physicians will reinforce their ethical stand on this issue—perhaps through public expressions of solidarity with professional codes of ethics.

For society, if patients are not told of useful but uncovered services, then they cannot become engaged in important priority-setting discussions in health care. This, too, however, raises an important question about professional ethics and society. Namely, to what degree is it possible, and a professional obligation, for physicians to try to explain to their patients why some useful services are not covered?

Editor's Notes

Top Study Methods Study Results Discussion Editor's Notes NOTES

 
Matthew Wynia is director of the Institute for Ethics at the American Medical Association (AMA) in Chicago. Jonathan VanGeest is a senior scientist in the AMA’s Medicine and Public Health Unit and director of the AMA’s Program on Health Disparities. Deborah Cummins is senior program manager at the National Patient Safety Foundation, based in Chicago. Ira Wilson is an associate professor of medicine at Tufts–New England Medical Center, Division of Clinical Care Research, and Tufts University School of Medicine, in Boston.

These findings were presented in part at the Society for General Internal Medicine’s annual meeting, May 2002, in Atlanta, Georgia. The authors acknowledge Jeanne Uehling, Jennifer Matiasek, and Kari Karsjens for assistance with research and manuscript preparation, and Gregg Bloche for helpful comments on an earlier draft. The views and opinions expressed in this paper are those of the authors and should in no way be construed as representing official policies of the American Medical Association.

NOTES

Top Study Methods Study Results Discussion Editor's Notes NOTES

 

1. Institute for Ethics, American Medical Association, "Commonly Excluded Health Care Services," www.ama-assn.org/ama/pub/category/9461.html (10 April 2003); P.B.Peele, J.R. Lave, and K.J. Kelleher, "Exclusions and Limitations in Children’s Behavioral Health Care Coverage," Psychiatric Services 53, no. 5 (2002): 591–594; [Abstract/Free Full Text]J.A.Buck et al., "Behavioral Health Benefits in Employer-Sponsored Health Plans, 1997," Health Affairs (Mar/Apr 1999): 67–78; and K.Titlow et al., "Drug Coverage Decisions: The Role of Dollars and Values," Health Affairs (Mar/Apr 2000): 240–247.
2. A.M.Garber, "Evidence-Based Coverage Policy," Health Affairs (Sep/Oct 2001): 62–82.
3. California HealthCare Foundation, Determining Medical Necessity: Balancing Science, Economics, and Policy (Oakland: CHCF, 2000).
4. T.M.Shaneyfelt, M.F. Mayo-Smith, and J. Rothwangl, "Are Guidelines Following Guidelines? The Methodological Quality of Clinical Practice Guidelines in the Peer-Reviewed Medical Literature," Journal of the American Medical Association 281, no. 20 (1999): 1900–1905.[Abstract/Free Full Text]
5. M.K.Wynia et al., "Physician Manipulation of Reimbursement Rules for Patients: Between a Rock and a Hard Place," Journal of the American Medical Association 283, no. 14 (2000): 1858–1865; [Abstract/Free Full Text]R.M.Werner et al., "The ‘Hassle Factor’: What Motivates Physicians to Manipulate Reimbursement Rules?" Archives of Internal Medicine 162, no. 10 (2002): 1134–1139[Abstract/Free Full Text]; and V.G.Freeman et al., "Lying for Patients: Physician Deception of Third Party Payers," Archives of Internal Medicine 159, no. 19 (1999): 2263–2270.[Abstract/Free Full Text]
6. AMA, American Medical Association Code of Medical Ethics, Current Opinions (Chicago: AMA, 2002), 138; Ethics and Human Rights Committee, American College of Physicians–American Society of Internal Medicine, "Ethics Manual, Fourth Edition, American College of Physicians," Annals of Internal Medicine (1 April 1998): 576–594; and American College of Obstetrics and Gynecology, "Deception: ACOG Committee Opinion, Committee on Ethics, Number 87—November 1990," International Journal of Gynecology and Obstetrics 37, no. 1 (1992): 63–64.
7. C.R.Gresenz et al., "Patients in Conflict with Managed Care: A Profile of Appeals in Two HMOs," Health Affairs (July/Aug 2002): 189–196; and D.S.Hilzenrath, "Healing vs. Honesty: For Doctors, Managed Care’s Cost Controls Pose Moral Dilemma," Washington Post, 16 March 1998.
8. M.K.Wynia et al., "Patient Protection and Risk Selection: Do Primary Care Physicians Encourage Their Patients to Join or Avoid Capitated Health Plans according to the Patient’s Health Status?" JournalofGeneral Internal Medicine 17, no. 1 (2002): 40–47.[CrossRef]
9. AMA, American Medical Association Code of Medical Ethics, Current Opinions, 112–113; and ACP-ASIM, "Ethics Manual."
10. H.Brody and V.L. Bonham, "Gag Rules and Trade Secrets in Managed Care Contracts: Ethical and Legal Concerns," Archives of Internal Medicine 157, no. 18 (1997): 2037–2043[Abstract/Free Full Text]; and J.H.Krause, "The Brief Life of the Gag Clause: Why Antigag Legislation Isn’t Enough," Tennessee Law Review 67, no. 1 (1999): 1–44.
11. Wynia et al., "Physician Manipulation"; and J.B. VanGeest et al., "Measuring Deception: Test-Retest Reliability of Physicians’ Self-Reported Manipulation of Reimbursement Rules for Patients," Medical Care Research and Review 59, no. 2 (2002): 544–549.
12. S.D.Goold et al., "Measuring Physician Attitudes towards Cost, Uncertainty, Malpractice, and Utilization Review," Journal of General Internal Medicine 9, no. 10 (1994): 544–549[Web of Science][Medline]; and VanGeest et al., "Measuring Deception."
13. Wynia et al., "Physician Manipulation"; and VanGeest et al., "Measuring Deception."
14. TomPasco, AMA, personal communication, 21 July 1999.
15. See, for example, E.J.Emanuel and L.L. Emanuel, "Four Models of the Physician-Patient Relationship," Journal of the American Medical Association 267, no. 16 (1992): 2221–2226[Abstract/Free Full Text]; and J.Balint and W. Shelton, "Regaining the Initiative: Forging a New Model of the Patient-Physician Relationship," Journal of the American Medical Association 275, no. 11 (1996): 887–891.[Abstract/Free Full Text]
16. C.R.Braddock, "Advancing the Cause of Informed Consent: Moving from Disclosure to Understanding," American Journal of Medicine 105, no. 4 (1998): 354–355[CrossRef][Web of Science][Medline]; and B.Brody, "Patient Perception of Involvement in Medical Care: Relationship to Illness Attitudes and Outcomes," Journal of General Internal Medicine 4, no. 6 (1989): 506–511.[Web of Science][Medline]
17. AMA, American Medical Association Code of Medical Ethics, 112–113; and ACP-ASIM, "Ethics Manual."
18. P.Lee, quoted in CHCF, Determining Medical Necessity, RT6.
19. G.C.Alexander et al., "Support for Physician Deception of Insurance Companies among a Sample of Philadelphia Residents," Annals of Internal Medicine 138, no. 6 (2003): 472–475.[Abstract/Free Full Text]
20. Wynia et al., "Physician Manipulation."
21. S.D.Watson, "Race, Ethnicity, and Quality of Care: Inequalities and Incentives," American Journal of Law and Medicine 27, nos. 2–3 (2001): 203–224.
22. M.G.Bloche, "Race and Discretion in American Medicine," Yale Journal of Health Policy, Law, and Ethics 1, no. 1 (2001): 95–131.
23. Henry J.Kaiser Family Foundation, "Survey of Race, Ethnicity, and Medical Care: Public Perceptions and Experiences," in National Survey of Physicians: Part 1: Doctors on Disparities in Medical Care (Chart Pack) (Menlo Park, Calif.: Kaiser Family Foundation, 2002).
24. S.Felt-Lisk and G.P. Mays, "Back to the Drawing Board: New Directions in Health Plans’ Care Management Strategies," Health Affairs (Sep/Oct 2002): 210–217.
25. Brody and Bonham, "Gag Rules and Trade Secrets."

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