Health Affairs, 22, no. 6 (2003): 283-284 doi: 10.1377/hlthaff.22.6.283 © 2003 by Project HOPE	New Online   Obama's Success & Next Steps   3 Health Policy Options for President Obama   A Hybrid Proposal   Bipartisan Compromise

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Letters

Physicians Facing Coverage Restrictions

The basic dilemma is this: Are there limits to the health coverage available to most Americans (and, for that matter, to most people anywhere in the world)? Are there instances in which some physicians would like to offer a service that is not covered by the patient’s health benefit package? The answer to both is yes. But there is nothing new about this dilemma. The earliest forms of U.S. health insurance provided indemnification for hospitalization only. Doctors offering services other than hospitalization for acute illness were well aware that patients would have to pay for such treatments out of pocket. Did this cause doctors not to discuss these services with patients? Perhaps it did, rarely, for reasons such as the patient’s indigence or uncertainty about outcome. But it has never been suggested that such behavior was the norm.

What has changed is that medicine today is more complicated and expensive, and the range of available services and treatments has vastly increased. Private and public purchasers try to maximize access to services within their ability to finance benefits, and health plans work to create plans that will meet both purchasers’ requirements and patients’ expectations. But coverage, which is much more inclusive than in the hospitalization-only days, is ultimately limited by purchasers’ ability to pay.

Instead of acknowledging the inevitable tension between what consumers may want and what purchasers can afford, the authors chose to ask physicians loaded questions. Because of the vague and subjective formulation of these questions, we cannot be sure from this paper whether doctors are hogtied by objectively unreasonable coverage restrictions; unclear about what is or isn’t covered and why, and thus uncertain about what to suggest to their patients; or simply expressing their frustration that not everything they want to do will always be covered by employers’ benefit packages. The authors would lead readers to choose the first interpretation, but it would be just as reasonable to conclude that there are many U.S. physicians who withhold information from patients solely because of "perceived" rather than actual coverage restrictions. If true, this would be cause for profound concern about their ethical integrity. Fortunately, there is scant evidence to justify such concern. Good doctors do not deal in speculative perceptions about coverage and care options, any more than they would make a complex diagnosis without actually seeing the patient.

Karen Ignagni

American Association of Health Plans Washington, D.C.

We agree that knowledgeable observers can disagree about what is medically necessary and that finding the balance between available and appropriate is indeed a challenge. Karen Ignagni asserts that we ignore the "inevitable tension" between what patients may want and what purchasers can afford. To the contrary, the main goal of our research was to empirically examine how physicians address this tension in day-to-day practice. Our data do not suggest, as she implies, that it is "the norm" for doctors not to discuss uncovered services with patients. In fact, our results suggest that this is relatively uncommon. Almost 70 percent of physicians reported "never" or "rarely" doing so. Research to understand the magnitude and trend of this problem can help inform dialogue about the tensions Ignagni describes.

Regarding our research question, in the discussion we note that one limitation of surveys is that they register respondents’ perceptions. Since many physicians must deal with ten or more health insurance plans, we postulated that some physicians might be incorrect in reporting about coverage restrictions. Finally, Ignagni concludes that it is "no secret that surveys can be designed to prove what their designers want to prove." In previous work we showed that a sizable minority of physicians report manipulating reimbursement rules so that patients can receive care that physicians perceive is necessary.¹ This finding was in line with our a priori hypotheses. The survey item about not offering useful services was included as an intended contrast to the manipulation items. That is, we expected that only a negligible number of physicians would endorse it, and we were quite surprised by our findings.

Matthew K. Wynia

American Medical Association Chicago, Illinois

Editor's Notes

The views in this letter are those of the authors and should not be construed as official policies of the AMA.

NOTE

1. 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]

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