Study shows public support for doctors who deceive insurers

March 17, 2003

One out of four people preparing to hear the truth, the whole truth and nothing but the truth have no objection to a doctor lying to an insurance company, according to a study in the March 18 issue of the Annals of Internal Medicine.

When medical researchers surveyed prospective jurors they found that 26 percent of their subjects believed a physician should mislead an insurance company in order to persuade the company to pay for medical care. This finding highlights the public's lack of trust in the health care system and raises concerns about pressures on physicians to bend the rules.

"Both patients and doctors resent restrictions," said study author Caleb Alexander, MD, a research fellow in the Robert Wood Johnson Clinical Scholars Program at the University of Chicago. "Our study suggests that this backlash against managed care has led to considerable public support for physician 'gaming' to gain access to needed care."

Earlier studies found that physicians, frustrated by insurance companies, are willing to misrepresent clinical facts in order to get patients the care they need. These reports raised questions about whether physicians, in trying to help their patients, were instead making people lose trust in them. The current study shows, however, that many of the general public support the idea of misrepresenting clinical facts to insurance companies.

The researchers surveyed 700 prospective jurors, a convenient captive audience, at the Philadelphia County Courthouse in the fall of 1999. Each questionnaire included one of two clinical vignettes.

In one, a physician suggests cardiac bypass surgery for a 55-year-old woman with angina, but the insurance company refuses to pay for the operation unless her symptoms get worse. In the other, a physician wants an MRI scan for a 55-year-old man with persistent back pain who has not gotten better after conservative therapy, but the request is denied.

Should the doctor accept the insurance company's decision, the survey asked, or appeal the decision, or misrepresent the facts to obtain care?

Overall, 26 percent of respondents sanctioned deception, far higher than the 11 percent of physicians who, faced with the same vignettes, would choose little white-coated lies. Seventy percent of the subjects favored appealing the decision. Four percent were willing to accept the company's ruling as final.

Physicians frequently have to struggle to gain access to care for their patients, pitting their dedication to the patient against their commitment to fairness and their obligation to insurance companies and society. Many of the participants in this survey worried that physicians simply did not have the time to appeal denials of care, a process that may soon become even more difficult. Half of those jurors supported deception.

The researchers worry that pressure from patients could make physicians more willing to game the system.

"Insurance companies, in response, may clamp down that much harder on physicians, in efforts to control health care costs and hold down rapidly rising insurance premiums, triggering a vicious cycle," said co-author Peter Ubel, MD, of the University of Michigan Medical School.

Since the pressure to contain health care costs is unlikely to diminish, the difficulty of choosing between advocacy and honesty is likely to increase.

"Dishonesty is a serious threat to physician professionalism," Alexander said. "Better education of the public about the trade-offs between cost containment and access and a more streamlined appeal process might lessen some of the pressure on physicians and increase trust in the system."

The Robert Wood Johnson Foundation and the Department of Veterans Affairs funded this study. Additional authors of the paper are Rachel Werner, MD, and Angela Fagerlin, PhD, of the University of Michigan.

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