Physician manipulation of reimbursement rules for patients - Between a rock and a hard place
Physician manipulation of reimbursement rules for patients - Between a rock and a hard place
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DOI：
10.1001/jama.283.14.1858
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发表时间：
2000-04-12
影响因子：
120.7
通讯作者：
Wilson, IB
中科院分区：
文献类型：
--
作者：
Wynia, MK;Cummins, DS;Wilson, IB
健康计划利用审查规则旨在执行保险合同，并可以改变和限制医生向患者提供的服务。医生可以操纵这些规则，但他们多久这样做是unknow.Objective以确定频率与医生操纵报销规则，以获得覆盖的服务，他们认为是必要的，和医生的态度和个人和实践的特点与这些manipulations.Design，设置，和参与者一个随机的国家样本的1124执业医师进行了调查，通过邮件在1998年;主要观察指标过去一年中“有时”或更频繁地使用3种不同的策略：（1）夸大患者病情的严重程度;（2）改变患者的账单诊断;和/或（3）报告患者没有的体征或症状，以帮助患者获得所需的护理。9%的医生报告说，在过去一年中，他们“有时”或更频繁地使用至少一种策略。在多变量模型中，将这些医生与“从不”或“很少”使用这些策略的医生进行比较，使用这些策略的医生更有可能（1）认为“游戏系统”是当今提供高质量护理的必要条件（比值比[OR]，3.67; 95%置信区间[CI]，2.54-5.29）;（2）收到患者欺骗保险公司的请求（OR，2.44; 95%CI，1.72-3.45）;（3）在患者就诊期间感到时间紧迫（OR，1.69; 95%CI，1.21-2.37）;（4）超过25%的患者接受医疗补助（OR，1.60; 95%CI，1.08-2.38）。值得注意的是，更担心起诉欺诈并不影响医生使用这些策略（P =.34）。使用这些策略的报告，54%的报告这样做更经常比5 years force.Conclusions一个相当大的少数医生报告操纵报销规则，使患者可以接受医生认为是必要的护理。除非新的策略来解决这个问题，更大的使用限制，在卫生保健系统很可能会增加医生使用这种操纵性的“隐蔽宣传”策略。
Context Health plan utilization review rules are intended to enforce insurance contracts and can alter and constrain the services that physicians provide to their patients. Physicians can manipulate these rules, but how often they do so is unknown.Objective To determine the frequency with which physicians manipulate reimbursement rules to obtain coverage for services they perceive as necessary, and the physician attitudes and personal and practice characteristics associated with these manipulations.Design, Setting, and Participants A random national sample of 1124 practicing physicians was surveyed by mail in 1998; the response rate was 64% (n = 720).Main Outcome Measure Use of 3 different tactics "sometimes" or more often in the last year: (1) exaggerating the severity of patients' conditions; (2) changing patients' billing diagnoses; and/or (3) reporting signs or symptoms that patients did not have to help the patients secure coverage for needed care.Results Thirty-nine percent of physicians reported using at least 1 tactic "sometimes" or more often in the last year. In multivariate models comparing these physicians with physicians who "never" or "rarely" used any of these tactics, physicians using these tactics were more likely to (1) believe that "gaming the system" is necessary to provide high-quality care today (odds ratio [OR], 3.67; 95% confidence interval [CI], 2.54-5.29); (2) have received requests from patients to deceive insurers (OR, 2.44; 95% CI, 1.72-3.45); (3) feel pressed for time during patient visits (OR, 1.69; 95% CI, 1.21-2.37); and (4) have more than 25% of their patients covered by Medicaid (OR, 1.60; 95% CI, 1.08-2.38). Notably, greater worry about prosecution for fraud did not affect physicians' use of these tactics (P =.34). Of those reporting using these tactics, 54% reported doing so more often now than 5 years ago.Conclusions A sizable minority of physicians report manipulating reimbursement rules so patients can receive care that physicians perceive is necessary. Unless novel strategies are developed to address this, greater utilization restrictions in the health care system are likely to increase physicians' use of such manipulative "covert advocacy" tactics.