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Why the medical system is `gamed'

Posted: Thursday, April 20, 2000

Ira Wilson prefers to think of it as a biopsy rather than a study. In a biopsy, after all, a small sample of tissue says a great deal about the patient.

In this case, the patient is the health care system itself and the biopsy that Wilson performed with Matthew Wynia and others was on 720 doctors. They collected and dissected information about how doctors deal with insurance companies.

Their ``biopsy report'' in the Journal of the American Medical Association diagnosed a runaway case of deception. But the authors use more benign and more accurate words to characterize the doctors' behavior: ``manipulation,'' ``fudging,'' and best of all, ``gaming the system.''

A stunning 40 percent of a random sample of doctors deceived the insurers ``sometimes'' or more often. They exaggerated illnesses, they changed diagnoses, they documented false symptoms. They found ways around the rules and regulations of third-party payers.

This was not, the researchers explain, for the doctors' own profit. Nor was this big-time fraud. It was, rather, a kind of medical civil disobedience.

The physicians gamed the system in small, daily ways to get patients the medical care - another day in the hospital, a different medication, another test - they believed was necessary. Indeed an astonishing 28.5 percent thought the only way to get proper care was to play the game.

As the lead author, Dr. Wynia of the AMA's Institute of Ethics says, ``If a doctor thinks the trade-off is between harming the patient and adhering to a strict contract, I can tell you the patient will win every time.''

That doesn't mean that this diagnosis of deception is benign or even healthy. Today many doctors feel caught. They have ethical and legal obligations to provide the best care for patients. They have contractual obligations to a huge number of health care insurers, each with its own arcane set of rules.

Doctors are not just gaming when it's a matter of life and death. According to the survey they are fudging the facts and the papers when patients ask for treatments and saying no is hard. They are fudging when they are pressed for time and when they want to avoid the Byzantine, infuriating business of making appeals and filing forms. And when too many appeals could turn them into a ``troublemaker'' and lead to their dismissal.

``It's an indictment of the system,'' says Wynia, ``that a physician can't do right by patients and play fair with insurance companies.''

It's not just a matter of deceptive doctors or unfeeling payers. We set up the game that everyone knows about and no one has acknowledged or addressed as openly as now.

Historically, we trained doctors to think of patients one by one. We want them to put us first. Yet as costs rose, we gave insurers - private and public - the social task of keeping the lid on, passing out limited funds and rationing health care.

As a result, says ethicist Haavi Morreim of the University of Tennessee, we have ``a war of escalation between payers and providers.'' Physicians look for a way around the rules. Payers tighten the rules. Then physicians search for the wiggle room.

Morreim remembers when she first heard doctors tell each other, ``If you want to get a mammogram paid for, write down, `rule out breast cancer.''' When the insurers caught on, doctors coached each other to write: ``possible breast mass.''

These days the game escalates on and on, with both sides warily eyeing each other. ``Deception causes more deception,'' says Dr. Wilson. It's waged overtly over fuzzy words like ``medically necessary.'' And it's waged covertly over paperwork and denials, documentation and appeals.

We never meant to have a system in which you get what your doctor fights for or fudges for. We never meant to have a system based on subversion rather than discussion. Doctors and patients need to believe there is a fair, rational standard for approving or denying payment for tests, hospital stays, or medication. We need a streamlined appeals process. Not a war of endurance.

You see, the other result of this biopsy shows the doctors' unease. While nearly 40 percent feel they have gamed the system, only 15 percent agree that it is ethical. Call it a ``game'' if you will, but in medicine the moral gray area is not a comfortable playground.

Ellen Goodman is a columnist for the Boston Globe.



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