Article

Impact of managed care on physicians' decisions to manipulate reimbursement rules: an explanatory model.

WellStar College of Health and Human Services, Kennesaw State University, Kennesaw, GA 30144-5591, USA.
Journal of Health Services Research & Policy (Impact Factor: 1.73). 08/2007; 12(3):147-52. DOI: 10.1258/135581907781543102
Source: PubMed

ABSTRACT To develop and test an explanatory model of the impact of managed care on physicians' decisions to manipulate reimbursement rules for patients.
A self-administered mailed questionnaire of a national random sample of 1124 practicing physicians in the USA. Structural equation modelling was used. The main outcome measure assessed whether or not physicians had manipulated reimbursement rules (such as exaggerated the severity of patients conditions, changed billing diagnoses, or reported signs or symptoms that the patients did not have) to help patients secure coverage for needed treatment or services.
The response rate was 64% (n = 720). Physicians' decisions to manipulate reimbursement rules for patients are directly driven not only by ethical beliefs about gaming the system but also by requests from patients, the perception of insufficient time to deliver care, and the proportion of Medicaid patients. Covert advocacy is also the indirect result of utilization review hassles, primary care specialty, and practice environment.
Managed care is not just a set of rules that physicians choose to follow or disobey, but an environment of competing pressures from patients, purchasers, and high workload. Reimbursement manipulation is a response to that environment, rather than simply a reflection of individual physicians' values.

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