Impact of managed care on physicians' decisions to manipulate reimbursement rules: an explanatory model.
OBJECTIVE
To develop and test an explanatory model of the impact of managed care on physicians' decisions to manipulate reimbursement rules for patients.


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.
VanGeest
Jonathan
J
WellStar College of Health and Human Services, Kennesaw State University, Kennesaw, GA 30144-5591, USA. jvangees@kennesaw.edu
Weiner
Saul
S
Johnson
Timothy
T
Cummins
Deborah
D
D001291:Attitude of Health Personnel; D008192:Deception; D019538:Health Care Surveys; D006801:Humans; D007344:Insurance Claim Reporting / Q000592:standards* / Q000706:statistics & numerical data; D007349:Insurance, Health, Reimbursement; D007357:Insurance, Physician Services / Q000191:economics*; D008329:Managed Care Programs / Q000191:economics*; D010344:Patient Advocacy / Q000191:economics*; D010820:Physicians / Q000523:psychology* / Q000706:statistics & numerical data; D017009:Professional Autonomy; D011795:Surveys and Questionnaires; D014481:United States; D014600:Utilization Review