Embargoed for release
Tuesday, July 8, 2003, 12:01 a.m. ET
  For more information, contact:
Janet Firshein or Linda Loranger at 301/652-1558
Jon Gardner, Health Affairs, at 301/656-7401, ext. 230

 

NEW STUDY FINDS THAT COVERAGE RESTRICTIONS KEEP MANY
PHYSICIANS FROM OFFERING PATIENTS USEFUL MEDICAL SERVICES

Thirty-One Percent of Doctors Surveyed Say They Don’t Always Discuss Beneficial
But Uncovered Treatments; Trend Seems To Be Rising

(Bethesda, MD)—In what may be a growing trend, nearly one-third of physicians say they sometimes refrain from offering patients useful medical services that aren’t covered by their health plans, according to a study published today in the journal Health Affairs.

The finding raises the question of whether physicians are voluntarily censoring themselves to avoid being squeezed between patients’ needs or preferences for certain services and health plans’ refusal to pay for those services.

Thirty-one percent of the more than 700 physicians surveyed in the study said that they don’t discuss useful treatments with some patients because of health plans’ coverage restrictions. Among those physicians, 35 percent reported using this tactic more frequently during the past five years. Only 42 percent of physicians surveyed said that they never withhold medical care options from patients because of coverage restrictions.

Most medical codes of ethics strongly discourage physicians from holding back information on useful care from their patients because of coverage rules.

“Sadly, significant numbers of physicians are withholding information from some patients as a way of dealing with restrictive coverage rules,” said lead study author Matthew K. Wynia, director of the Institute for Ethics at the American Medical Association (AMA) in Chicago. “As a result, patients aren’t getting the whole story. This is especially troubling in a time when we are encouraging patients to participate more actively in their own health care decisions.”

Wynia adds that failing to address uncovered services also denies patients the opportunity to argue to change inappropriate coverage restrictions, and "may lead to an erosion of trust in physicians."

Wynia and his colleagues offered several possible explanations for this trend:

• Some physicians said they felt uncomfortable in the past when patients asked them to deceive third-payer payers to obtain uncovered services. Most physicians believe that “gaming the system” for patients is unethical, and “may elect not to offer useful but uncovered services in the hope of avoiding these tense situations,” the study authors write.

• Physicians who cared for larger volumes of Medicaid patients were more likely to sometimes withhold information on useful but uncovered treatments. This rationale, while reflecting sympathy for poor patients who can’t afford to pay for care on their own, is “also paternalist and sometimes incorrect,” the study authors note. They also said this attitude may contribute to racial disparities in health care, since African Americans are much more likely than whites to be covered by Medicaid.

• Financial pressures also appear to play a role. Physicians whose incomes depended to a large extent on risk-sharing arrangements with managed care plans for patient care costs tended to say they did not offer some patients useful but uncovered services.

The researchers note that in the late 1990s some managed care plans inserted “gag clauses” in their contracts with physicians that discouraged or prevented them from discussing uncovered services with patients. That practice was largely dropped amid strong protests by patients and physicians, which led to moves by many states to ban gag clauses.

“It is a disturbing irony that some physicians are now effectively gagging themselves in response to coverage restrictions," Wynia said.

Wynia coauthored the study with Jonathan B. VanGeest, of the AMA’s Medicine and Public Health Unit and its Program on Health Disparities; Deborah S. Cummins, of the National Patient Safety Foundation, Chicago; and Ira B. Wilson, of Tufts-New England Medical Center and Tufts University School of Medicine, Boston.

Health Affairs, published by Project HOPE, is a bimonthly multidisciplinary journal devoted to publishing the leading edge in health policy thought and research. Copies of the July/August 2003 issue will be provided free to interested members of the press. Address inquiries to Jon Gardner at Health Affairs at 301-656-7401, ext. 230 or via e-mail, press@healthaffairs.org. Selected articles from the July/August issue are available free on the journal’s Web site, www.healthaffairs.org.

###

©2003 Project HOPE–The People-to-People Health Foundation, Inc.