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  •   THE ETHICS SQUEEZE

    Healing vs. Honesty?
    For Doctors, Managed Care's Cost Controls Pose Moral Dilemma

    About This Series
    PART ONE: Health care's cost-cutting prompts some doctors to cheat on patients' behalf.

    Part Two: Lawyers' world changes as law firms scramble to lure clients, increase billings.

    Part Three: Accountants are under financial pressures that some say imperil their independence.

    First of three articles

    By David S. Hilzenrath
    Washington Post Staff Writer
    Sunday, March 15, 1998; Page H01

    The pressure to contain health care spending has brought some doctors to this: lying and cheating to get coverage for care they say patients need.

    With a torn conscience, a California internist explained how it is done. As the doctor saw it, an elderly and impoverished heart patient needed emergency treatment last year for fluid in her lungs. However, unless the patient was subsequently admitted to the hospital, validating the seriousness of her condition, her managed-care health plan would hold her responsible for an emergency room co-payment that she could not afford. According to the doctor, the patient said she would sooner forgo treatment than incur the charge.

    Faced with this dilemma, the doctor bent the rules.

    Though requiring the woman to stay in the hospital was not medically necessary, "I admitted her, and then, once she was admitted, as soon as she got to the floor, discharged her," said the doctor, who asked that his name be withheld.

    "It's a lie," the doctor said. "What I would call a white lie." The system "puts us in a horrible situation, and I don't know what the right answer is."

    The gaming of the system reflects the rising moral tension in American medicine -- what Georgetown ethicist Daniel P. Sulmasy calls the profession's "moral stress test."

    As managed care transforms American health care, sweeping away the blank-check autonomy many physicians once enjoyed and imposing bottom-line discipline in its place, many doctors say their professional ethics are being tested as never before.

    The leaders of the revolution say the goal is to eliminate wasteful and unnecessary spending. But years of conventional practice have left many physicians ill-prepared to balance their own sense of what is in their patients' interest against the sometimes conflicting demands and pressures of medicine's new order. In such predicaments, doctors sometimes conclude that dishonesty is the best policy.

    Lying and cheating are hardly new to the medical profession. For as long as anyone can remember, some doctors have padded bills and performed unnecessary services just to bilk the system. Such profit-motivated deceptions have generated a steady caseload for health care fraud-busters and medical disciplinary boards.

    Indeed, the financial pressure to cheat may be growing as managed-care companies squeeze physician pay, doctors say.

    But the sea change in the health care industry is fueling a less familiar form of dishonesty: the conscience-driven deception.

    Few physicians are willing to discuss the phenomenon openly. Some cite feelings of guilt or fear of repercussions. Yet interviews and other research suggest that these deceptions are more than isolated occurrences.

    If the response to researcher Matthew K. Wynia's unscientific questionnaire is any indication, such lying and cheating are common. Wynia didn't attempt to poll a representative sample of the nation's doctors; he collected 134 replies at a medical conference last year.

    More than a quarter of the doctors who returned the questionnaire said they had reported nonexistent symptoms or had otherwise fabricated medical findings to help a patient secure coverage for treatment or service during the past year. Six in 10 said they had changed the diagnosis shown on billing records to help someone get coverage. Seven in 10 said they had exaggerated the severity of a patient's condition to prevent him or her from being sent home from a hospital prematurely.

    Four out of five doctors surveyed said they had used at least one of those methods to deceive a health plan.

    In the minds of doctors, ethicists and other experts, that raises troubling questions about the state of the medical profession and the health care system.

    "If the health care delivery system is heading in a direction that requires physicians to misrepresent their patients' needs in order to be able to get services for a patient, then I think that we need to look hard at what we're evolving here as a mechanism of taking care of patients," said Larry Oates, associate medical director of the physicians group serving the Kaiser Permanente HMO in the mid-Atlantic region.

    Distinguishing right from wrong can be difficult enough in today's environment, some doctors say. Mustering the courage to do what they believe is right can be even harder, because clashing too often with the administrators who enforce the cost-containment rules can jeopardize a doctor's livelihood, they say.

    "It's a very challenging moment," said Daniel D. Federman, dean for medical education at Harvard Medical School. "I would say if we tend to judge things on a scale of 10, if 10 is acquiescence in torture or being forced to give gas in the death chamber . . . I would say that we were in the four to five range."

    The survey conducted last year by Wynia, then a health services researcher at Tufts University School of Medicine, suggested that, at least among the respondents, lies and distortions are on the rise. More than half of the doctors who answered Wynia's informal poll said they were deceiving health plans to advance patients' interests more often than they were five years ago, while only a scattering said they were doing it less.

    Wynia handed out his questionnaire at a leadership conference of the American Medical Association, which sets professional standards and lobbies for physicians. He now directs research on ethics and managed care at an AMA-affiliated institute.

    A separate survey last year by Victor G. Freeman and other researchers at Georgetown University Medical Center suggested that managed care, the increasingly dominant force in American health care, might influence doctors' notions of professional morality. Unlike Wynia's study, Freeman's was intended to meet strict academic standards, though it was limited by a small sample.

    Doctors were more likely to condone deception if they practiced in cities where health maintenance organizations had achieved high market penetration, the survey of 165 doctors chosen at random in eight cities found. For example, in areas where HMOs had sizable market share, 64 percent of doctors surveyed said a physician should provide false documentation, if necessary, to get a health plan to pay for surgery to prevent gangrene of the foot. In areas of low HMO penetration, only 46 percent endorsed the ploy.

    "What it says is that in an environment where there is intense managed care pressure, we find physicians more willing to condone deception in order for patients to get medically indicated care," Freeman said.

    Good Deeds, or Bad?

    Does lying for a patient make a doctor a hero or a fraud?

    A Massachusetts minister who was the beneficiary of a lie said he feels no moral qualms about his doctor's conduct, and is instead grateful. "He did the dirty work that was necessary to get good medical care for myself," said the minister, who requested anonymity to avoid getting the doctor in trouble.

    After undergoing surgery several years ago to repair a hernia, the minister noticed that his medical chart falsely stated he had been complaining of "abdominal pain" before the operation. When the minister asked the doctor for an explanation, the doctor replied that he routinely noted "abdominal pain" on hernia patients' charts whether or not it applied, because some insurance companies would not pay for hernia repairs in the absence of pain, infection or more severe complications.

    The minister said he never doubted the operation was warranted. "If your intestines are spilling out of your gut, I think the insurance company should pay to sew it up," he said.

    Still, some observers question whether the doctor-patient relationship, which is based on trust, can withstand deceit.

    "Once doctors start lying, nobody's going to want to trust them," said Bernard Lo, director of a medical ethics program at the University of California, San Francisco.

    As Matthew Wynia put it, patients might wonder: If the doctor is willing to lie for them, would the doctor lie to them?

    The morally correct course would be for doctors to champion their patients' interests through the official channels while working to change the system, many doctors and ethicists say. However, when it comes to treating an individual patient, some of these same people say, fighting the system head-on isn't always a practical solution.

    Health plans typically require doctors to get authorization before undertaking costly tests and procedures or hospitalizing patients. Seeking such approval can be a time-consuming and exasperating process, doctors say.

    Once patients are hospitalized, doctors are frequently pressed to keep their stay as short as possible. Some health maintenance organizations give doctors financial incentives to limit medical expenses and reserve the right to drop doctors who overshoot accepted spending levels.

    Mid Atlantic Medical Services Inc. (MAMSI), an HMO company based in Rockville, put it this way in a 1996 letter to doctors: "We are terminating the contracts of physicians and affiliates who fail to meet the performance patterns for their specialty. It is our intent to maintain a relationship only with those providers who are committed to providing quality care and who are willing to deliver it in an efficient manner."

    Kaiser Permanente's Texas division bluntly warned doctors in urgent care centers not to tell patients they required hospitalization, as one Kaiser administrator recalled. "We basically said [to] the UCC doctors, 'If you value your job, you won't say anything about hospitalization. All you'll say is, 'I think you need further evaluation,' " so other designated doctors could assess the need, Associate Medical Director John O. Vogt said in a 1995 speech.

    Magic Words

    While playing by the rules can be difficult, beating the system can be as simple as knowing the magic words. Thus, when routine mammograms are not covered, some doctors write that they are seeking the test to "rule out cancer," even if they have no reason to suspect the disease.

    Similarly, when one employer's health plan showed a willingness to cover psychiatric treatment for "involutional melancholia," an obscure diagnostic term that was dropped from the profession's standard reference book in 1980, doctors made thorough use of it, according to James Wrich, who audits behavioral health claims for employers. In 1995, claims for "involutional melancholia" accounted for 49 percent of the money that employer spent on mental health and substance abuse treatment for its workers, Wrich said.

    Louisville gynecologist Douglas O. Peeno said an assistant in his office appeared to be losing the battle to get a hysterectomy approved until the health plan interviewer asked whether the patient experienced "dyspareunia" -- pain during sex. The doctor's assistant said yes, even though she had no idea whether that was true, and the operation was approved, Peeno said.

    At UCLA Medical Center in Los Angeles, emergency doctor David Schriger said he routinely encounters patients -- such as a frail elderly woman with the flu -- who are not in immediate medical danger but might face serious problems if sent home alone in the middle of the night.

    "At this point I have to figure out a way to put her in the hospital . . . and typically I'll come up with a reason acceptable to the insurer," he said. Schriger said he would order a blood test and a chest X-ray -- "the minimum required to paint a picture of a patient who requires admission." If "a little haziness" should appear on the X-ray, "we'll call it pneumonia and admit her and everything is fine from the payor's perspective," he said.

    This may require convincing the patient's primary care physician that hospitalization is justified. "If I know them, they'll become partners in the same game," Schriger said.

    The distinction between fact and fiction sometimes blurs.

    "Many of us game the system by . . . stretching the truth," said Carlos A. Silva, a general surgeon and former president of the Medical Society of the District of Columbia. Though patients requiring gallbladder removal may experience only vague symptoms such as discomfort and indigestion, health insurance plans tend to look for more specific complaints such as pain or vomiting, Silva said. "So when the question is asked, is the patient having pain, you say yes. You're not really lying but you're not telling the entire truth either," Silva said.

    Having lost arguments for coverage of therapy sessions when he believed the merits were on his side, New York psychiatrist Edward M. Stephens contends that the only way to win may be to distort a patient's symptoms. "In order to get permission to do treatment for serious conditions, you must make it sound worse than it is," Stephens said.

    One psychiatrist said he was planning to exaggerate for a patient who recently attempted suicide. To continue treating the woman for depression, "I'm going to have to report her as a 51-to-60" on psychiatry's 100-point Global Assessment of Functioning Scale -- a score that denotes "moderate" symptoms -- "when in fact, on any given day, she may be functioning as a GAF 80 or without any symptoms at all," said the psychiatrist, who asked that his name not be used.

    The distortions can take an emotional toll. "It's a feeling of being uncomfortable, of being uneasy: 'Am I really lying?' " Silva said. For UCLA's Schriger, though, a sense of duty banishes any doubts. "I feel like my primary obligation is with the patient, and as long as I feel I'm doing the best for them, I feel no guilt," Schriger said.

    Costs vs. Care

    Some ethicists worry that doctors will fail the moral stress test by acquiescing to overzealous cost control efforts and withholding needed care.

    That's what 17-year-old Paige N. Lancaster of Stafford, Va., and her mother, Barbara L. Lancaster, allege took place at the Kaiser Permanente HMO clinic in Woodbridge over a period of almost five years while Paige Lancaster complained of severe recurring headaches, nausea and a bloodshot eye.

    Beginning in September 1991, doctors at the clinic saw Lancaster at least 10 times, according to records of a lawsuit the Lancasters filed. The doctors treated her with adult-strength painkillers and other medication. But doctors Corder C. Campbell and Lisa Pauls did not refer Lancaster to a neurologist and did not obtain such diagnostic tests as an MRI or EEG until May 1996, after a worried psychologist at Lancaster's high school wrote a letter urging that tests be performed, according to court filings.

    Tests then revealed a tumor and cystic mass occupying 40 percent of Lancaster's brain cavity, according to court records. Lancaster has undergone two brain operations and is likely to require periodic follow-up surgery as a result of the delay in diagnosing her, said Michael J. Miller, an attorney for the Lancasters.

    Kaiser would not discuss details of the case, and the two physicians would not comment. "We believe the medical care provided to Miss Lancaster was appropriate," Kaiser spokesman Wayne Rosenkrans said. "We strongly dispute plaintiffs' claims . . . that the care provided was driven by economic considerations," he added.

    Paige Lancaster, who is in the 11th grade, and her mother, Barbara Lancaster, who drives a school bus and helps teach special-needs students, said their trust in doctors has been shattered. "In this environment, medical ethics is a contradiction in terms," Barbara Lancaster said.

    Sulmasy, the physician who heads Georgetown's Center for Clinical Bioethics, said it was exhaustion that caused him to concede one particular battle instead of arguing more forcefully. The issue was a health plan's refusal to provide additional blood monitoring materials for a patient with diabetes. In the war of attrition, Sulmasy had already spent his ammunition that day winning permission for a cancer patient to see a top surgical specialist.

    "I'm not very proud of it," Sulmasy said. "I said, 'I don't have the energy to fight this,' because I had spent so much time on the phone fighting for the other" patient.

    Some doctors are so confident in their own judgment -- and so unaccustomed to having it questioned -- that they don't even allow for the possibility that the managed-care company knows better. Nor do they consider the potential downside of their deceptions. If the false information left in patients' medical records creates an appearance of serious health risks, it could result in their being denied insurance or charged higher premiums, analysts say.

    To prepare young doctors for the challenges, some medical schools have modified their curriculums. At UCLA, medical students are required to discuss a videotape in which actors play out ethical dilemmas based on actual cases.

    In one scenario, a budget manager for a physician group takes an orthopedic surgeon to task for proposing a total hip replacement for a patient.

    The patient "is very disabled by his injury," the surgeon argues. The operation "will give him pain relief. It will give him better quality of life. It will allow him to continue working."

    "Well, at this point, I'm more concerned about our budget," the administrator replies.

    Michael S. Wilkes, director of the UCLA doctoring curriculum, said students need to study such situations "because they'll occur again and again."

    As part of a training program at the Harvard Pilgrim Health Care HMO and Brigham and Women's Hospital in Boston, internist Steven D. Pearson ran a seminar in which he asked medical residents what they would do if a managed-care company denied hospitalization for a terminally ill patient suffering at home. Would they lie to justify the admission? Would they admit the patient without permission and risk being expelled from the health plan?

    The residents refused to lie but vowed to fight for the patient, said Pearson, associate director of the Harvard-affiliated Center for Ethics in Managed Care.

    Pearson painted the dilemma in increasingly dire terms, until one of the residents declared that it would be time to quit the health plan.

    "There is a point at which they should all recognize not only their ability to quit but their duty to quit when their own professional principles are too compromised," Pearson said. "I just want them all to know that they've got a backbone. I want them to find it, know where it is, know how to use it."

    Truth and Consequences

    Researchers at Georgetown University asked doctors whether a colleague should deceive a health plan, if necessary, to get it to pay for appropriate care in several hypothetical cases. For example, to secure psychiatric treatment for a patient with depression, should a doctor falsely report that the patient has talked about committing suicide?

    Doctors in cities where HMOs controlled a large share of the market (more than 45 percent) were more likely to condone deception than doctors in cities where HMOs had a small share of the market (less than 25 percent)

    Though the pattern was consistent, the differences were statistically significant in only two of the scenarios, which are designated by an asterisk.

    Percent condoning deception in cities with high HMO penetration and cities with low HMO penetration

    To secure vascular surgery to prevent the loss of toes or foot from impaired blood circulation:*

    cities with high HMO penetration 64%

    cities with low HMO penetration 46%

    To secure coronary bypass surgery for a patient with severely blocked arteries:

    cities with high HMO penetration 60%

    cities with low HMO penetration 53%

    To secure intravenous pain medication and nutrition for a terminally ill cancer patient:

    cities with high HMO penetration 52%

    cities with low HMO penetration 42%

    To secure breast cancer screening for a 55-year-old woman with a family history of the disease:*

    cities with high HMO penetration 43%

    cities with low HMO penetration 23%

    To secure psychiatric treatment for a patient with depression:

    cities with high HMO penetration 37%

    cities with low HMO penetration 25%

    SOURCES: V.G. Freeman, S.S. Rathore, K.A. Schulman, D.P. Sulmasy, Georgetown University Medical Center

    Doctor's Code of Ethics

    The most well-known code of ethics for doctors is "Thy Physician's Oath" by Hippocrates. Here are excerpts:

    I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrongdoing.... I will keep pure and holy both my life and my art ... In whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrongdoing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in the course of my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.

    NOTE: Translation by W.H. Jones

    A Profession Transformed

    The managed care industry has been steadily expanding its share of the health care market over the past few years.

    Percentage of employees enrolled in managed care plans

    1992: 49%

    1997: 85%

    SOURCE: Foster Higgins National Survey

    Stretching the Truth

    Researcher Matthew K. Wynia received 134 replies to a questionnaire he distributed at a medical conference last year. Seventy-one percent of the doctors who responded to this unscientific survey said they had exaggerated the severity of a patient's illness in the past year to keep someone from being sent home from a hospital prematurely; 61 percent said they had changed a billing diagnosis in the past year to get a health plan to pay.

    How often have you exaggerated a patient's severity of illness to avoid early discharge?

    Sometimes 28%

    Rarely 34%

    Never 29%

    Often 9%

    How often have you changed a billing diagnosis to secure coverage for a treatment or service?

    Sometimes 19%

    Rarely 31%

    Never 39%

    Very often 2%

    Often 9%

    SOURCE: Dr. Matthew K. Wynia

    © Copyright 1998 The Washington Post Company

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