"Doctors have to get over their old-fashioned idea that they are advocates for individual patients. Now [a physician’s] job is to manage a population of patients, and that means finding what works for most of them, most of the time, at a price everyone can accept."1
Do you always tell the truth? What about the ghastly paperweight given to you by your office staff as a means of honoring you on Boss’s Day? Overwhelmed by their thoughtfulness (you didn’t even know there was such a thing as Boss’s Day), how could you say anything but, "Thank you, what a beautiful gift."?
Fortunately, dentistry has not reached the point where its practitioners are pressured into gaming the system.
These little "white lies"—daily occurrences in everyday life—function not to deceive but rather to spare the feelings of a person loved or respected. They are distinguished from so-called "black lies"—untruths specifically designed to mislead, often for personal gain.
What about the situation in which a falsehood is told on behalf of another person without any personal benefit to the fabricator?
Can there be such a thing as a "noble lie"?
Yes, if you ask a significant number of physicians. Motivated by an altruism that derives its interpretive support from their medical ethic that places patient needs ahead of their own, many health professionals are filing less than truthful diagnostic claims to qualify their patients for the treatment they feel is best.
As evidence, consider the results of three recent studies of physician behaviors. In the first investigation, 169 board-certified internists were asked, through a series of hypothetical vignettes, whether they would sanction a colleague’s deception of a third-party payer.2
Fifty-seven percent of physicians condoned subterfuge in the vignette that would result in a patient being approved for bypass surgery. Forced to change companies, the patient’s new health contractor would not pay for her preexisting condition even though the angiogram indicated severe three-vessel coronary occlusion. Only if the physician would lie and say her chest pains had increased in frequency would the surgery be granted.
What would you advise?
Percentages in favor of deception for the other vignettes ranged from 48 percent in a case authorizing a diagnosis sufficient to get intravenous pain medication for a terminal cancer patient to just 3 percent in a case involving cosmetic rhinoplasty.
Against that hypothetical framework are the results of a Kaiser-Family Foundation survey in which almost 90 percent of physicians reported having experienced some form of denial of coverage for their patients’ health services.3 For example, 79 percent claimed that during the last two years, a plan had disapproved coverage for a prescription drug they believed a patient needed.
These physicians believe that between one-third and two-thirds of these denials resulted in serious decline in a patient’s health status. It’s no wonder, then, that 26 percent of these physicians reported exaggerating a patient’s condition, either often or sometimes, to get needed care. Another 22 percent admitted doing this on "rare" occasions.
Similar percentages were noted in a study of 400 physicians conducted by the American Medical Association’s Institute for Ethics. In that survey, 39 percent of physicians said they sometimes, often or very often used deception to help patients obtain coverage for needed services.4 Twenty-six percent reported exaggerating the severity of a patient’s condition to avoid premature hospital discharge, 23 percent changed a billing diagnosis, and 9 percent reported symptoms patients did not have to secure additional coverage.
So much for good deeds! Physicians who act with their hearts instead of their minds—tampering with health policies they view as unreasonable—could be undermining future benefits for other patients as well as setting themselves up for potential medical board and litigation problems.
"Gaming," the name given to this practice of acting against a distribution system that the physician believes is unfair to his or her patients, has its own share of critics. They suggest that gaming could interfere with the future trust patients have for physicians. They ask: Would the physician who lies for the patient also be capable of lying to the patient?
Distributive justice—getting resources to those who have a right to them—is undermined by gaming, some health ethicists contend. By going against the health plan to get more service for their patient, the physician is either directly or indirectly taking future resources from other health plan patients.
Furthermore, this new health system requires the physician to recognize the contractual obligation the patient has with his or her plan. Because physicians no longer own the resources, as distributors they must follow the rules.
Not all physicians readily accept this "materialistic" philosophy. One wrote, in response to a Denver Post article, "Is the decision I make for this patient made independently of any financial impact that decision may have on me or any entity other than my patient? That question must be answered in the affirmative for truly ethical care."
The ADA’s "Principles of Ethics and Code of Professional Conduct" could be interpreted as lending support to that position. It states: "The same ethical considerations apply whether the dentist engages in fee-for-service, managed care or some other practice arrangement. Dentists may choose to enter into contracts governing the provision of care to a group of patients; however, contract obligations do not excuse dentists from their ethical duty to put the patience’s welfare first."
Depending how "welfare first" is interpreted, dentists could find themselves in the difficult position of acting against a distribution system that they believe is unfair. Fortunately, dentistry has not reached the point where its practitioners are pressured into gaming the system.
Credit the lack of penetration by health maintenance organizations into the dental marketplace for this enviable position. Dentistry’s solo and small group practices continue to compete successfully with alternative dental delivery systems.
Surveys of dentists and patients demonstrate the high satisfaction levels with fee-for-service programs when compared with alternatives. Indeed, in the next few months, studies conducted by the ADA and the highly respected Rand Corp. will be published in JADA. You will be heartened by their conclusions.
It appears that for the immediate future any gaming dentists are involved in won’t be with insurance claim forms.
