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Doctors hesitate to suggest treatment options that insurers won't cover

But an organization for health plans said a study on the issue is flawed because it deals with perceived coverage restrictions.

By Damon Adams, AMNews staff. July 28, 2003.

Doctors may be doing more than a disservice to patients when they fail to mention treatments not covered by insurance. They may be violating medical ethics and eroding patient trust as well.

Furthermore, they could be held liable for the omissions, which, in a recent study, almost one in three doctors admitted making. They said there were occasions when they didn't inform patients about useful medical services because of health plan rules.

With this article   Insurance plans dictate treatment plans   See related content

Physicians and ethicists said withholding services not covered by insurance makes doctors seem more concerned with costs than care.

"It's outrageous. Not only from the standpoint of medical ethics but also from a point of public relations. That's exactly what the patients are worried about -- that you're an advocate for the insurance company," said Michael Grodin, MD, director of the medical ethics program at Boston University School of Medicine and professor of health law at the university's School of Public Health.

"In the role of caring for the patient, you have to think clearly and solely for the benefit of the patient," he said. "Whether they are covered is not the issue. It's what's best for the patient. Then you try to figure out how to get it covered."

The study is the third in four months to raise questions about the physician-patient relationship.

A study in the April American Journal of Public Health found that physicians are too busy to give preventive care to their patients. The study said doctors would need 7.4 hours a day to provide all the preventive care recommended by a U.S. task force, and advocated using nurse practitioners and others to help with prevention.

And in June, the New England Journal of Medicine reported that American adults receive only slightly more than half the recommended health care measures for their conditions. While the study, by the Rand Organization, was limited because the sample that was analyzed included only 37% of the eligible adults, its findings drew significant attention to the issue of quality care.

Unethical and possibly negligent

The new study, "Do Physicians Not Offer Useful Services Because of Coverage Restrictions?", appears in the July/August Health Affairs. Researchers asked 720 physicians nationwide in 1998 how often they decided not to offer useful services to patients because of health plan rules.

Nearly one-third, 31%, said they at least sometimes did not offer services to patients because of coverage restrictions. Of that amount, 35% said they withheld information on uncovered services more often than they did five years ago.

That would seem to go against the AMA's medical ethics code, which states that physicians "have an ethical obligation to assure the disclosure of medically appropriate treatment alternatives, regardless of cost."

"We're always making triage decisions about what's important [for patients] and what's not. You have to choose the thing that's relevant or important, but insurance coverage is not supposed to come into that," said Matthew Wynia, MD, the study's lead author and director of the Institute for Ethics at the AMA.

Medical ethicists said physicians also might be negligent for withholding treatment information and could be held liable in court.

"The [physician] is legally and morally obligated to tell them what is medically necessary," said John Banja, PhD, a clinical ethicist at the Center for Ethics at Emory University in Atlanta. "If I'm your physician and I determine that you clearly need this or that diagnostic test and I withhold that information from you and you have a bad experience or die, I might legitimately be sued. That's negligence."

The study said managed care "gag clauses," prevalent in the 1990s, prevented physicians from discussing uncovered services. Protests and state bans led health plans to drop the clauses from contracts, but now, the study said, some physicians appear to be gagging themselves.

Financial pressures play a role

The study's authors offered possible explanations:

• Doctors previously have been asked by patients to deceive health plans to get treatments covered ("gaming the system") and may try to avoid that situation by not mentioning uncovered services.
• Physicians often have incomes depending largely on risk-sharing arrangements with managed care plans and thus tend not to discuss uncovered services.
• Physicians who have larger volumes of Medicaid patients also are more likely to withhold information, reasoning that it's not compassionate to discuss services patients couldn't afford. But physicians shouldn't make that assumption, Dr. Banja said. "Some of these patients may have a big rainy-day fund. It would be a hell of a thing for a doctor to withhold that kind of information and the patient somehow is able to come up with the dough."

Dr. Wynia said physicians should have honest conversations with patients and mention services, regardless of coverage. Patients should be included in the decision-making process.

Jose Angel, MD, an internist in Des Moines, Iowa, said he does not withhold treatment information.

"I'll say, 'These things are available and they have this amount of benefit.' If they can't afford it, we'll go to the next best drug or the next best test," he said.

The American Assn. of Health Plans doubts that doctors are withholding necessary treatments.

The organization is critical of the study because researchers did not define "useful" services. It also said the study dealt with perceived coverage restrictions.

"We actually find it difficult to believe that that's going on," said AAHP spokeswoman Susan Pisano. "You're left with the impression that physicians are somehow sizing up each person who comes in the door and their ability to cover certain medical services."

Physicians and ethicists understand that some doctors factor cost in treatment decisions, but they said cost should not be the primary driver for conversations with patients. They said some plans have lessened restrictions in recent years, but the 1998 survey still is relevant and holds an important message for doctors.

"A physician's duty, No. 1, is to practice the best medicine for their patient," said Mitchell Miller, MD, a Virginia Beach family physician and president-elect of the Medical Society of Virginia. "Ultimately, a physician needs to be able to look themselves in the mirror at night and say, 'I did the best for my patient.' "

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Copyright 2003 American Medical Association. All rights reserved.

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