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EditorialA No Win SituationNiranjan Kissoon, M.D., Editor |
| The issue of manipulation of reimbursement rules has reared its ugly head in the popular press as well as the latest issue of the Journal of the American Medical Association. As the authors of the JAMA article rightly points out, we are caught between a rock and a hard place. My interpretation however, is that we and our patients are caught in an intricate reimbursement web from which it is unlikely that any winners will emerge. Physicians bend the rules for a variety of reasons. They perceive themselves as patient advocates and see their professional obligation as doing what is right for their patient. The health maintenance organizations (HMOs), in trying to control costs, are putting pressure on physicians to increase patient volume. Pressure to increase output may have inadvertently increased the possibility of gaming by physicians feeling pressed for time. It is gratifying to see from this study that most of the gaming was not done for the benefit of physicians themselves. While gaming may be viewed as doing what is right for our patients, physicians are caught between conflicting demands. We have a legal obligation to honor contractual arrangements regarding reimbursement. In fact, health insurance advocates have contended that by gaming the system we are encouraging patients to receive care for which they have not paid. However, we also subscribe to the ethical principal of social justice and beneficence which stipulates that we do what is right for our patients. Another factor that places physicians in an untenable legal conundrum is that we are responsible for the care of our patients whether they have agreed to a contract that may not fully serve their medical needs. Patients are not good health care consumers and ultimately agree to contracts that may not be in their best interests. On the other hand, the HMOs are responsible for generating profits to shareholders and are progressively in the business of controlling costs rather than providing care. At the present time the arrangement and constraints under which we function are not going to change and further attempts to decrease reimbursement may escalate gaming. The authors raised a very important question: "When, if ever, is it good for a contract to be broken in a surreptitious act of mercy?" The answer to this question would vary depending on the individual circumstances and life experiences and expectations of physicians for their patients. There is no doubt that our healthcare system is a market-orientated system with emphasis on quality and value. As such, we can all be better advocates for our patients by educating them on quality and value of medical care. They would then be able to purchase health insurance based on sound information. Informed decisions are never flawed. We also have a role to play as educators of insurance providers. The issue of when and if gaming is acceptable and when it is necessary to break the rules is an individual decision. I cannot predict what is likely to occur in the near future and whether there will be an increase or resolution of the problems which entice one to "game the system". In the meantime, one thing we can all do to help our colleagues is to not judge them harshly. Gaming the system for personal benefit rightly should be viewed with a jaundiced eye. However, when personal gain is not the objective, we need to be supportive of each other. It would take the "wisdom of Solomon" to find a satisfactory solution to this dilemma. Jacksonville Medicine / June, 2000
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