Werner Rachel M, Alexander G Caleb, Fagerlin Angela, Ubel Peter A
Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
Arch Intern Med. 2002 May 27;162(10):1134-9. doi: 10.1001/archinte.162.10.1134.
Some physicians are willing to misrepresent clinical information to insurance companies to circumvent appeals processes. Whether characteristics of appeals processes affect the likelihood of misrepresentation is unknown. This study sought to determine the relationship between the likelihood of a successful appeal, appeals process length, and severity of the health condition and physicians' willingness to sanction deception.
A random sample of 1617 physicians was surveyed by mail to assess their willingness to accept an insurance company restriction, to appeal the restriction, or to misrepresent the facts to an insurance company to obtain coverage for a patient.
Most respondents would appeal (77%) rather than accept (12%) or misrepresent (11%) regarding a restriction on medically necessary care. Physicians' decisions were related to the likelihood of a successful appeal (chi(2) = 7.56; P =.02), the appeals process length (chi(2) = 8.53; P =.01), and the severity of the medical condition (chi(2) = 71.10; P<.001). A small but significantly larger number of physicians chose to misrepresent the facts to an insurer as the appeals process became more cumbersome. Among physicians asked about severe angina, their decisions were particularly affected by the hassle associated with appealing, being more likely to choose to misrepresent the facts to the insurer than to appeal as the hassle increased.
Physicians are more willing to sanction deception when the appeals process is longer, the likelihood of a successful appeal is lower, and the health condition is more severe. Changes in the difficulty of appeals processes may ease the tensions physicians face regarding patient advocacy and honesty.
一些医生愿意向保险公司歪曲临床信息以规避上诉程序。上诉程序的特征是否会影响歪曲行为的可能性尚不清楚。本研究旨在确定成功上诉的可能性、上诉程序的时长、健康状况的严重程度与医生认可欺骗行为的意愿之间的关系。
通过邮件对1617名医生进行随机抽样调查，以评估他们对于接受保险公司限制、对该限制提出上诉或向保险公司歪曲事实以为患者获得保险赔付的意愿。
对于医疗必需护理的限制，大多数受访者会选择上诉（77%），而非接受（12%）或歪曲事实（11%）。医生的决定与成功上诉的可能性（χ² = 7.56；P = 0.02）、上诉程序的时长（χ² = 8.53；P = 0.01）以及健康状况的严重程度（χ² = 71.10；P < 0.001）有关。随着上诉程序变得更加繁琐，选择向保险公司歪曲事实的医生数量虽少但显著增加。在被问及严重心绞痛的医生中，他们的决定尤其受到上诉带来的麻烦的影响，随着麻烦增加，他们更有可能选择向保险公司歪曲事实而非上诉。
当上 诉程序更长、成功上诉的可能性更低且健康状况更严重时，医生更愿意认可欺骗行为。上诉程序难度的变化可能会缓解医生在患者维权和诚实方面所面临的紧张关系。
