Coverage restrictions may keep physicians from offering services

October 1, 2003

Pharmaceutical Representative

Nearly one-third of physicians say they sometimes refrain from offering patients useful medical services that aren't covered by their health plans.

Nearly one-third of physicians say they sometimes refrain from offering patients useful medical services that aren't covered by their health plans, according to a study published online in the journal Health Affairs.

Thirty-one percent of the more than 700 physicians surveyed in the study said they don't discuss useful treatments with some patients because of health plans' coverage restrictions. Among those physicians, 35% reported using this tactic more frequently during the past five years. Only 42% of physicians surveyed said they never withhold medical care options from patients because of coverage restrictions.

"Sadly, significant numbers of physicians are withholding information from some patients as a way of dealing with restrictive coverage rules," said lead study author Matthew K. Wynia, director of the Institute for Ethics at the Chicago-based American Medical Association. "As a result, patients aren't getting the whole story. This is especially troubling in a time when we are encouraging patients to participate more actively in their own healthcare decisions."

Reasons for the trend

The authors of the study cite several potential reasons doctors might be censoring themselves. Some physicians said they felt uncomfortable in the past when patients asked them to deceive third-party payers to obtain uncovered services. Also, physicians whose incomes depended to a large extent on risk-sharing arrangements with managed care plans for patient care costs tended to say they did not offer some patients useful but uncovered services. PR

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