Walter Anderson Study
by Jane Lamptom, University of Mississippi School of Medicine
Grahic Jump Location
Is it ever ethical for a physician to code a patient's diagnosis falsely
in a medical record to gain benefits for the patient? The small amount of
empirical research available suggests that many physicians do indeed choose
to deceive third-party payers. In a decade-old survey, 70% of a sample of
clinicians stated that hypothetically, they would write "rule out cancer"
to secure funding for screening mammography if the patient's insurance would
not otherwise fund it.1 Nearly half the
physicians in a more recent survey admitted to exaggerating the severity of
patients' conditions to get the care they felt the patient needed.2 In another study, in 1998, 39% of the physician
sample admitted to exaggerating the severity of patients' conditions, changing
official billing diagnoses, and documenting nonexistent symptoms—all
to gain additional benefits for patients.3
Several approaches to such a dilemma have been articulated. One consider
the ethics of lying. Sissela Bok champions the "principle of veracity," which
emphasizes the intrinsic moral undesirability of a lie because no one likes
to be deceived.4 Others worry about the
effect lying would have on trust on the patient-physician relationship.5 Still others worry that exaggerated and inaccurate
diagnoses may frighten patients and compromise their future clinical care.6
Alternatively, the question may be interpreted as one of distributive
justice. The reimbursement boundaries set by third-party payers are a de facto
resource allocation mechanism. Much has been written about whether physicians
should ever withhold available interventions because of a high cost-to-benefit
ratio.7- 8 The same reasoning
applies to the question of whether physicians should ever transgress reimbursement
boundaries to secure benefits not covered by insurance plans.
Entrants in the 1999 John Conley Ethics Essay Contest for Medical Students
were asked: "Suppose a potentially useful procedure is available that is not
covered by a patient's medical insurance. Under what circumstances, if any,
would you consider it appropriate to miscode (and thereby make available)
the needed procedure?" Peter Ubel, MD, frames the issue as a question of distributive
justice. Then, from opposed perspectives, the winners of this year's contest
argue that miscoding is unethical because of its effect on the "medical commons"
(Dena Rifkin) and that miscoding is sometimes justifiable based on the role
society accords physicians (Greg Webster). On reading these essays, we hope
readers will be better equipped to answer this question for themselves.
The explosion of medical technology in the late 20th century has forced
physicians to think seriously about cost containment. When my father first
practiced medicine in the 1950s, his pharmaceutical armamentarium included
a handful of antibiotics and 2 or 3 antihypertensives. The most expensive
diagnostic tests were plain film radiographs. It was easier to give patients
the best health care money could buy, because there was not as much health
care to buy.
Now, however, physicians can order $2000 magnetic resonance imaging
(MRI) scans that may have little chance of finding anything clinically relevant.
Screening women annually for cervical cancer by Papanicolaou smear costs over
$1 million per life saved.1 Screening people
a sixth time for colon cancer with fecal occult blood testing costs over $26
million per life saved.2 In short, today
we can offer our patients many interventions that bring small benefits at
great financial cost. From my perspective as a physician who did not begin
practicing medicine until the late 1980s, the cost of health care has always
been an issue to consider.
Pressure to contain health care costs places physicians and other health
care practitioners in difficult positions. If we pursue our patients' best
interests without regard to costs, we will accelerate health care inflation,
a serious concern in an era in which governments throughout the industrialized
world are struggling to offer health care to their populations. But if we
forsake patients' best interests in favor of society's pocketbook, we risk
alienating our patients, who expect that we will be their untiring advocates.
Most contemporary medical ethicists argue that physicians should pursue
patients' best interests regardless of cost. According to this view, health
care rationing should be done at higher levels than the patient-physician
encounter,3- 4 such as by
formulary committees, which limit the medications available to clinicians,
and by utilization reviewers, who tell us when insurers will stop paying for
extra hospital days. It is my position, however, that physicians need to relax
their advocacy duties in order to control health care costs.5
Debates about the moral status of bedside rationing do not often recognize
its already pervasive presence in clinical medicine. Suppose, for example,
that a physician who believes that she should not ration care from her patients
is faced with a formulary committee that restricts the use of proton pump
inhibitors to patients with severe gastroesophageal reflux. Should she advocate
for her patients' best interests by liberalizing her interpretation of what
qualifies as "severe reflux"? If not, she is participating in the rationing
of care. When should this physician accede to and participate in third-party
rationing mechanisms, and when should she fight them, even to the point of
misrepresenting patients' conditions to get them what is in their best interests?
Often, an extra hospital day is only mildly beneficial, or a new medication
is only 1% better than an older, less expensive one. At the same time, health
insurance in the United States is so expensive that many employers no longer
offer health benefits to their employees, thereby swelling the ranks of the
uninsured. In times like ours, physicians need to be willing to forego small
benefits for their patients by acceding to reasonable third-party payer rationing
Each physician must decide what constitutes a "small benefit" and a
"reasonable rationing mechanism." When very important health care resources
are being withheld from our patients, we need to fight third-party payers
aggressively to obtain the resources. But other times, when the resources
being withheld are only slightly better than available resources, we need
to take third-party payer restrictions as a reminder that not all benefits
are worth pursuing, given the great importance of controlling health care
It is, of course, often possible to bend third-party payer rules without
technically breaking them. The difference between moderate and severe gastroesophageal
reflux, for example, is a judgment call. A physician who has a low threshold
for classifying reflux as "severe" is not necessarily breaking a rule. In
fact, most third-party payer rules leave generous room for interpretation.6 Ultimately, though, deliberate bending of the rules
amounts to a deliberate misinterpretation of their spirit.
Physicians need to think hard about the societal and personal consequences
of such rule-bending. The societal consequences are clear: frequent rule-bending
will fuel continued health care inflation. The personal consequences, however,
can be even more dramatic. A physician who always errs on the side of providing
additional resources will be unpopular with third-party payers, who may refuse
to contract with him or her in the future. In interpreting third-party payer
reimbursement rules, we need to remember that such rules exist because society
wants us to control health care costs. If physicians bend too many rules,
the health care system is bound to break.
Funding/Support: Dr Ubel is a Robert Wood Johnson
Foundation Generalist Physician Faculty Scholar and a recipient of career
development awards in health services research from the Department of Veterans
Mrs Paul walks stiffly into the office, settling into
a chair with obvious relief. "This pain is just the worst thing there is.
Even getting the mail is bad. What in the world can I do?"
Dr Jones removes Mrs Paul's shoe. The woman's foot
is grossly misshapen, and she winces in pain throughout the examination. The
bunion clearly has affected her mobility; Dr Jones notes that Mrs Paul has
gained 15 pounds since her first appointment with this Medicaid HMO. Yes,
Dr Jones thinks. I could remove that bunion surgically. Of course, bunion
removal isn't covered in this new insurance plan—but bone spur removal
is. Mrs Paul wouldn't know the difference. I can't get all my patients everything
they need—people would begin to notice—but at least I can help
one person at a time.
Whose interests must the physician uphold? Those of the insurance organization
that formulates the rules and provides the payments? Or those of the patient,
who cannot afford the procedure but possibly would have less pain and better
mobility if she were treated? The ethical challenge facing physicians like
Dr Jones is one that has long been the province of law and jurisprudence:
the tangled morality of breaking rules in order to provide "true" justice.
Health insurance plans have created a legal microcosm of rules and regulations.
By buying or qualifying for a health insurance policy, an individual enters
into a common set of rules with all the other people covered by that particular
insurer. The insurers may try to create a system that philosopher and ethicist
John Rawls might call "formally just": the rules are clearly stated, changed
only with due notice, and applied equally to all cases, with proper opportunity
for appeal and judgment.1 The actual rules
that are being enforced in this way may or may not be what Rawls calls "substantively
just"; the content of the rules, regardless of the system in which they are
enforced, may or may not provide what the community considers to be good and
The physician has a dual role in this system. First, he or she has the
responsibility to act for the insurers by upholding the rules of coverage,
both to preserve the integrity of the system and to protect patients from
unfair and unequal treatment. Second, the physician has the often opposing
responsibility to act for the patient by deciding whether a policy or rule
is substantively just; that is, whether it provides the patient with a basic
standard of health care or whether upholding the rules would damage the health
of the patient.
In miscoding a procedure on an insurance form, however, the physician
violates both of these responsibilities. By furtively disobeying an unjust
rule, the physician violates the rights of other patients within the system
and fails to defend openly the patient's need for the procedure. Even if the
physician believes that the insurance system is antithetical to good care,
the ethical step is not to evade the rules but rather to fight them openly
for the sake of all patients within the system.
In the immediacy of the traditional patient-physician encounter, the
needs of an individual patient are more salient than this ethical responsibility
to the community. The increasing control of health care by insurance organizations,
however, has forced population-based medicine into doctors' offices and given
physicians far greater accountability to patients outside their own practices.
Misrepresenting a diagnosis seems like an innocuous way to deal with
insurance rules because unlike an individual patient, the insurance provider
is anonymous and has tremendous resources. If insurance has a face, it is
often that of a highly paid CEO; expenditures for health care totaled over
$1 trillion in 1997, making the cost of a bunion removal seem trivial in comparison.2 Why, then, should doctors honor the rules of this
In medicine, the patient-physician relationship has always been held
sacred; physicians have a responsibility to treat patients appropriately,
respect their confidences, and act as their advocates in a confusing and impersonal
health care system. But what responsibility does a physician have for the
faceless other patients, the people who could be adversely affected by preferential
treatment of his or her patients? For example, aggressive use of broad-spectrum
antibiotics has created the specter of vancomycin-resistant staphylococci
and other pathogens that threaten new populations of patients. Analogously,
miscoding procedures so that insurance will finance them depletes the shared
pool, leaving other patients to face stricter rules or to be denied insurance
altogether. The "tragedy of the commons," as Garrett Hardin put it, happens
when every person pursues his or her own interests within a shared community
resource.3 Each individual may reason that
taking a bit more of the pie will not damage the resource; however, when each
individual acts on this reasoning, the commons are destroyed. Medical insurance,
private or public, cannot command an infinite system of resources. Instead,
insurance creates a finite "medical commons,"4- 5
which should be distributed according to a sound system of rules.
In Oregon, an attempt to distribute the medical commons by rationing
Medicaid resources has led to strict cut-offs for procedures of lower priority.6 The cut-off line on a list of prioritized procedures
is adjusted according to budgetary considerations and Health Care Financing
Administration (HCFA) restrictions.7 However,
doctors have circumvented the guidelines by miscoding uncovered procedures;
the increasing costs of the system have led to abandonment of the original
goal of covering all uninsured citizens and exclusion of more procedures from
coverage.8 In other insurance systems, the
losses due to miscoding are more difficult to pinpoint; or premiums rise so
that some people cannot afford them, or a preventive program is cut, or perhaps
an administrator's raise decreases. Certainly, the patient in the office with
the throbbing foot is of more immediate concern than these considerations.
Yet the physician must weigh these unseen costs against the benefits to the
individual patient, just as he or she must consider the risk of creating resistant
bacteria, which could harm unknown patients, when prescribing powerful antibiotics.
The medical commons is a reality: there is only so much health care to go
For a physician to break the rules selectively on behalf of certain
patients is biased medicine, patently unfair, and discriminatory. The discrimination
arises because the only way to "game the system," or to subvert the rules
of the insurance plan, is to do so occasionally. An unusual pattern of cases,
such as miscoding a large number of deviated nasal septae for an uncovered
procedure like rhinoplasty, would be too recognizable. The physician, then,
must choose which patients merit this procedure and which do not. The hotly
debated case of baseball player Mickey Mantle illustrated dramatically how
these choices can be biased: although Mantle had cancer of the liver, a condition
that often rules out transplant, he was placed at the top of the waiting list
and quickly received a transplant, prompting accusations of medical favoritism.9
In daily practice, the basis for preferential selection may be more
subtle, even unconscious; it may involve personal sympathy for particular
patients or implicit judgments about the value of health for different people.
Miscoding procedures necessitates ad hoc, bedside rationing of care, a practice
often decried as discriminatory.10 Preferential
selection violates the integrity of a system in which similar cases should
be treated similarly.
If a scientist invents or misrepresents data, we call it intellectual
dishonesty; so, too, a doctor who miscodes a diagnosis is falsifying data,
an act that can have widespread ramifications in the scientific community.
A system rife with miscoded procedures may lead researchers to track an inaccurate
pattern of disease, which could lead to inappropriate allocation of research
to the fabricated diagnosis or procedure and corresponding neglect of the
true disease. Statistical analysis of insurance records, particularly those
collected by HCFA, is used extensively in epidemiological research and in
economic forecasting. Miscoding corrupts these data and, paradoxically, will
tend to lower the priority of the very procedure that the physician is underreporting.
More insidiously, the idea that physicians miscode solely to provide
the patient with needed care masks a less noble ethical decision: the choice
not to provide care pro bono. Pro bono care has long been a part of medicine,
and many physicians consider it an essential part of their work. Between 1990
and 1994, the percentage of physicians providing uncompensated care and the
amount of time spent on such services both rose, with about 68% of physicians
providing some pro bono care.11 Despite
Medicare and Medicaid subsidization, hospitals still finance a key component
of uncompensated care for indigent patients.12
While physicians and hospitals cannot and should not bear the full burden
of supporting inadequate insurance systems, they can continue to help needy
individuals by providing service free of charge for procedures that may be
useful but are of low priority. In this way, the rules of the insurance system
are upheld, the patient receives care, and the physician preserves both professional
and personal integrity.
For the sake of all the patients in the system, the physician should
appeal unjust rules, voice opposition publicly, and advocate openly and honestly
for the needed treatment. This kind of activism takes time and effort, jeopardizes
the physician's relationship with insurance providers, and may well threaten
a career with an HMO. Physicians feeling helpless and alone in the face of
unjust insurance regulations would do well to remember the lessons of civil
disobedience, first expressed by Henry David Thoreau and taken up by Martin
Luther King, Jr, and other civil rights leaders: the collective voices of
all those opposed to an unjust rule can break it, while silence and subterfuge
only make it stronger.
For most physicians, population-based medicine is antithetical to the
goals of bedside care. Yet considering the needs of the population can save
lives as well, by distributing the medical commons equitably, by determining
which treatments can maximize the health of the community, and by providing
accurate data on health trends. Physicians must bridge the gap between people
and numbers, treating individuals fairly and humanely while recognizing the
impact of individual decisions within a larger system.
Miscoding looks like the quick movement of a black pen. If one stood
and watched 1000 doctors miscode and 1000 doctors check the appropriate boxes
there would be no telling the white hats from the black hats. Perhaps a certain
doctor chewed her pen a moment before scribbling. Perhaps the other paused
thoughtfully before writing down his recommendations. Good physicians who
feel forced to miscode must first consider a number of moral issues. They
must be able to discern the greater good and must believe that the miscoding
deception serves the greater good. Given that, when the physician's conscience
and the larger ethics of professional conduct would allow the omission of
an appropriate diagnosis and when those same ethics condone inserting a new
one, the physician may ethically miscode a patient's diagnosis.
A debate on miscoding leads nowhere if a physician is not allowed to
deceive under any circumstances. Benign deception, however, is widely practiced
in medicine. Every physician commits ethical errors of omission during a commonplace
physically for instance, telling the patient who queries about a thump, "I'm
just seeing what's going on," or "I'm just listening to your lungs here."
The physician has decided not to discuss all possible diagnoses with the patient.
Few physicians would argue that every patient who comes in with swollen lymph
nodes should be told that he or she might be carrying the plague. Hopefully,
the doctor has dismissed that possibility by the end of the examination and
the omission has served both the physician and the patient.
Withholding an obscure diagnosis for 5 minutes so that it can be dismissed
quietly is a minor breach, if one at all, and perhaps attributable more to
a nebulous pool of "people skills" than to an ethical dilemma. Perhaps the
idea of misinformation is better illustrated by examining a more active lie.
Mr J, an 82-year-old gentleman, walks into a clinic in a small town presenting
with a complex spectrum of complaints. The new doctor begins to take his history
and Mr J reveals that he has a "bad back" and it is being effectively treated
by his family doctor. The physician asks how it is being managed. The patient
responds that he is being treated with pills, specifically "pyruvate precursor,"
which he has brought with him. Tipping the prescription container reveals
nothing more exciting than a handful of M&Ms.
The placebo is an ancient crutch of medicine. It would be a heartless
clinician indeed who would deprive Mr J of his M&M back pills either by
snatching them out of his grasp or by shredding the illusion of their effectiveness.
There is a time and a place for placebo medications, and there is certainly
a point where their use is deleterious. Judicious use of placebos, however,
has allayed a great deal of suffering.
These cases intimately relate to the original question of miscoding
because they establish benevolent deception as a tool of physicians. We do
not vilify physicians who occasionally practice this form of deception. Rather,
we call them compassionate and look up to them as keen students of their patients'
needs. If we as a profession will admit to these deceptions, then it is not
a large leap to apply deceptions in other situations, similarly warranted
by necessity and the greater good.
Miscoding appears at first, however, to be a greater ethical breach
than prescribing placebos. The physician must pick up a pen and check the
wrong box. He or she must fill in a date and time and affix a signature, just
as if no error in judgment were occurring. To make matters more difficult,
the physician may even find it necessary to scribble "Rule out _______" in
a hand quite unrecognizable in many ways from his or her usual, honest scrawl.
There it sits, a black and white testimony to the physician's arrogance, using
someone else's money to cure the patient's illness. The act does not seem
like something to take pride in. Prescribing placebos and checking the wrong
box are, after all, both acts of lying, and are therefore not different in
Miscoding may be ethically inappropriate because physicians can always
try to change the insurance rules. The ethically untainted solution would
be for the physician to appeal to the insurance company, document the evidence,
and request a special dispensation. On discovering that the special permission
has been denied, the physician could then crusade to have the disease recategorized
so that the test is covered for everyone who presents with similar symptoms.
That course of action is pleasing but impractical in the real world. Not only
does a physician not have the time or inclination to rail against the corporate
structure each time an institutional blockade is presented, but other patients
in the practice would necessarily suffer from inattention.
The physician who is considering miscoding must be assured (1) that
the test truly is the best and only means of obtaining the necessary information
and (2) that the test will bring substantial gain to the patient relative
to inaction as well as to alternate, perhaps multiple, insured actions. This
logic applies to all tests, treatments, therapies, and procedures, regardless
of cost. Size or price does not alter ethical responsibility.
These breaches of confidence, by omission and by commission, must be
balanced against some nebulous idea of the greater good. The most weighty
question concerns determining whether the physician has the ability to discern
the greater good. Every day, decisions are placed in physicians' hands that
involve weighing the good of the one against the good of the many. Is it appropriate
to give antibiotics if the overuse of antibiotics may increase resistant organisms?
It is the family physician who must decide every day. Is this particular newborn
really the best use of these cardiac funds? The cardiac team must make that
decision. If we refuse to admit that physicians are equipped to make decisions
about the greater good, we make the profession impotent. Society should expect
physicians, as professionals, to be able to make responsible decisions about
the allocation of medical resources. If that prerogative is refused, then
the practice of medicine must grind to a standstill. We must therefore conclude
that doctors can and should make decisions pertaining to the greater good.
But does the miscoding truly represent the greater good? The process
of being forced to miscode heightens a physician's awareness of the circumstances
that led to the miscoding. If a desired procedure is unavailable, the physician
must either miscode—a situation that is ethically disturbing—or
cumbersomely work around the unavailable procedure. Either way, a large enough
number of physicians sufficiently troubled about the same problem will eventually
create a critical mass, enabling direct appeal to insurance companies to change
their policies. In the meantime, the physician has continued to serve patients
to the best of his or her abilities. Being able to serve both the patient
and the administrative machinery of medicine can be an elusive goal. Achieving
a reasonable balance between these ends, though, speaks of a decision rooted
in the greater good.
The process of assuring an ethical miscoding depends on the ability
of the physician to exercise sound judgment. The only way to sort out these
judgments is, first, to convince oneself that the miscoding is the best clinical
opinion available and, second, that the miscoding substantially and materially
helps the patient. The third task is for the physician to weigh the immediate
gain for one patient against the cost to society. Society relies on physicians
not only to look after people's medical health but also to prevent other sectors
of society from disrupting medical care. Miscoding to save a patient is the
last resort for the physician with experience and talent. If physicians are
not granted the ability to apply their judgment and do not take the responsibility
into their own hands, there is no other source to fill the void.
The Medical Student JAMA is pleased to announce
its sixth annual essay competition for medical students, sponsored by the
John Conley Foundation for Ethics and Philosophy in Medicine. This year's
topic examines an issue raised by the expanding technology available in medicine.
Traditionally, preservation of life has been the foremost concern of medicine.
With new technologies available to prolong life, ethical issues have emerged
around who determines and how one measures the quality of life. In their essays,
medical students are asked to address the following scenario: Suppose that
a neonate with trisomy 21 is found also to have a medical condition that is
easily repaired surgically, but lethal if not corrected. The parents of the
newborn are not prepared to raise a child whose quality of life they believe
will be impaired and ask that no further medical intervention take place.
What are the ethical obligations of the physician?
Essays will be judged based on clarity of presentation and writing and
applicability to actual decision-making. Essays should address the ethical
dilemma presented in the scenario and not focus on
the science of genetic testing or the mechanisms of the disease. The author(s)
of the best essay(s) will be awarded $5000 or a portion thereof and will be
encouraged to use some of the funds to attend an ethics conference of their
choice. Winning essays will be considered for publication in MSJAMA. Essays must not have been previously published in print or
electronic format and must not have been submitted to any other journal during
the review period.
All current medical students are eligible. Essays should be less than
2000 words in length. Please submit essays typed and double-spaced, with the
author's identification (name, address, telephone number, and medical school
class) on a cover sheet only—not on the essay pages, which
will be anonymously judged. Entries must be postmarked by January 15, 2000,
and sent to:
John Conley Essay Contest, c/o MSJAMA, 515 N State St, Chicago, IL 60610
Essays winning honorable mention in the 1999 John Conley Ethics Essay
Contest can be found online at http://www.ama-assn.org/sci-pubs/msjama/index.htm. The honorable mention winners are Matthew R. Cooperberg, Yale University
School of Medicine, "Justified Deception? Miscoding on Insurance Claims";
Rishi Agrawal, Northwestern University School of Medicine, "A Change of Heart";
and Stephen Jae Kim, Johns Hopkins University, "The Choice."
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and
Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early
dhildhood mortality and growth failure data and their association with maternal
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