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Saturday, December 19, 2009

Gaming behavior in Medicine

I spent much of the morning trying to find any writings on gaming behavior in medicine. There is only a very modest amount written on this subject. This is not surprising since there is essentially no upside to whomever would decide to undertake such a project. There was a study published in JAMA in 2000 (Wynia, et al; 283: 1858) which undertook a survey of physicians. They found that almost 40% would game the payment system in order to further the ends of their patients. While this raises all sorts of ethical questions, in my estimation it misses the more prevalent and less noble gaming opportunities.

I found a very interesting letter published on December 5, 1990 in JAMA (264:2742) sent in by Dr. Paul M. Allen discussing what was then the novel activity of unbundling". He astutely identified this as identifying an economic and not a medical activity. What was most striking was his realization that:

"The magnitude of the problem is illustrated by the fact that companies have been formed whose sole purpose is to teach physicians or their office staff how to code."

This was a very interesting letter which had two citations.The first was the 1990 CPT book published by the AMA. The second was George Orwell's Animal House. There is a message here.

Thus the norms in 1990 were that this development (the formation of consultant billing entities) was a problem, a far cry from the present state where not only is this not viewed as a problem, it is viewed as an essential business practice. As part of our residency assessment were are required to have this as part of resident education. In the span of less than twenty years we have gone from being mortified by a particular behavior to viewing it as required.

The lesson is that financial pressures over time can and will alter norms. Our actions will move toward where our rewards (mostly financial) are derived. We will ultimately rationalize our behavior to justify our actions.

How common is the gaming behavior which serves physician interests? I can only speculate in the absence of hard data. However, if you take the 40% number derived from the JAMA study, it is not unreasonable to assume that at least an equivalent percentage will game the system to further their own ends. Most of the gaming activities are neither illegal nor are they frowned upon by peers. Quite the contrary; over time they are increasingly viewed as essential aspects of practice, much like believing the cows were struck by lightning (see

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