Physicians gaming the system: Modern-Day Robin Hood?

• Author: Regis, Catherine
• Position: Canada

From childhood, people have considered the storybook character Robin Hood as a hero who stole from the rich to give to the poor. Even if we were all taught that stealing was something bad, in certain circumstances, we would consider it acceptable if the goal were laudable. Perhaps our hero is simply a petty thief. But what if the gold that Robin Hood stole had an impact on an entire village? What if the stolen gold was intended for all of the villagers in order to pay them for their yearly harvests, but because of the justifiable robbery, none of them could therefore be paid? Would we have as much sympathy for Robin Hood or accept his act of thievery? To a certain extent, the actions of doctors can lead us to consider them as the "Modern-Day Robin Hood". Indeed, in order to help their patients, some physicians choose to break health care rules and regulations regarding access to care and/or reimbursement (1), that is, gaming the system for the personal benefit of individuals in need.

Compared to fraud, gaming is essentially based on altruistic motives and is not primarily carried out from a perspective of self-interest. Those who use gaming will resort to such tactics as over-claiming (e.g. billing for an insured service while providing an uninsured service) or will misrepresent patient data (e.g. queue-jumping, misclassification--for example, exaggerating the severity of an individual patient's condition to obtain more expeditious care or to help a patient secure coverage for required care). (2)

People's opinions, with respect to gaming, vary greatly. Some believe that the practice of gaming indirectly promotes equity and quality in the allocation of health care resources by allowing doctors to offer required health care services to patients who otherwise would not receive such care. Furthermore, some physicians believe it is their role to determine priorities among their patients, even if they must bypass the system in order to do so. To others, gaming renders the health care system susceptible to important repercussions, such as increased overall costs and a reduction of the quality of health care services. (3)

Should something be done about gaming? If so, what exactly? In this article, I will argue that, even if it sometimes appears to be praiseworthy, gaming is not a good practice in general, and its potential impact on the health care system is sufficiently significant to substantiate intervention. Thereafter, I will propose guidelines that should be implemented regarding such conduct. These guidelines must also be understood and combined with other topics, namely education and a user-friendly resources allocation revision mechanism. Even if gaming can also be executed by hospitals to the benefit of patients or by physicians to the benefit of hospitals--or to that of any other health care establishment--I will confine my remarks to the specific circumstance of physicians who carry out gaming to the benefit of their patients.

The Necessity to Intervene Regarding the Practice of Gaming (4)

Is gaming an acceptable or an unacceptable practice? The answer to this question often depends on one's point of view or situation vis-a-vis the issue. Undeniably, gaming will be considered good practice to those who would not otherwise benefit from a particular type of care or other services. However, only considering this question, by focussing on potential individual benefits, gives us but a partial view of a vastly more complex issue. As our health care system is based on common social values such as universality, accessibility (based on people's needs) and public administration (5), gaming should be considered while taking into account its impact on those values or principles. Examined in this way, we can understand that such a practice might have a negative impact on the entire health care system and, in the long run and if overly widespread, might even become a threat to its very existence. In the following treatise, I will firstly explain how gaming can diminish the confidence people have in the health care system by, most notably, upsetting equity and weakening solidarity values. Secondly, I will discuss how the practice affects the standard of care, and finally, I will present the potentially serious financial consequences on the system.

To begin, confidence in the health care system is essential as "the system will survive if people think it's fair". (6) Hence, the perception of equity is extremely significant. Behaviour such as gaming can have an impact on that fundamental value as it can cause the resource allocation system to stray from its main objective: fair distribution, that is, distribution based on needs. Indeed, if such a practice becomes prevalent, patients, whose physicians refuse to do so, will be penalized and see their chances to receive care, even if greatly needed, diminished as other patients illegitimately (7) benefit from it. Additionally, physicians may have a natural tendency towards gaming when those requiring care are friends or family (8), or when the patients are more capable or forceful in their requests for such practices (9). There is a risk of creating "second-class" patients comprised of individuals without such privileged acquaintances or who are unable to adequately request care (10). In short, gaming could become an extremely penalizing practice to those who do not benefit from it and may even ultimately become futile by requiring physicians to "standardize" such procedures to ensure the very services they wish to procure for their patients. Thus, the practice of gaming is unfair with respect to the afore-mentioned objective of distribution based on the priority of needs and therefore risks hindering confidence in the health care system, eventually leading to the rejection of the system as a whole.

In addition, the loss of confidence in the health care system can possibly lead to--or be driven by--an...