PubMed Health⌕ Search

Biomedical subjects

G Caleb Alexander

Publications and source records attributed to G Caleb Alexander.

30 records · Page 2Linked to original sources
PubMed2004

Lying to insurance companies: the desire to deceive among physicians and the public.

This study examines the public's and physicians' willingness to support deception of insurance companies in order to obtain necessary healthcare services and how this support varies based on perceptions of physicians' time pressures. Based on surveys of 700 prospective jurors and 1617 physicians, the public was more than twice as likely as physicians to sanction deception (26%versus 11%) and half as likely to believe that physicians have adequate time to appeal coverage decisions (22%versus 59%). The odds of public support for deception compared to that of physicians rose from 2.48 to 4.64 after controlling for differences in time perception. These findings highlight the ethical challenge facing physicians and patients in balancing patient advocacy with honesty in the setting of limited societal resources.

Deception↗
PubMed2004

Barriers to patient-physician communication about out-of-pocket costs.

BACKGROUND: Though many patients and physicians believe that they should discuss out-of-pocket costs, research suggests that they infrequently do. OBJECTIVE: To examine barriers preventing patient-physician communication about out-of-pocket costs among study subjects recalling a time when they wanted to discuss these costs but did not do so. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional surveys of 133 general internists and 484 of their patients from 3 academic and 18 community practices in a large midwestern metropolitan region. MEASUREMENTS: Patient- and physician-reported barriers to discussing out-of-pocket costs. MAIN RESULTS: Overall, 54 patients (11%) and 27 physicians (20%) were able to recall a specific time when they wanted to discuss out-of-pocket costs but did not do so. Among patients, a wide variety of barriers were reported including their own discomfort (19%), insufficient time (13%), a belief that their physician did not have a viable solution (11%), and concerns about the impact of discussions on quality of care (9%). Among physicians, the most common barriers reported were insufficient time (67%) and a belief that they did not have a solution to offer (19%). CONCLUSIONS: Efforts to promote discussions of out-of-pocket costs should emphasize the legitimacy of patients' concerns and brief actionable alternatives that physicians can take to address them.

Adolescent↗
PubMed2003

Patient-physician communication about out-of-pocket costs.

CONTEXT: Out-of-pocket costs account for approximately one fifth of health care expenditures and are increasing. Previous research suggests that these costs are associated with medication nonadherence and considerable economic burden among some patients. Little is known about patient-physician communication regarding these costs. OBJECTIVE: To identify patients' and physicians' beliefs and practices regarding discussions of out-of-pocket costs. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional paired surveys of 133 general internists and 484 of their outpatients, aged 18 years or older, in 3 academic and 18 community general medicine practices in the Chicago metropolitan area, March-November 2002. MAIN OUTCOME MEASURES: Patient and physician beliefs regarding discussions of out-of-pocket costs, frequency and predictors of discussions, and physician recognition of patient burden from out-of-pocket costs. RESULTS: Sixty-three percent of patients reported a desire to talk with their physician about their out-of-pocket costs, and 79% of physicians believed that patients in general want to discuss these costs. By contrast, only 35% of physicians and 15% of patients reported ever having discussed the study patient's out-of-pocket costs. Multivariate analysis indicated that discussions were significantly more likely to occur with patients burdened by their out-of-pocket costs (prevalence ratio [PR], 2.55; 95% confidence intervals [CI], 1.62-3.76) and with those patients seen in a community practice (PR, 5.19; CI, 1.86-8.93). Among patients burdened by out-of-pocket costs, physicians were substantially more likely to recognize this burden when a prior discussion regarding out-of-pocket costs had taken place (80% vs 51%). CONCLUSIONS: Among respondents, both patients and physicians believed that discussions of out-of-pocket costs were important, yet these discussions occurred infrequently. Physician communication with patients about out-of-pocket costs may be an important yet neglected aspect of current clinical practice. Further research should identify the prevalence of this problem in broader populations, investigate its causes, and evaluate the impact of enhanced communication about out-of-pocket costs on patient satisfaction, utilization of care, and outcomes.

Attitude of Health Personnel↗
PubMed2003

Support for physician deception of insurance companies among a sample of Philadelphia residents.

BACKGROUND: Some physicians seem to be willing to sanction deception of insurance companies. Little is known about public attitudes regarding this practice. OBJECTIVE: To assess public attitudes regarding physician deception of insurance companies. DESIGN: Cross-sectional survey using clinical vignettes. SETTING: Philadelphia County Courthouse, Philadelphia, Pennsylvania. PARTICIPANTS: Convenience sample of 700 prospective jurors. MEASUREMENTS: Participants were asked whether, in response to restriction of health care, a physician should 1) accept restriction, 2) appeal restriction, or 3) misrepresent a patient's condition to obtain the desired service. The proportion of respondents reporting that the physician should misrepresent a patient's condition was determined. RESULTS: 26% of respondents sanctioned deception, 70% supported appealing, and 4% supported accepting the insurance company decision. Among the 27% of respondents believing physicians have inadequate time to appeal coverage decisions, 50% sanctioned deception. CONCLUSIONS: Sanctioning of deception was substantial in this sample of prospective jurors. Preferences regarding insurance company deception are related to perceptions of physician workload and may further pressure physicians struggling to balance advocacy with honesty.

Adult↗
PubMed2002

The "Hassle Factor": what motivates physicians to manipulate reimbursement rules?

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Analysis of Variance↗
PubMed2002

Variation in access to kidney transplantation across dialysis facilities: using process of care measures for quality improvement.

BACKGROUND: Kidney transplantation rates differ by patient and dialysis-facility characteristics, yet little is known about the sources of this variation or how access to transplantation can be improved. Examining specific steps in the transplantation process may guide quality improvement efforts that ultimately improve the equity and efficiency of transplantation. METHODS: We sought to examine variation across dialysis facilities in the completion of four specific steps (medical suitability, interest in transplantation, pretransplantation workup, and waiting list) after adjustment for patient characteristics. Using 11,674 patients on chronic hemodialysis therapy between January 1993 and December 1996 at 206 facilities in Indiana, Kentucky, and Ohio, we derived facility-specific: (1) actual completion rates at each step; (2) expected completion rates based on patient age, race, sex, and cause of renal failure; and (3) ratio of actual to expected completion rates. RESULTS: Actual completion rates varied greatly, with facilities at the 75th percentile having a twofold greater completion rate than facilities at the 25th percentile (eg, 59% versus 32% at the first step). Although patient characteristics were strongly associated with step completion, adjustment for these characteristics did not decrease variation across facilities. At each step, approximately 20% of facilities had a significantly greater than expected completion rate, whereas approximately 15% had a significantly lower than expected completion rate. CONCLUSION: There is substantial variation across dialysis facilities in access to kidney transplantation, even after adjustment for patient characteristics. Identifying steps with less than expected completion rates may help facilities target such efforts as treatment of medical conditions, patient education, and early referral for pretransplantation workup and waiting list placement.

Adult↗
PubMedDate not supplied

The doctor-patient relationship in the post-managed care era.

The growth of managed care was accompanied by concern about the impact that changes in health care organization would have on the doctor-patient relationship (DPR). We now are in a "post-managed care era," where some of these changes in health care delivery have come to pass while others have not. A re-examination of the DPR in this setting suggests some surprising results. Rather than posing a new and unprecedented threat, managed care was simply the most recent of numerous strains on the DPR that have occurred throughout the century. These strains are a constant, inevitable consequence of the varying needs and concerns of patient and physicians as they seek to balance their desires for a certain type of DPR with their simultaneous desire for other aspects of care such as lower costs, greater technological sophistication, and improved outcomes.

Humans↗
PubMedDate not supplied

Rethinking professional ethics in the cost-sharing era.

Changes in healthcare financing increasingly rely upon patient cost-sharing to control escalating healthcare expenditures. These changes raise new challenges for physicians that are different from those that arose either under managed care or traditional indemnity insurance. Historically, there have been two distinct bases for arguing that physicians should not consider costs in their clinical decisions--an "aspirational ethic" that exhorts physicians to treat all patients the same regardless of their ability to pay, and an "agency ethic" that calls on physicians to be trustworthy advisors to their patients. In the setting of greater patient cost-sharing, physicians' aspiration and agency roles increasingly conflict. Satisfactorily navigating the new terrain of consumer-driven healthcare requires physicians to consider these two roles and how they can best be reconciled so as to maximize quality of care while respecting the heterogeneity of patients' financial resources and willingness to pay.

Bioethical Issues↗
PubMedDate not supplied

Consumers' perceptions about risk of and access to nonprescription medications.

OBJECTIVES: To examine how consumers balance the principles of safety with regulatory access to pharmaceuticals and to identify respondent characteristics, including prior misuse of nonprescription medications, that are associated with a preference for nonprescription status. DESIGN: Cross-sectional survey within-subject attitudinal analysis. SETTING: Large midwestern metropolitan region of the United States. PARTICIPANTS: Convenience sample of 553 members of the general public. INTERVENTIONS: Anonymous self-administered surveys with hypothetical vignettes in which a heartburn or antihypertensive drug could be available without a prescription but in doing so would entail an increased risk (1/100,000, 1/10,000, or 1/1,000 chance of heart attack) to the user that would not be present with the medical care afforded by prescription drug status. MAIN OUTCOME MEASURE: Proportion of respondents preferring nonprescription availability. RESULTS: Overall, 33%, 19%, and 11% of respondents preferred nonprescription availability when the additional risks of a heart attack with nonprescription availability were 1/100,000, 1/10,000, and 1/1,000, respectively. Risk tolerance did not differ between the heartburn and antihypertensive vignettes. Although preference for nonprescription status was significantly greater among respondents who were men (42% versus 28%) and white (42% versus 32%), and a statistical trend was evident among respondents with higher self-reported health (37% versus 27%) and a college education (36% versus 28%), most of these differences did not persist on multivariate analysis. CONCLUSION: A substantial minority of the public appears willing to accept considerable risk to gain greater access to pharmaceuticals. Heterogeneity among the general public with regard to how safety and access to nonprescription medications should be balanced challenges policy makers working to design responsive yet appropriate regulatory policies.

Adult↗
PubMedDate not supplied

Ready and willing? Physicians' sense of preparedness for bioterrorism.

Little is known about contemporary physicians' sense of preparedness for bioterrorism, willingness to treat patients despite personal risk, or belief in the professional duty to treat during epidemics. In a recent national survey few physicians reported that they or their practice are "well prepared" for bioterrorism. Still, most respondents reported that they would continue to care for patients in the event of an outbreak of "an unknown but potentially deadly illness," although only a narrow majority reported believing in a professional duty to treat patients in epidemics. Preparing physicians for bioterrorism should entail providing practical knowledge, preventive steps to minimize risk, and reinforcement of the profession's ethical duty to treat.

Adult↗