The good, the bad, and the ugly of medication coverage: Is altering a diagnosis to ensure medication coverage ethical?

Recently, a patient presented to the dermatology clinic suffering from disabling, recurrent palmoplantar vesicles and pustules. Biopsy demonstrated nondiagnostic histologic findings without unequivocal evidence for psoriasis. The localized rash was recalcitrant to a host of standard therapies. An anti-tumor necrosis factor biologic was considered, and experience suggested that this expensive medication would only be approved for coverage if a diagnosis was submitted for a Food and Drug Administration–approved indication as psoriasis. All health-care providers face similar dilemmas in caring for their own patients. To whom is the physician’s primary responsibility when what is best for the patient may not align with the realities of our health-care system? Should a physician alter or exaggerate a medical diagnosis to obtain insurance coverage for a needed medication? What are the ethical implications of this action? If the physician’s fiduciary duty to the patient had no limits, there would be multiple potential consequences including compromise of the health-care provider’s integrity and relationships with patients, other providers, and third-party payers as well as the risk to an individual patient’s health and creation of injustices within the health-care system.