Abstract
Capitation-based reimbursement significantly influences the practice of medicine. As physicians, we need to assure that payment models do not jeopardize the care we provide when we accept higher levels of personal financial risk. In this paper, we review the literature relevant to capitation, consider the interaction of financial incentives with physician and medical risk, and conclude that primary care physicians need to work to assure that capitated systems incorporate checks and balances that protect both patients and providers. We offer the following proposals for individuals and groups considering capitated contracts: (1) reimbursement for primary care physicians should recognize both individual patient encounters and the administrative work of patient care management; (2) reimbursement for subspecialists should recognize both access to subspecialty knowledge and expertise as well as patient care encounters, but in some situations, subspecialists may provide the majority of care to individual patients and will be reimbursed as primary care providers; (3) groups of physicians should accept financial risk for patient care only if they have the tools and resources to manage the care; (4) physicians sharing risk for patient care should meet regularly to discuss care and resource management; and (5) physicians must disclose the financial relationships they have with health plans and medical care organizations, and engage patients and communities in discussions about resource allocation. As a payment model, capitation offers opportunities for primary care physicians to influence the future of health care by improving the management of resources at a local level.
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References
Blumenthal D. Health care reform—past and future. N Engl J Med. 1995;332:465–8.
Relman AS. The Health Care Industry: Where is it taking us? N Engl J Med. 1991;325:854–8.
Epstein AM, Begg CB, McNeil BJ. The use of ambulatory testing in prepaid and fee-for-service group practices. N Engl J Med. 1986;314:1089–94.
Murray JP, Greenfield S, Kaplan SH, Yano EM. Ambulatory testing for capitation and fee-for-service patients in the same practice setting: Relationship to outcomes. Med Care. 1992;30:252–61.
Clement DG, Retchin SM, Brown RS, et al. Access and outcomes of elderly patients enrolled in managed care. JAMA. 1994;271:1487–92.
Ransom SB, McNeeley GS, Kruger ML, et al. The effect of capitated and fee-for-service remuneration on physician decision making in gynecology. Obstet Gynecol. 1996;87:707–10.
Goldzweig CL, Mittman BS, Carter GM, et al. Variations in cataract extraction rates in medicare prepaid and fee-for-service settings. JAMA. 1997;277:1765–8.
Greenfield S, Nelson E, Zubkoff M, et al. Variations in resource utilization among medical specialties and systems of care. JAMA. 1992;267:1624–30.
Miller RH, Luft HS. Managed care plan performance since 1980. JAMA. 1994;271:1512–8.
Mitchell JM, Sunshine JH. Consequences of physicians’ ownership of health care facilities — joint ventures in radiation therapy. N Engl J Med. 1992;327:1497–500.
Swedlow A, Johnson G, Smithline N, et al. Increased costs and rates of use in the California workers’ compensation system as a result of self-referral by physicians. N Engl J Med. 1992;327:1502–6.
Hillman AL, Pauly MV, Kerstein JJ. How do financial incentives affect physicians’ clinical decisions and the financial performance of health maintenance organizations? N Engl J Med. 1989;321:86–92.
Manning WG, Leibowitz A, Goldberg GA, et al. A controlled trial of the effect of a prepaid group practice on use of services. N Engl J Med. 1984;310:1505–10.
Cooper RF, Nicholes LM, Tayler AK. Patient choice of physician: Do health insurance and physician characteristics matter? Inquiry. 1996;33:237–46.
Kerr EA, Mittman BS, Hays RD, Leake B, Brook RH. Quality assurance in capitated physician groups. Where is the emphasis? JAMA 1996;276:1236–9.
Sulmasy DP. Physicians, cost control, and ethics. Ann Intern Med. 1992;116:920–6.
Dougherty CJ. Ethical values at stake in health care reform. JAMA. 1992;268:2409–12.
Emanuel L. Bringing market medicine to professional account. JAMA. 1997;277:1004–6.
Berwick DM. Payment by capitation and the quality of care. N Engl J Med. 1996;335:1227–31.
Hillman AL. Health maintenance organizations, financial incentives, and physicians’ judgments. Ann Intern Med. 1990;112:891–4.
Selker HP. Capitated payment for medical care and the role of the physician. Ann Intern Med. 1996;124:449–51.
Simon CJ, Emmons DW. Physician earnings at risk: an examination of capitated contracts. Health Aff (Millwood). 1997;16:120–6.
Swartz K, Brennan T. Integrated health care, capitated payment, and quality: The role of regulation. Ann Intern Med. 1996;124:442–50.
Pearson SD, Sabin JE, Emanuel EJ. Ethical guidelines for physician compensation based on capitation. N Engl J Med. 1998;339:689–93.
Pedersen CA, Rich EC, Kralewski J, Feldman R, Dowd B, Bernhardt TS. Primary care physicians incentives in medical group practices. Arch Fam Med. 2000;9:458–62.
Shortell SM, Waters TM, Clarke KW, Budetti PP. Physicians as double agents. JAMA. 1998;280:1102–8.
Bodenheimer TS, Grumbach K. Capitation or decapitation. JAMA. 1996;276:1025–31.
Grumbach K, Osmond D, Vranizan K, Jaffe D, Bindman AB. Primary care physicians’ experience of financial incentives in managed-care systems. N Engl J Med. 1998;339:1516–21.
Ingber MJ. The current state of risk adjustment technology for capitation. J Ambulatory Care Manage. 1998;21:1–28.
Bierman AS, Bubolz TZ, Fisher ES, Wasson JH. How well does a single question about health predict the financial health of Medicare managed care plans? Eff Clin Pract. 1999;2:56–62.
McNamara RL, Powe NR, Shaffer T, Thiemann D, Weller W, Anderson G. Capitation for cardiologists: accepting risk for coronary artery disease under managed care. Am J Cardiol. 1998;82:1178–82.
Newhouse JP, Buntin MB, Chapman JD. Risk adjustment and Medicare: taking a closer look. Health Aff (Millwood). 1997;16:26–43.
Kipp RA, Towner WC, Levin HA. Financial and actuarial issues. In: Disease Management: A Systems Approach to Improving Patient Outcomes. Chicago: American Hospital Pub; 1997.
Newhouse J, Buntin M, Chapman J. Risk Adjustment and Medicare. New York: Commonwealth Fund Publication; 1999.
Kuttner R. The risk-adjustment debate. N Engl J Med. 1998;339:1952–6.
Kronick R, Beyer JD. Paying plans to care for people with chronic illness. In: Kronick R, Beyer JD, eds. Medicare HMOs: Making Them Work for the Chronically Ill. Chicago: Health Administration Press; 1999:27–68.
Fowles JB, Weiner JP, Knutwon D. Taking health status into account when setting capitation rates. JAMA. 1996;276:1316–22.
Newhouse JP, Manning WG, Keeler EB. Adjusting capitation rates using objective health measures and prior utilization. Health Care Financ Rev. 1989;10:41–54.
Iezzoni LI, Ayanian JZ, Bates DW, Burstin HR. Paying more fairly for Medicare capitated care. N Engl J Med. 1998;339:1933–8.
Jellinek MS and Nurcombe B. Two wrongs don’t make a right, managed care, mental health, and the marketplace. JAMA. 1993;270:1737–9.
Kerr EA, Hays RD, Mittman BS, Siu Al, Leake B, Brook RH. Primary care physicians’ satisfaction with quality of care in California capitated medical groups. JAMA. 1978;278:308–12.
Center for Health Policy Research (American Medical Association). Physician Marketplace Statistics. Profiles for Detailed Specialties, Selected States and Practice Arrangements/AMA Center for Health Policy Research. Chicago: American Medical Association; 1998.
Gold MR, Hurley R, Lake T, Ensor T, Berenson R. A national survey of the arrangements managed-care plans make with physicians. N Engl J Med. 1995;333:1678–82.
Robinson JC, Casalino LP. The growth of medical groups paid through capitation in California. N Engl J Med. 1995;333:1684–8.
Iglehart JK. Physicians and the growth of managed care. N Engl J Med. 1994;332:1167–72.
Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA. 1995;273:323–8.
Leopold N, Cooper J, Clancy C. Sustained partnership in primary care. J Fam Pract. 1996;42:129–37.
Safran DG, Tarlov AR, Rogers WH. Primary care performance in fee-for-service and prepaid health care systems. JAMA. 1994;271:1579–86.
Conrad DA, Maynard C, Cheadle A, et al. Primary care physician compensation method in medical groups. Does it influence the use and cost of health services for enrollees in managed care organizations? JAMA. 1998;279:853–8.
Greenfield S, Rogers W, Mangotich M. Outcomes of patients with hypertension and non-insulin-dependent diabetes mellitus treated by different systems and specialties. JAMA. 1995;274:1436–44.
Lurie N, Christianson J, Finch M. The effects of capitation on health and functional status of the Medicaid elderly. Ann Intern Med. 1994;120:506–11.
Yelin EH, Criswell LA, Feigenbaum PG. Health care utilization and outcomes among persons with rheumatoid arthritis in fee-forservice and prepaid group practice settings. JAMA. 1996;276:1048–54.
Brook RH, Ware JE, Rogers WH, et al. Do free care improve adults’ health? N Engl J Med. 1983;309:1426–33.
Siu AL, Sonnenberg FA, Manning WG, et al. Inappropriate use of hospitals in a randomized trial of health insurance plans. N Engl J Med. 1986;315:1259–66.
Ware JE Jr, Rogers WH, Davies AR, et al. Comparison of health outcomes at a health maintenance organization with those of fee-for-service care. Lancet. 1986:1017–22.
Ware JE, Bayliss MS, Rogers WH, et al. Differences in 4-year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-for-service systems. JAMA. 1996;276:1039–47.
Kao AC, Zaslavsky AM, Green DC, Koplan JP and Cleary PD. Physician incentives and disclosure if payment methods to patients. J Gen Intern Med. 16:181–8.
Pearson SD and Racke LH. Patients’ trust in physicians: many theories, few increases, and little data. J Gen Intern Med. 2000;15:509–13.
Am College of Phy. Physicians and the pharmaceutical industry. Ann Intern Med. 1990;112:624–6.
Levinson W. Paid not to refer? J Gen Intern Med. 16:209–10.
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The views expressed by Dr. Bierman do not necessarily represent the position of the Agency for Health Care Policy and Research or the Department of Health and Human Services.
Dr. Fein is the Co-Principal Investigator on Partnerships in Quality Education, funded in part by the Pew Charitable Trusts, Inc.
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Goodson, J.D., Bierman, A.S., Fein, O. et al. The future of capitation The physician role in managing change in practice. J GEN INTERN MED 16, 250–256 (2001). https://doi.org/10.1046/j.1525-1497.2001.016004250.x
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DOI: https://doi.org/10.1046/j.1525-1497.2001.016004250.x