Physicians direct sick patients out of capitated plans

AMA study shows that primary care doctors encourage sicker patients to join health plans with fewer restrictions while leading healthy patients toward HMOs.

By Myrle Croasdale, amednews staff. Feb. 4, 2002.

The perceived quality of the plan -- and not the chance for their own financial gain -- is the reason more physicians have pushed their patients to join fee-for-service HMOs than they have capitated plans, according to a study. And by doing that, doctors may have unwittingly extended the life span of capitation.

The American Medical Association's Institute for Ethics, in a survey of 787 physicians, found that 40% of doctors encouraged more complex or ill patients to avoid capitated plans, while 23% encouraged healthier patients to join such plans.

Planned exodus

Capitated plans pay doctors based on the number of covered patients in their practice, not on how many times they see a patient or on the amount of care the patient receives. Physicians share in the role of insurer, bearing the risk of how sick or healthy these patients are.

The study, which appears in the January issue of the Journal of General Internal Medicine, was done during 1997 and 1998 when capitated plans were strong and looked like the wave of the future. In recent years, doctors have rebelled against such plans, and insurers have backed off of them as well in some areas.

In some way, physicians' desires to keep sicker patients out of capitated plans may have encouraged insurers to continue pushing them.

"The main problem, even when doctors do the right thing in telling people who are sick to get out of lower quality plans, is that they are protecting the lower quality plans," said Matthew Wynia, MD, co-author of the study. "This is a system that rewards lower-quality plans by taking the sickest patients out of them."

Dr. Wynia said they expected to find out if physicians were directing patients out of capitated plans because they could make more money if sick patients had other insurance.

This wasn't the case, he said. "We weren't able to find good evidence of financial motivations," he added.

But the patient's access to care was a concern. "I believe this is more tied to quality worries," he said. "If it were a noncapitated plan with lower quality, I think the doctors would have answered the same. It's a little bit surprising and disappointing that more than a third of doctors believe the capitated plans they are dealing with are not providing enough resources to allow them to provide good quality care."

The American Assn. of Health Plans questioned the study's structure and objectivity and decried the perception that capitated plans restricted physicians' options and offered patients less quality.

"There are a lot of unanswered questions in this study," said Mohit Ghose, AAHP spokesman. "We do need to understand a couple of points. One hopes physicians, regardless of how they are being paid, will give the best care they can. And the payment perception of quality is erroneous. There are capitated plans out there, like Kaiser [Permanente], that have a proven track record of quality health care.

"In the larger scheme of things, a physician has a wider range of options in managed care. It permits physicians to think creatively on how to tackle a patient's situation without having to think of billing constraints. I'd be hard pressed to think that managed care or capitated plans aren't good for sicker people."

ADDITIONAL INFORMATION:

Planned exodus

Highlights from the AMA Institute for Ethics' survey of doctors regarding how they handle capitation.

44% reported encouraging patients either to join or to avoid capitated health plans according to the patients' health status.
40% encouraged more complex and ill patients to avoid capitated plans.
23% encouraged healthier patients to join capitated plans.

Source: AMA Institute for Ethics study as published in the January Journal of General Internal Medicine