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, AMNews 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.

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. [...]