Physician's Capitation Trend-Dislike of capitation eases among physicians
Doctors get high marks from patients
When Abraham Lincoln said, "You can't please all the people all the time," he could have well been referring to capitation, too. As of late 1999, when it comes to capitation and its variations, public perception is going downhill while physicians are reporting greater acceptance. And amid all the controversy over HMOs and other risk-sharing arrangements, the public is reporting increased satisfaction with their physicians.
These are key findings from two studies released at about the same time — one of HMO members nationwide and one of physicians in a large urban physician-hospital organization (PHO).1,2
Continued concern, but less anxiety
From the physician point of view, the PHO study shows mixed views about HMO risk contracts. Physicians are reporting:
• lessened anxiety about capitation;
• continued concern about perverse incentives in capitation;
• a growing awareness of ways to ensure capitation contracts are fair and effective;
• a growing awareness that fee-for-service has its own potential for conflict of interest, too.
The patient survey comes from an Atlanta-based consumer research group, Caredata.com., which in August surveyed 24,802 health plan members in 159 managed care plans in 27 major managed care markets.
The study of physician viewpoints, conducted by six internists at Brigham and Women's Hospital in Boston, captures two years of physician opinion with the goal of looking at whether physician attitudes changed over that period.
In the first year of that survey, physicians had only 5% capitated patients and a year of education and introduction to capitation methodologies. The second year, 25% of their patients were in capitated contracts, thus giving the physicians more experience in capitated approaches.
The internists' survey included 587 physicians. The majority of those surveyed were relatively young (30-39 year-olds composed 51%-54% of respondents in each year); most were medical subspecialists (57%); and most were male (72%-75%).
Patient complaints are centering more around customer service than clinical care, says Tod Cooperman, president of Caredata.com's consumer research group. In particular, the three highest areas of complaints were HMOs' help with medical decisions, ability to contact plan representatives, and the inability of HMO representatives to answer their questions. Here are some key indicators from HMO enrollees:
• 55% of HMO members say they are satisfied overall with their plans, a 3% drop from the year before.
• 54% of point-of-service (POS) members say they are highly satisfied with their health plan, a 5% increase over the previous year.
• Fewer HMO enrollees (72%) are satisfied with their plans' pharmacy benefit, a drop of 7% from the year before.
Once the biggest draw for HMO enrollees, pharmacy benefits are waning in their allure, notes Cooperman. Now enrollees cite formulary restrictions, drug substitutions, and an inability to obtain optimal medications as their biggest complaints regarding that particular benefit.
Patients aren't blaming MDs for HMO woes
Despite patient concerns about managed care, physicians are getting good marks from both HMO and POS enrollees.
Among HMO enrollees, 67% report satisfaction with their primary care practitioners (PCPs) — up 1% from last year — and 70% are highly satisfied with their specialists, also up 1%.
POS members registered at 66% in satisfaction with their PCPs (up 4%), and 72% were satisfied with their specialists (also up 4%).
These were the most surprising of the findings, Cooperman says. Historically, member satisfaction for HMOs has been higher than that for POS enrollees. Also, Cooperman says it is notable that patient satisfaction with physicians in both primary and specialty care cuts across all disease conditions.
In the trenches, where physicians work day-to-day with patients and capitation arrangements, Brigham and Women's internist Eric Nadler, MD, and colleagues found these physician trends:
Initially, when physicians had 5% of their patients capitated and were starting with a year of education and experience in capitation, feelings were negative, even in areas where capitation has potential advantages.
From 1996 to 1997, when the physicians' capitation caseload increased to 25%, physician satisfaction improved for nearly every domain of their practice (based on indicators of quality of patient care, patient load and mix, hours worked, and time to accomplish clinical services). "This suggests that the reality of capitation, at least in this phase, was better than the anxiety the year before," Nadler says, noting that capitation growth was the major change in the practices of these physicians.
Even though physicians show more comfort with capitation, they still report a stronger preference for fee for service.
Physicians want to maintain autonomy
Physicians say capitation's most beneficial effect — even upon enrollees outside of capitation — is the improvement of support services, or coordinated care, such as home health.
Capitation runs awry of physician satisfaction when physicians see it as reducing personal autonomy, freedom to order tests, and control over factors necessary to care for patients.
Clearly, capitation is raising ethical concerns among physicians, Nadler and team report. In the first year of the study, 86% of the PHO phy sicians said capitation represents a conflict of interest. In the following year, however, with more experience, that number dropped to 75% of physicians.
Nadler and colleagues point out that many leading physicians and theoreticians believe capitation can be ethical and rational and can lead to better care. For that to happen, they point out, these safeguards should be in place: adequate severity adjustments, routine measurement of quality of care, care that doesn't place too much financial risk on providers, and patient education on how the plan works.
Until managed care organizations are required to meet these standards, Nadler says, physicians are not likely to be comfortable with capitation's risks.
References
1. "1999 Commercial Health Plan Member Survey." Atlanta; Caredata.com.
2. Nadler ES, et al. Does a year make a difference? Changes in physician satisfaction and perception in an increasingly capitated environment. Am J Med 1999; 107:38-44.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content