The brouhaha over capitation is puzzling to this salaried reporter.
Some doctors, lawyers, politicos and pundits argue that capitation is a system that prompts doctors to deny care. They say paying doctors a set fee per member per month may tempt them to save money-especially for patients who require more services-by not making referrals to specialists, prescribing needed tests or spending adequate time with patients.
The pronouncements are dire-and call up the ghost of Karl Marx, one of the great economic determinists of history. To Marx, whose reputation has fallen along with the Iron Curtain and certain governments, economics motivates all human endeavors.
Marx might nod his head if he could read some of the extreme statements being published today about physicians and managed care. According to a recent physician commentary in the New England Journal of Medicine, the capitation-plus-bonus method of payment "rewards physicians for denying care and threatens to turn the American physician into Homo economicus-a creature whose clinical decisions are based in part on personal economic considerations rather than purely medical ones."
Writing in Unique Opportunities, a magazine for physicians, Diane Price says: "With contractual and capitation limits, managed-care physicians have been put in the uncomfortable situation of choosing between their own welfare or the patients' best interest. And maintaining the trust patients place in them while trying to ignore the rewards that come with providing their charges with minimal care is not always easy."
A headline in U.S. News and World Report reads, "Managed-care doctors concerned about their incomes have an incentive to stint on care."
Wait a minute. Is one payment method sacred and another evil? And what kind of doctor would be tempted to deny necessary care to save money?
Doesn't that line of thinking assume that doctors are too easily influenced by filthy lucre?
Before this whole debate began, the image of a doctor was of a benevolent, knowledgeable being whose principal aim was to make you well. Were we wrong? And if we can't trust doctors with capitation, how trustworthy are they anyway?
Apply that thinking to any profession, say journalism. Reporters are paid a salary-a lump sum per year-no matter how many stories they write. You could think of it as capitation.
I don't mean to undervalue the skill, knowledge and effort required to be a good doctor. News stories are rarely life-and-death matters. But this analogy goes to the heart of professional behavior, whatever profession we are talking about.
As a reporter, I get a fixed amount of pay per year, no matter how prolific I am. Why wouldn't I be tempted to write fewer stories? Why wouldn't I be tempted to skip the stories that require a great deal of effort and just skim quickies off press releases? Why wouldn't I ignore a big story until it went away?
How about elementary school teachers? Do we assume they are tempted to ignore the students that take more of their time and just concentrate on the good students?
And then we have classes of people who put not only their livelihoods but their very lives at risk. How about firefighters? Do we suspect they might not respond to all alarms, big and small, although they cannot possibly be paid enough for what they are required to do in their line of work?
How about soldiers or Secret Service agents who are willing to take a bullet for their country?
Why wouldn't good journalists, firefighters, teachers and soldiers behave that way? For the same reasons good doctors don't deny care when a capitated patient needs it.
Here are my reasons. The first one is pride. I know what a good story is and I want to write it. I have a beat to cover. My name is on the page. I have colleagues and readers, and I value their regard.
The second reason is ethics and social responsibility. I owe my readers information and perspective. And I want to pull my share of the weight and help maintain the magazine's reputation because my colleagues and I are in this together.
The third reason is practical. Big stories don't go away. They come back to haunt you-like improperly treated illnesses. If I don't cover the big stories and as many of the small ones as I can, and do so competently, I will be replaced.
And there's another reason. Despite the frustrations, I enjoy my job.
The hyperventilating critics of capitation don't seem to be doing any favors for the image of American medicine. Why don't they give doctors as much credit for pride, ethics, practicality and love for their profession?
Why do they assume capitation will result in denial of care? Is it because they suspect doctors have traditionally been more money-oriented than other professionals?
Is there a suspicion that-apart from their love of medicine-a lot of doctors love the good life a little too much?
Did that have something to do with the skyrocketing medical costs that gave rise to managed care?
Kertesz covers managed care for MODERN HEALTHCARE.