Louise Kertesz's commentary ("Root of all evil?" March 17, p. 25) highlights the conflicts of incentives and interests that capitation creates. I agree with Kertesz that capitation will not likely lead to the wholesale abandonment of patient interests by physicians. However, I dispute the logic of comparing a salaried employee with financially at-risk physicians.
Let's use her example of a salaried journalist. She states that being paid a salary regardless of production can be viewed as capitation. This doesn't accurately reflect how capitation works. If Kertesz were capitated the way a physician is, her compensation would work in the following manner: If she writes too many articles, thereby using too many resources (pencils, paper, computer time, etc.), she would in fact have less money to take home at the end of the day. If she undertook a particularly difficult assignment and required the assistance of another journalist, she would have to pay for that assistance out of her own pocket. I wonder if this would make her think twice before enlisting a second journalist in the creation of her story.
As salaried employees, Kertesz's fellow journalists have no reason for concern if she writes articles, does literature searches, interviews, rewrites and performs the other tasks of journalism all day and night. However, if a capitated physician were to order more than the "usual" number of tests or make "excessive" referrals, the other physicians in the practice might be penalized. The physician who is an "economic outlier" could end up out of a job.
Kertesz also implies that part of the reason for increasing healthcare costs may have stemmed from physicians' "love (of) the good life." While fee-for-service compensation may provide a theoretical incentive to overtreat, it is difficult to demonstrate that a physician orders a test or performs a procedure that has no medical indication solely for financial gain. However, if you take the mix of a 35-year-old physician fresh out of residency or fellowship, throw in $100,000 or more in educational debt, consider the costs of starting a practice, and then add in an at-risk pool of capitated money, the possibility for conflict between patient and physician welfare becomes all too real.
BRENT R. MOODY, M.D.
Assistant in medicine
Washington University School of Medicine