More and more doctors, reacting to a personal perception that capitated health insurance leads to inferior care, are steering their sicker patients away from those plans, a new national survey has discovered.
About one-third of all physicians in the survey said they believe the level of care provided by capitated health plans is of lower quality than that offered by other managed-care plans. As a result, those doctors were twice as likely to steer sicker patients away from such plans, raising a complex set of legal, ethical and public-policy questions, according to study author Matthew Wynia, M.D., director of the Institute for Ethics at the American Medical Association.
Under the scenario described in the survey, more and more of the sickest patients would gravitate toward top-quality, noncapitated health plans based on the advice of their doctors, Wynia said. Ultimately, those plans would be forced to raise prices to underwrite the costs of these chronically ill enrollees.
"They're going to be punished in the marketplace," Wynia said.
Meanwhile, the so-called "lower-quality" health plans would enjoy bigger profits because of an abundance of healthier enrollees, he said.
Among the 787 physicians surveyed in the study, which appears in the January issue of the Journal of General Internal Medicine, 40% said they encouraged patients who are sicker or who have more complex illnesses to avoid capitated health plans. Meanwhile, about 23% of the doctors advised their healthier patients to join capitated plans. Under capitation, doctors and other providers receive a set monthly fee per patient no matter the level of service provided, with some exceptions.
Susan Pisano, a spokeswoman for the Washington-based American Association of Health Plans, questioned the basic assumptions of the survey, saying that national data show that managed-care plans-capitated or otherwise-are doing a good job of caring for America's chronically ill. She said about 200 million Americans are now covered by some form of managed care, a scope that tends to minimize cherry- picking by insurers and balances out risk.
"There are physicians who believe that captitation actually promotes managed-care principles by providing the right care at the right time in the right setting," said Pisano, whose group represents more than 1,000 health plans with about 170 million enrollees.
William Hall, M.D., president of the American College of Physicians-American Society of Internal Medicine, said the study highlights a growing role for doctors-helping to guide patients through the confusing maze of health plans. "I think that it probably should come as no surprise," he said, "that physicians do offer advice to patients when they're presented with a variety of health plans. It would be naive to suggest they wouldn't-and, in some cases, it would be unethical for them not to."
Like many of his colleagues, Earl Washburn, M.D., a pediatrician from Placerville, Calif., said he discusses a patient's choice in health plans when he is asked direct questions about insurance coverage. He said patients "deserve a fair answer to a fair question."
"I would guess that most of the doctors are directing their patients who have the most severe medical problems toward the plans with the best coverage in the best interest of the patient," he said. "Often, these better plans have premiums that are much higher, but for high-need patients, the higher premium is worth the extra cost."
Still, the survey results underscore the ethical dilemma doctors face in discussing coverage options with patients. Though those discussions are an important part of physician advocacy, they inadvertently help some managed-care plans cherry-pick the lowest-risk members, Wynia said.
"Physicians are being placed in a bind," he said. "On the one hand, clearly it's our obligation to tell patients which plans are better or worse. But by doing that, we're getting those patients out of low-quality plans, (and) we're protecting low-quality plans."
The dilemma isn't universal: 54% of the doctors surveyed said they never advise their patients about health plan choice.
"I would endorse the idea that physicians ought to talk to patients about what health plans are best for them," Wynia said. "I think we need to very carefully be looking at quality across health plans to make sure lower-quality plans are not able to cherry- pick the least ill patients."
Wynia said the survey indicates doctors aren't counseling patients based on their own economic incentives, even though noncapitated health plans often provide higher total reimbursement. Still, "the line between quality concerns and financial self-interest may become blurred" when physician groups are in financial trouble, he said.