Contact: Dr. Wynia Call Ross Fraser (312) 464-4443
Doctors Steer Sick Patients Away From Capitated HMOs Quality Concerns Drive Inadvertent "Cherry Picking"
Many doctors unwittingly are helping managed care plans "cherry pick" healthier patients, while sicker patients are being steered toward safety-net providers, according to a new study.
In a national survey of 787 physicians, 40 percent reported encouraging patients who are sicker or who have more complex illnesses to avoid capitated managed care plans, in which doctors receive a flat monthly rate per patient. At the same time, 23 percent reported encouraging healthier patients to join such plans, finds the study published in the January issue of the Journal of General Internal Medicine.
Although the data don't clearly identify whether it is cost or quality considerations alone that motivate them to make such recommendations, the study shows that physicians are contributing to risk selection among capitated managed care plans, raising legal, ethical and policy issues, according to author Matthew K. Wynia, M.D., M.P.H., of the American Medical Association's Institute for Ethics.
On the one hand, "medical leaders have suggested that physicians ought to help their patients make [health plan] selections," because assisting patients in this way is an important form of physician advocacy, the authors note.
Unfortunately, this study shows that "even well-intentioned physician advice may foster risk selection," say Wynia and colleagues. "Risk selection undermines insurance pools by causing disproportionate enrollment of less costly patients into certain health plans. This is expensive for some payers, who overcompensate health plans with healthier-than-expected enrollees and financially risky for providers who do not or cannot risk-select, such as safety net providers."
Physicians also were asked whether they felt capitated payment plans undermined their ability to offer a quality of care equal to that of other types of managed care reimbursement. One-third of the surveyed doctors said capitated care was of lower quality and were twice as likely to steer sicker patients away from capitated plans.
Although quality concerns clearly influenced physicians' advice, the influence of economic incentives was less clear. Physicians who had more of their income derived from capitated plans, were no more likely to guide sicker patients away from these plans than those who received less of their salary through capitated plans.
"While physicians under capitation are largely responsible for the quality of care delivered, where physician groups are going bankrupt under capitated payments, the line between quality concerns and financial self-interest may become blurred," they say.
The researchers point out that doctors' participation in risk selection is dangerous for several reasons. Because they have access to much more detailed patient information than plans, doctors can more effectively "cherry pick" patients than plans could do on their own. It is also potentially much more difficult for regulators to control this type of patients pooling than the more systematic approach taken by health plans.
"Risk selection can arise from more than one motivation and … it may be an inherent feature of combining health insurance financing and health care delivery functions," the authors say.
The study was funded in part by the Agency for Healthcare Research and Quality through the Division of Clinical Care Research at New England Medical Center and by a grant from the American Medical Association Foundation.
# # # The Journal of General Internal Medicine, a monthly peer-reviewed journal of the Society of General Internal Medicine, publishes original articles on research and education in primary care. For information about the journal, contact Renee F. Wilson at (410) 955-9868.
Center for the Advancement of Health Contact: Ira R. Allen Director of Public Affairs 202.387.2829 press at cfah.org
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