A reader writes:
Capitation leads to “creaming” — selecting healthier/cheaper patients to treat rather than sicker/more expensive patients (where possible). We already know this. Any capitation system has to be tied to a severity index that provides meaningfully more money for meaningfully sicker patients and allows flexibility for patient improvement and deterioration over time. Do you see anything like that happening?
Absolutely. If not, the scenario described is entirely plausible.
Financial and reporting incentives influence physician behavior. Take a look at the cardiothoracic surgeons in New York. Once their morbidity and mortality rates were published, it naturally moved some of them not to take complicated or very sick cases, leaving them to academic medical centers.
The same goes for capitation and pay for performance. This presents a clear financial incentive for physicians only to take care of healthy patients. There has to be some type of payment sliding scale to prevent this. Sicker patients take more time and effort to care for, and subsequently the doctor should be better rewarded.
My question is, given the complexity of the spectrum of disease, how do you come up with a feasible system to address this?
