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There have been a rash of bankruptcies among large medical groups taking on
full-risk contracts in California, and it's raising the question of how much
risk medical groups can reasonably take on. Some argue that the bankruptcies
are simply a market shakeout, with poorly managed groups going under as a
natural consequence of the business cycle. Others see it as a harbinger of the
collapse of global capitation. A panel of experts--practicing doctors,
insurance actuaries, and medical directors--debate the future of physicians
taking on financial risk in this feature from "Between Rounds," a "webzine" for
This article from "Between Rounds" (a "webzine for physicians") explores
alternatives to traditional capitation--"reverse capitation," in which primary
care physicians are paid on a fee-for-service basis, while specialists are
capitated; "contact capitation," which rewards specialists who take more
referrals; and payment of a fixed fee for all services required for various
"episodes of care," for example, the course of a pregnancy. Each of these
models is an attempt to counteract the incentives for undertreatment inherent
in the traditional capitation model. The article concludes, however, that these
systems, too, have their flaws.
FRONTLINE's 1998 report on the managed care revolution provides a wealth of
background readings and interviews on the emergence and triumph of managed care
in the 1980s and 90s.
Although "Managed Care" magazine is targeted toward doctors, the articles
collected here--including "The March of Capitation: Reversed or Just Delayed?"
and "The Future of Capitation In a World of Shared Risk"--
are accessible and provide further background for the layman interested in
understanding capitated payment systems and their place in managed care
The Center for Patient Advocacy is a non-profit organization that lobbies for
consumer-oriented health care reform and offers assistance to consumers trying
to navigate the maze of managed care. Their web site provides resources for
"checking out your doctor": questions to ask him or her about training and
background, and state-by-state contact information for boards of medicine; fact
sheets and articles on health insurance and managed care; and updates on
managed care and other health care reform legislation.
The Center also has a toll-free hotline (800-846-7444) for advice and
assistance with managed care issues.
"Managed Care Central" is a project of Families USA, a national nonprofit
organization "dedicated to the achievement of high-quality, affordable health
and long-term care for all Americans." Their web site includes an
extensive section called "What Consumers Needs to Know" which provides tips on
choosing an HMO and links to a variety of resources through which consumers can
rate their health plans. The site also includes contact information for
submitting complaints about your managed care plan, updates on "patient bill of
rights"legistation under consideration and extensive state-by-state information
on legislation and services.
The NCQA has run a voluntary accreditation system for managed care
organizations since 1991. Their web site offers an interactive "health plan
report card," which allows consumers
to access the ratings and accreditation status of individual health plans with
respect to access and service, qualified providers, staying healthy, getting
better, and living with illness. The NCQA also oversees the development of
HEDIS (Health Plan Employer Data and Information Set) a set of standardized measures used
to compare health plans, complementary to but different from accreditation.
HEDIS evaluates the results a health plan actually achieves in dozens of
key areas of care and service such as immunization rates, cholesterol
management, and member satisfaction.
This is a resource provided by the Massachusetts Hospital Association and The
Picker Institute. It answers frequently asked questions; recommends further
questions for you to ask your doctors, nurses, and hospital staff; and offers
strategies to help you get the most out of your hospital care.
The JCAHO evaluates and accredits more than 18,000 health care organizations
and programs in the United States. Click on 'General Public' to find advice on
choosing health plans as well as other health services such as ambulatory
care, home care, hospitals, long-term care, substance abuse help, mental health
services, and child/adolescent services. There's also a place on this site for
registering complaints against accredited health care providers.
Care Counsel is a privately held company based in San Rafael, California,
founded in 1996 to provide expert help for consumers as they navigate the new
health care environment. They offer a "health care Assistance Program" for
employers to help employees understand and navigate managed care systems. In
addition, their web site provides a number of helpful essays and fact sheets
for consumers, including "Navigating Managed Care with Patient Advocacy,"
"Choosing a Primary Care Physician," "How to Get Your Medical Records,"
"Keeping a Personal Health Record, Second Opinions," "Talking with Your
Doctor," and "Selecting a Health Plan."
FACCT is a non-profit organization devoted to providing comprehensive
comparative information about health plans and providers to consumers to enable
them to make more educated decisions when choosing a plan or course of
treatment. This extensive research project is still under development.
Currently the site provides a number of measurement guides designed for doctors
and other providers. According to FACCT President David Lansky, their exclusive consumer-oriented content
providing ratings for doctors and health plans will be available on line
beginning August, 2000.
· CareGroup health care System
· Joslin Diabetes Center
· Beth Israel Deaconess Medical Center
· The Official U.S. Government Site for Medicare Information
· American Association of Medical Colleges
inside the dilemma ·
financial incentives ·
cost v. care
ask the producer ·
producer's notebook ·
tapes & transcripts ·