title: Patient protection and risk selection: do primary care physicians encourage their patients to join or avoid capitated health plans according to the patient's health status?
abstract: BACKGROUND
  Individual physicians who are paid prospectively, as in capitated health plans, might tend to encourage patients to avoid or to join these plans according to the patient's health status. Though insurance risk selection has been well documented among organizations paid on a prospective basis, such physician-level risk selection has not been studied.
  
  
  OBJECTIVE
  To assess physician reports of risk selection in capitated health plans and explore potentially related factors.
  
  
  METHODS
  National mailed survey of primary care physicians in 1997-1998, oversampling physicians in areas with more capitated health plans.
  
  
  RESULTS
  The response rate was 63% (787 of 1,252 eligible recipients). Overall, 44% of physicians reported encouraging patients either to join or to avoid capitated health plans according to the patients' health status: 40% encouraged more complex and ill patients to avoid capitated plans and 23% encouraged healthier patients to join capitated plans. In multivariable models, physicians with negative perceptions of capitated plan quality, with more negative experiences in capitated plans, and those who knew at each patient encounter how they were being compensated had higher odds of encouraging sicker patients to avoid capitated plans (odds ratios, 2.0, 2.2, and 2.0; all confidence intervals >1).
  
  
  CONCLUSIONS
  Many primary care physicians report encouraging patients to join or avoid capitated plans according to the patient's health status. Although these physicians' recommendations might be associated primarily with concerns about quality, they can have the effect of insulating certain health plans from covering sicker and more expensive patients.
authors.affiliation: Institute for Ethics, American Medical Association, Chicago Ill., USA. matthew_wynia@ama-assn.org
authors.forename: Matthew K
authors.initials: MK
authors.lastname: Wynia
authors.forename: Deborah
authors.initials: D
authors.lastname: Zucker
authors.forename: Stacey
authors.initials: S
authors.lastname: Supran
authors.forename: Harry P
authors.initials: HP
authors.lastname: Selker
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D002204:Capitation Fee; D005260:Female; D006304:Health Status; D006801:Humans; D015273:Insurance Selection Bias; D008329:Managed Care Programs / Q000191:economics / Q000706:statistics & numerical data*; D008875:Middle Aged; D015999:Multivariate Analysis; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D010817:Physician-Patient Relations; D011320:Primary Health Care / Q000191:economics / Q000592:standards*; D012017:Referral and Consultation; D012307:Risk Factors; D014481:United States