When sick patients switch primary care physicians: The impact on AMCs participating in capitation

Patients facing catastrophic illness often desire choice when selecting spe cialist physicians and will sometimes request specialists at academic medic al centers (AMCs). Under capitated payment systems, community primary care physician (PCP) gatekeepers have an incentive to refer patients to local sp ecialists with whom they regularly collaborate rather than to AMC specialis ts, who generally are more expensive and with whom they may not have workin g relationships. As a result of the financial pressures of capitation and t he desire to work with familiar specialists, some PCPs in community-based r isk-sharing groups are reluctant to refer sick patients in capitated health plans to AMC-affiliated specialists. Forced to choose between their existi ng primary care relationships and their desired specialists; some patients are terminating their existing primary care relationships to enroll with PC Ps affiliated with the AMCs to which they wish to be referred. The authors' observations at their AMC indicate that most of the patients l eaving their PCPs in die community do so to gain access to oncology and sur gical specialty services. The shifting of sick patient's in capitated healt h plans to AMC-affiliated PCPs creates a financial burden for both AMCs and their affiliated physicians. Health plans and AMCs must cooperate in devel oping a solution; for example, risk-adjust each risk unit's capitation paym ent based on the health status and disease burden of its population. The au thors propose strategies aimed at enabling patients to have access to AMC t ertiary care services while ensuring that the cost of caring fur the sickes t patients is not borne solely by AMC risk groups. They conclude that it is in the best interests of all concerned to modify the current counterproduc tive incentives that promote the problems they have described.