Robert M. Hansen, MD, MBA
Potential Financial Conflicts of Interest: None disclosed.
Hansen RM. Toward a 21st-Century Health Care System: The Devil Is in the Details. Ann Intern Med. 2009;151:366. doi: 10.7326/0003-4819-151-5-200909010-00022
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Published: Ann Intern Med. 2009;151(5):366.
TO THE EDITOR:
The first recommendation in the article by Arrow and colleagues (1) to replace fee-for-service payment with an alternative, such as capitation, would require revolutionary changes in how physicians are organized among themselves and how they relate to hospitals and other facilities. Although the Kaiser Permanente model exists, most physicians in the United States practice fee-for-service medicine. The vague description of a payment system that enhances innovation, which is a laudable goal, requires concrete details. In addition, no evidence exists to suggest that capitated systems promote innovation. Anecdotally, the opposite is true. My wife worked as an emergency department nurse in the Kaiser Permanente system for years. Emergency department physicians who demanded that surgeons perform necessary appendectomies in the middle of the night never made partner. Emergency department physicians who acquiesced to the surgeon's desire for appendectomies the next day watched their patients perforate and get avoidable colostomies—but they made partnership. This behavior pattern is no trivial matter in a capitated system.
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