Disclosure of Physicians' Financial Incentives

To the Editor: In their article on disclosure of physician financial incentives,¹ Ms Miller and Dr Sage mention in passing the possibility that fee-for-service medicine may "lead to inappropriate care," but the remainder of their article is lopsidedly biased against capitated medicine. The words "managed care" appear no fewer than 26 times, always in a critical context, while the term "fee-for-service" is used only 7 times, and then tangentially. There are also 11 references to health maintenance organizations (HMOs), underuse, and incentives to limit treatment, but none to overuse and its clinical and economic risks. There is no meaningful discussion of the devastating consequences of excessive and unnecessary care, which is powerfully incentivized in the fee-for-service world. This bias, and its amplification by a hysterical media, have rendered it almost impossible for health care to be managed intelligently today. Any decision not to implement a consultation, procedure, or treatment, no matter how carefully thought out, is construed as a negatively charged "denial." The nascent third-party review industry feeds primarily on managed care, and the Health Care Financing Administration's (HCFA's) "expedited review" process is directed exclusively to at-risk programs, even though precisely the same fundamental questions underlie all clinical decisions, regardless of payer.