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.