The Dilemmas of Managed Care-Reply

David Mechanic, PhD
JAMA. 1997;278(10):820. doi:10.1001/jama.1997.03550100046030.
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In Reply.  —Ms Johns is correct in noting the importance of financial incentives in both capitated practice and fee-for-service. It is also likely that, as managed care organizations transfer greater risk to physicians as an alternative to more intrusive controls, and as physicians' incomes are at stake, physicians' advocacy for patients will be less vigorous.It remains unclear how much risk reasonably can be transferred to physicians without jeopardizing the quality of patient care. Contextual factors, such as how widely risk is shared among groups of physicians and the integrity of the quality-assurance mechanisms in place, may exaggerate or moderate the risk of particular financial incentives. The goal is to identify incentives that motivate thoughtfulness and judiciousness without encouraging denial of needed services. Since need can be ambiguous, the usefulness of practice guidelines and evidence-based practice is evident. It is noteworthy that increasing numbers of managed care organizations now adjust physician


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