At-Risk Agreements
These take capitation a step further. Your doctor receives capitation not only for his work, but also to pay the bills for any care he orders.
At-risk agreements are generally only offered to very large medical groups, like hospital networks, that already have many of the primary care doctors and specialists on salary and own their own test equipment. Some plans may offer them to groups of doctors with enough patients under their care to spread out the risk if one or two are dreadfully sick. In some markets, plans have enough market power to force at-risk contracting for potentially expensive care (like prescriptions) on doctors who really can't afford it
It can work out well for patients - for instance, since the specialists are already on salary, it doesn't directly cost anything to refer a patient, so referrals may be easier to get.
On the other hand, if you want to see a specialist who is not on the hospital system salary, you will likely encounter some resistance -- or at least a higher out-of-pocket cost.
Theoretically, if the HMO can make money being at-risk, your doctor can, too. But since your doctor has no say in setting premium rates or choosing which patients to sell insurance to, it makes the HMO less interested in making sure its rates are high enough to not lose money. Besides, the HMO keeps a chunk of the money anyway, to cover the costs of marketing itself.
If your doctor gets into financial trouble, you lose, too. In the Philadelphia area, some large hospital systems have lost massive amounts of money on these types of arrangements; in California, a shocking percentage of doctor practices are near bankruptcy because such arrangements are forced on more doctors in that market. When financial problems happen, doctors seek employment elsewhere, staff is cut, phones ring a long time, paperwork takes a while to complete, appointments are harder to get, etc.
©2000 Eileen K. Carpenter, MD