Withholds and Bonuses

These sound different, but are basically the same. The plan offers a minimum payment to the doctor and a maximum payment, and pays something in the middle depending on how the doctor fulfills certain expectations.

The criteria include how much money the plan had to pay for the doctor's patients' care. Usually it also includes extra payment if the doctor meets certain quality standards, like having a certain percentage of patients who get their mammograms and flu shots on time, but since those are some of the same costs that were already counted against the doctor, it's not as noble as it sounds.

It is an incentive for the doctor to order less care. In reality however, it is not nearly as powerful an incentive as at-risk contracting. Psychologists can demonstrate that taking something away from someone is a more effective motivator than promising them something they don't have yet.

And frankly, the doctors are completely dependent on the HMO's giving them information: How many of their patients showed up for their procedures? How much did the plan have to pay? Was the care for patients who weren't referred justified? (There are always plenty of patients who end up at hospitals where their primary care doctor isn't on staff and are seen by a legion of specialists the doctor has never heard of.) Meanwhile the whole bonus could evaporate if the plan is in financial trouble or declares bankruptcy. Something a doctor has so little control over is a weak influence.



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©2000 Eileen K. Carpenter, MD