To the Editor:

I enjoyed Robert Edsall's editor's page, “Putting in a Good Word for Capitation” [April 2000]. I, too, remain optimistic for capitation's continued presence in the reimbursement arena.

An additional “piece” that's essential for capitation to work is the physician mind-set that you do for the patient what he or she needs, not just what is reimbursed. Sometimes it costs you money and sometimes it doesn't, but it has to be a patient-centered decision, not an economic one. The old fee-for-service mind-set of “more is better” (for the patient and the doctor) will not work in the capitated environment. It quickly breaks the budget.

To the Editor:

I applaud Robert Edsall for his courage and foresight in “Putting in a Good Word for Capitation.”

The editorial shows courage because the current rage within medicine is to bash capitation as if it is responsible for all that is wrong with medicine. Yet it's only a contractually agreed upon way of being paid for providing services to patients. Like other compensation systems, such as fee for service, capitation has its pros and cons and will be more suitable in some situations than in others.

The editorial shows foresight because capitation is likely to grow in some form. Capitation gives physicians, especially family physicians, an incentive to manage their patients' care for the benefit of the individual patient as well as the entire population of patients. It provides a financial and philosophical reason to embrace things such as case management, disease management and various types of prevention. Fee-for-service payment systems do not support these practices as well or as affordably.

The track record of capitation is not one its promoters can be proud of, but if and when capitation is done well, it holds the promise of aligning the interests of patients, payers and family physicians in promoting the elimination of diseases and their complications. It creates incentives to decrease and eliminate mistakes, which create their own financial, physical and other costs. Looked at starkly, fee-for-service systems lack these incentives. In fact, under fee for service, physicians do better when there are more diseases, complications and mistakes in their management.

We need to start thinking about how to get the best of both worlds—various hybrids of capitation, fee for service and other payment mechanisms. With the accelerating improvement in information systems and open minds, there exists the opportunity to enjoy the benefits of capitation and to decrease the adverse effects.