Chapter 8.E.3: Capitation Payment

To insert after Ch. 8.E.3 (p. 846):

For concerns about global capitation and the role of financial incentives generally (note 1), see Steffie Woolhandler & David Himmelstein, Extreme Risk: The New Corporate Proposition for Physicians, 333 New Eng. J. Med. 1706 (1995); Christopher Robertson, Effect of Financial Relationships on the Behavior of Healthcare Professionals, 40 J. L. Med. & Ethics 452 (2012).

For more on the ethics of physicians incentives (note 1), see Conflicts of Interest in Clinical Practice and Research (Roy Spece et al. eds., 1996); Peter A. Ubel, Pricing Life: Why It’s Time for Health Care Rationing (2000); Christopher Robertson et al., Effect of Financial Relationships on the Behaviors of Health Care Professionals, 40 J. L. Med. & Ethics 452 (2012); Gail Agrawal, Resuscitating Professionalism: Self-Regulation in the Medical Marketplace, 66 Mo. L. Rev. 341 (2001); Mark A. Hall, Rationing Health Care at the Bedside, 69 N.Y.U. L. Rev. 693 (1994); William M. Sage, Physicians as Advocates, 35 Hous. L. Rev. 1529 (1999); Timothy S. Hall, Bargaining with Hippocrates: Managed Care and the Doctor-Patient Relationship, 54 S.C. L. Rev. 689 (2003); Symposium, 40 J. L. Med. & Ethics 436 (2012); and the readings and sources cited in section D.1 and Chapter 1.D.5.

For general discussion of the methods, purpose, and performance of risk adjustment (note 2), see Mark A. Hall, Risk Adjustment Under the Affordable Care Act, 20 Kan. J. L. & Pub. Pol’y 222 (2011); David Blumenthal et al., The Who, What, and Why of Risk Adjustment, 30 J. Health Pol. Pol’y & L. 453 (2005); Fred Hellinger & Herbert Wong, Selection Bias in HMOs: A Review of the Evidence, 57 Med. Care Res. Rev. 405 (2000); Symposium, Private Employers and Risk Adjustment, 38 Inquiry 242 (2001).

For discussions of hospital gainsharing (note 3), see Richard S. Saver, Squandering the Gain: Gainsharing and the Continuing Dilemma of Physician Financial Incentives, 98 Nw. U. L. Rev. 145 (2003); Gail Wilensky, Gain Sharing: A Good Concept Getting a Bad Name?, 26(1) Health Aff. w58 (Jan. 2007); Catherine Martin, Incentive Payment and Shared Savings Programs: The New Gainsharing, 17 BNA Health L. Rep. 1011 (2008); Anne Claiborne et al., Legal Impediments to Implementing Value-Based Purchasing in Healthcare, 35 Am. J. L. & Med. 443 (2009). For discussion of the HMO rules, see M. Hall, Physician Rationing and Agency Cost Theory, in Spece, supra; David Orentlicher, Paying Physicians More to Do Less: Financial Incentives to Limit Care, 30 U. Rich. L. Rev. 155, 174 (1996); Stephen R. Latham, Regulation of Managed Care Incentive Payments to Physicians, 22 Am. J. L. & Med. 399 (1996); Douglas Blair, The “PIP” Regulations in Perspective, 29 U. Mem. L. Rev. 137 (1998).

For more on informed consent and the disclosure of payment arrangements (note 4), see E. Haavi Morreim, Diverse and Perverse Incentives of Managed Care: Bringing Patients into Alignment, 1 Widener L. Symp. J. 89, 123 (1996); Grant H. Morris, Dissing Disclosure: Just What the Doctor Ordered, 44 Ariz. L. Rev. 313 (2002); Susan M. Wolf, 35 Hous. L. Rev. 1631 (1999); Joan H. Krause, Reconceptualizing Informed Consent in an Era of Health Care Cost Containment, 85 Iowa L. Rev. 261 (1999). For more discussion of “gag clauses” (note 5), see Gordon Brand et al., The Two Faces of Gag Provisions: Patients and Physicians in a Bind, 17 Yale L. & Pol’y Rev. 249 (1998); Joan H. Krause, The Brief Life of the Gag Clause, 67 Tenn. L. Rev. 1 (1999). 

For a discussion of how fiduciary law principles apply to these issues generally, see Peter D. Jacobson & Michael T. Cahill, Applying Fiduciary Responsibilities in the Managed Care Context, 26 Am. J. L. & Med. 155 (2000); Marc A. Rodwin, Strains in the Fiduciary Metaphor: Divided Physician Loyalties and Obligations in a Changing Health Care System, 21 Am. J. L. & Med. 241 (1995).

For general commentary on Pegram and the issues it raises, see Michael T. Cahill & Peter D. Jacobson, Pegram’s Regress: A Missed Chance for Sensible Judicial Review of Managed Care Decisions, 27 Am. J. L. & Med. 421 (2001); Peter J. Hammer, On Peritonitis, Preemption, and the Elusive Goal of Managed Care Accountability, 26 J. Health Pol. Pol’y & L. 767 (2001); Richard A. Ippolito, Freedom to Contract in Medical Care: HMOs, ERISA and Pegram v. Herdrich, 9 Sup. Ct. Econ. Rev. 1 (2001); Arnold J. Rosoff, Breach of Fiduciary Duty Lawsuits Against MCOs, 22 J. Leg. Med. 55 (2001); William Sage, UR Here: The Supreme Court’s Guide for Managed Care, 19 Health Aff. 219 (2000); Jeffrey Stempel & Nadia Magdenko, Doctors, HMOs, ERISA, and the Public Interest After Pegram v. Herdrich, 36 Tort & Ins. L.J. 687 (2001); Symposium, 1 Yale J. Health Pol’y L. & Ethics (2001).