Physicians' views on capitated payment for medical care: does familiarity foster acceptance?

Physicians' attitudes toward capitated payment have not been quantified. We sought to assess physicians' views on capitated payment and to compare the views of those who did and did not participate in such payment. A written survey was given to 200 physicians with admitting privileges at a 600-bed Ohio hospital; 82 (41%) responded and were included in this study. Among respondents, 21 (26%) were primary care physicians, 18 (22%) were medical subspecialists, and 18 (22%) were surgeons. Fifty-eight (71%) were providers for managed care plans, and 35 (43%) participated in capitated payment arrangements. Among physicians who did not participate in capitated care, 100% believed that there was a conflict of interest in capitated payment, and 77% (23 physicians) believed that participation in plans that reduce physician income in proportion to medical expenditures is not acceptable. Among those who did participate in capitated payment contracts, 95% (41 physicians) believed these plans posed a conflict of interest, and 72% (31 physicians) said this was not acceptable (P = 0.4 and 0.66 for each comparison). There was no trend toward the opinion that capitated payment arrangements are acceptable with greater levels of experience in capitated care (P = 0.5 by Spearman test). There were trends suggesting that compared with those who were not receiving capitated payments, those who received capitated payment were 50% more likely to have never discussed capitated payment with any patient (63% versus 42%, P = 0.08), were 70% more likely to very strongly oppose the use of capitation to pay their own family's physicians (49% versus 29%, P = 0.07), and were 30% more likely to believe that it is impossible to stay in the practice of medicine without participating in capitated payment plans (84% versus 65%, P = 0.06). None of the respondents reported that they had a contractual "gag clause," but 34% (27 physicians) said they would not speak publicly about any perceived risks of capitated payments anyway. Among this sample of physicians, those who participated in existing capitated payment managed care plans had views that were as negative, or more negative, on the acceptability of capitated payment as did those of nonparticipating physicians. Many were participating in capitated payment plans in spite of these negative views because they feared that to do otherwise would force them out of medical practice. The hypotheses generated by this study must be tested in larger, national studies.