Dorsey and Berwick: Back to the Future with Capitation

The disease management blog would like to alert its readers to a perfect world of healthcare, where doctors jettison individual opinions of scientific merit. Where enlightened physician leaders can, with one meeting or one email or one EHR screen pop-up, change provider behavior. Where clinical outcomes, not return on investment, drive capital allocation. Where doctor’s salaries correlate with work effort and garner unrivaled professional satisfaction. Where is that place you ask? According to the Boston Globe editorialists Drs. Dorsey and Berwick, just pilgrim north, cross into Katmandu and navigate the Big Dig. Then gaze into the past and look for that great shining light on the hill, that paradise of professionalism, that citadel of care, the cornucopia of coordination, that of capstone of capitation, Harvard Community Health Plan ("HCHP").

While they were penning their editorial, Drs. Dorsey and Berwick must have been Googling the Disease Management Care Blog, because our examination of “Gaydolf”-style capitation presaged many of the themes in their Boston Globe editorial. As readers of the blog may recall, I argued that the “care coordination” 30% premium layered on top of a mathematically neutral capitation payment was used by some physicians in some settings in the past to build “systems” of care. Drs. Dorsey and Berwick tell us that HCHP was one of those settings. They also recognize the majority of other clinic settings neglected to put that 30% to work and were “hijacked” by dysfunctional incentives that pursued profits not patients. They suggest capitation got a bad rap because the success of HCHP didn’t get the attention it deserved. They think Gaydolf shouldn't be a dirty word. He got a bum rap. He wuz robbed.

In the opinion of the disease management blog, their treatise is not only confused, it’s naive. It’s confused because the HCHP progeny's considerable achievements under capitation have also been matched by considerable success in a non-capitated environment. It’s naïve because the practice settings described by Dorsey and Berwick have very little in common with the present-day, entrepreneurial, independent-minded, non-salaried physician-owned practices that occupy the majority of health care delivery in huge swaths of the United States. Toss in a cup of non-generalizability along with a generous dash of hubris and their vision sure tastes great but is filling... Not. There is no way Old-World capitation will work in the mainstream of typical office settings because it’s not fundamentally linked to the flowering of “systems” of care so beloved by the editorialists. Oh, and by the way, many independent physicians don’t think capitation is merely a “dirty word,” they loathe it as the Anti-Christ of Healthcare.

The disease management blog’s more seasoned - and humble - examination pointed out that a new and improved version of partial capitation – in addition to traditional fee for service – could be channeled into explicit chronic illness-linked, modern, risk-adjusted variants of population based chronic care that builds on patient registries, non-physician teaming, patient coaching and self care. This has less to do with “capitation” and much more to do with creating targeted cash flows that fund the Medical Home and/or disease management and preferably both.

Old capitation is Gaydolf-oid. Modern versions of population-based partial capitation Obama-oid. Which would you pick?