Letters

More good words for capitation

To the Editor:

I enjoyed Robert Edsall's editor's page, "Putting in a Good Word for Capitation" [April 2000, page 8]. 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.

Glen Couchman, MD
Temple, Texas

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.

James R. Chaillet Jr., MD
Hartland, Wis.

Something is wrong

To the Editor:

Thank you for the nice article about compassion fatigue ["Overcoming Compassion Fatigue," April 2000, page 39]. However, the next article, "How Emotional Distress Shapes the Patient Visit" [April 2000, page 47], revealed the results of a study which found that emotionally distressed patients were seen an average of 11.5 minutes and patients diagnosed with depression or anxiety were seen an average of 12.8 minutes. How can any patient be seen in such a short amount of time? No wonder doctors -- and patients -- are burning out.

I'm a solo family physician in a suburban area of a major metropolitan city. I schedule 30 minutes for routine patient visits and one hour or more for new patients. This allows ample time for emotionally distressed patients to have their needs addressed. I love my work, and my patients love the care they get. My practice is emotionally and financially rewarding. Something is very wrong with the way medicine is being practiced if over half the physicians are feeling compassion fatigue and burnout.

Aletha Tippett, MD
Cincinnati

Recovering from burnout

To the Editor:

The article "Overcoming Compassion Fatigue" touched my life deeply. The term "compassion fatigue" is excellent, and the description of physical, mental, emotional and spiritual exhaustion is so true.

I lost a practice opportunity because of the way I chose to deal with my fatigue, stress, depression and other negative emotions. Fortunately, I'm blessed with a wonderfully supportive husband and a close circle of friends who have helped me in the healing process. And I have worked with a psychiatrist who prescribed appropriate medications for the anxiety, depression and sleep disturbances. But it took three months before I could say, "I'm ready to go back to work."

With the help of this article, I plan to develop my own "practice principles" to assist me in sorting my priorities as I interview for positions.

Thank you for addressing an issue that many experience but don't know how to put into words.

Ann Thomas, MD
Marietta, Ga.

Copyright © 2000 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact fpmserv@aafp.org for copyright questions and/or permission requests.