The Honorable Mr. Newt Gingrich, so I learn from Healthre,
recently predicted, proposed or prescribed to the American
Medical Association that we should pattern our practice of
medicine on contemporary price-driven merchandizing such
as is exemplified by Walmart.

Without impugning Mr. Gingrich's thoughtfulness, I wonder
how a patient with an acute and serious ailment will be in
a position to shop around for the members of the specialists'
team to care for him; and even the price tag on a primary care
physician's "routine" examination would be virtually meaningless,
inasmuch as the major portion of its cost is attributable to the
ensuing recommendations: for laboratory studies, return visits,
specialists' consultations, surgical operations and hospitalization.
Thus Mr. Gingrich's prescription, it seems to me, unavoidably
entails capitation.

If one takes the Honorable Mr. Gingrich's ideas seriously,
as I think one should, one is left with the prospect of virtually
universal capitation of medical fees, capitation such as presently
makes managed care organizations so attractive to the agencies,
governmental and private, on which our patients rely for the
payment of their medical bills.

The primary, and I suspect the only reason, why HMO's and managed
care organizations have made such inroads upon the private practice
of medicine, is that these corporations have been able to offer
capitation to their subscribers, whereas individually practicing
physicians have been, because of their very independence, locked
out of the capitation market.

From my own point of view, as a practicing ophthalmologist, I
would have no difficulty in making a preliminary analysis of
the economics of my practice with a view to determining an
acceptable capitation rate. I could probably offer ophthalmological
services at fifty percent or less of what it costs HMO's.
For other specialists who would presumably encounter only a small
fraction of the patient population for the neurosurgical care, for
example, for which they had contracted, setting an appropriate
capitation rate would be far more difficult, but I should like
to think, not impossible. I would like to believe that independent
and imaginative physicians, organized in a network to provide the
full range of medical services, could compete very effectively
against the healthcare corporations.

Clearly the capitating sole practitioner will incur risks of
being swamped by some epidemic or other. Possibly insurance
could be devised to give him partial protection against such
risk.  But freedom inavoidably entails risk; the freedom to be
ones own master is no exception.

Foolishly or otherwise, I consider the task of devising
a capitation system for physicians practicing individually
a challenge in economic and social engineering. I don't know
whether or not we can arrive at a satisfactory solution,
but I would like to try. Even a failed effort is better
than the most eloquent of lamentations. I hope that some
of the economists, actuaries, and other physicians on this
list will help me. I should be pleased to pursue this issue
either on the List or privately with all who are interested.

                       * * * *

        The fault, dear Brutus, is not in our stars,
        But in ourselves, that we are underlings.

                                    Julius Ceasar