By NextBestFitLet people choose among public care organizations
One public payer, but people pick among competing integrated care organizations (e.g., Kaiser-style groups) paid by capitation.
Integrated systems (Kaiser/Geisinger style) can enroll patients who choose them, as in the detailed plan.
Review ledgerHow this path connects
This path
Let people choose among public care organizations
Requires:
Capitation for primary care and integrated systemsU.S. prices are far higher than in other countriesChosenConcrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Let people choose among public care organizations paid by capitation
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
What it fixes
- Losing the choice of health plan and insurer competition
Letting patients choose among integrated care organizations creates competition on service and integrated care without multiple insurers.
What it creates or worsens
- Paying a fixed amount per patient rewards doing less
Paying the competing care organizations by capitation retains the risks associated with that payment method.
3 paths soften this
Risk adjustment plus outcome monitoringPaying a fixed amount per patient rewards doing lessChosenBlended payment: part capitation, part fee-for-servicePaying a fixed amount per patient rewards doing lessChosenSalaried clinicians in public or non-profit groupsPaying a fixed amount per patient rewards doing lessRejected - Solves only part of the problem
Choice among competing integrated care organizations is limited in rural areas.
Who's affected
Who gains
- People with employer coverage
- Losing the choice of health plan and insurer competition: They can't keep or pick a plan they like, or switch if service is poor.
- Hospitals, clinics, and care organizations
- Paying a fixed amount per patient rewards doing less: They keep the difference when care costs less than fixed payments.
- Health insurers, brokers, and their shareholders
- Paying a fixed amount per patient rewards doing less: They keep the difference when care costs less than fixed payments.
Who loses
- People with ongoing or specialist care needs
- Paying a fixed amount per patient rewards doing less: Fixed payments encourage avoiding sick patients or providing less care.
Where it has been tried
- Sweden (regional choice reforms): Free choice of primary care provider with money following the patient.
- Sweden: A 2022 review reports private ownership of 44% of Swedish primary care centres, compared with about 30% before reform, and cites an earlier three-region survey in which about 60% felt they had chosen their provider.