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September 24, 1997

Clinical Crossroads: An 88-Year-Old Woman Facing the End of Life

JAMA. 1997;278(12):977. doi:10.1001/jama.1997.03550120037018

To the Editor.  —While I am reluctant to find fault with Dr Lynn's article1 elucidating the issues involved with dying patients and offering concrete suggestions for managing them, I am disturbed by the implication that achieving excellence in the care of the dying patient will have an adverse financial effect under capitation. While this is a possibility, there are no data offered to support this statement.The patients in health maintenance organizations who switch medical groups will probably need to leave their specialists along with their primary care physician. I believe that ill patients would want to stay with physicians who know them rather than move to a new group (even if it does have a reputation for excellence). Also, there is no reason to assume that awareness of an organization's exceptional reputation would not attract a higher proportion of healthy patients than ill patients. I believe sicker patients