Canadian physicians only need look to the south to see that capitation can control not only their fees but also the amount of resources they use, the amount of care their patients can expect and the way doctors and patients relate to one another. In the US, capitation is rewarding doctors for doing less and penalizing them if they do too much. "Instead of a being cash source," says Dr. John Verhoff, a family practitioner in Columbus, Ohio, "a patient visit is a cash drain." Milan Korcok looks at the ways capitation is changing medicine in the US.
Capitation-based reimbursement significantly influences the practice of medicine. As physicians, we need to assure that payment models do not jeopardize the care we provide when we accept higher levels of personal financial risk. In this paper, we review the literature relevant to capitation, consider the interaction of financial incentives with physician and medical risk, and conclude that primary care physicians need to work to assure that capitated systems incorporate checks and balances which protect both patients and providers. We offer the following proposals for individuals and groups considering capitated contracts: (1) reimbursement for primary care physicians should recognize both individual patient encounters and the administrative work of patient care management; (2) reimbursement for subspecialists should recognize both access to subspecialty knowledge and expertise as well as patient care encounters, but in some situations, subspecialists may provide the majority of care to individual patients and will be reimbursed as primary care providers; (3) groups of physicians should accept financial risk for patient care only if they have the tools and resources to manage the care; (4) physicians sharing risk for patient care should meet regularly to discuss care and resource management; and (5) physicians must disclose the financial relationships they have with health plans and medical care organizations...
OBJECTIVE--To assess the effect of each of the components of the national capitation funding formula--population projections and age and mortality weighting--at regional and district level. DESIGN--Application of age-cost and mortality weights to the projected 1997 populations of regions and districts, based on the Department of Health public health common dataset. SETTING--Regional and district health authorities in England. RESULTS--The application of the age-cost and mortality weights to projected populations resulted in greater changes in the shares of weighted populations relative to the estimated 1991 population at district level (mean 0, range -17% to 28%) than at regional level (mean 0, range -9% to 6%). At district level mortality weights had less scope for influence (mean 0, range -9% to 14%) than population projections (mean 0, range -16% to 31%) or age weights (mean 0, range -20% to 30%). CONCLUSIONS--The adjustments to the 1991 population shares due to the application of the national capitation funding formula depend on the interaction of three elements: the projected population by age group, the age-cost weight, and the mortality weight. Since each is open to uncertainty, either in terms of measurement (projected population...
A study was performed to assess whether the existing differential capitation fees for general practitioners accurately assess differential workloads. Data from the third morbidity study in general practice were used to compare capitation fees with relative workload in differing age and sex groups. The population mix which determined the payment by capitation for the 143 principals in the study provided the basis for examining the advantage or disadvantage the general practitioner got from the existing system. Capitation fees for the elderly underestimated the increased workload by 21% for those aged 65-74 and by 54% for those aged 75 or over but overestimated the workload for male adults aged up to 65. Nevertheless, 60% of the participating general practitioners were not advantaged or disadvantaged by more than 2.5% of their capitation fees (450 pounds a year for the average practitioner with a list of 2000 patients). Similarly 88% were not advantaged or disadvantaged by more than 5%; none were advantaged or disadvantaged by more than 10%. A three scale capitation fee for the age groups 0-64, 65-74, and 75 or over should be applied in the ratio of 3:5:7 rather than in the present ratio of 3:4:5, but given the present population mix in practices there is no case for differential capitation fees by sex or differential fees for the age group 0-4 years.
In every system of health care, capitation payments have become the accepted tool used by health care purchasers in much of the developed world to determine prospective budgets. The policy prescription of capitation is perceived to address both equity objectives (of great importance in publicly funded systems of health care) and efficiency objectives (the dominant concern in competitive insurance markets). An examination of the current state of the art in 20 countries outside the United States in which health care capitation has been implemented confirms that capitation has assumed central importance within diverse systems of health care. In practice, however, the setting of capitation payments has been heavily constrained to date by poor data availability and unsatisfactory analytic methodology.
This article evaluates changes in the use of drug services and the corresponding costs when the conventional fee-for-service system for reimbursement of pharmacists under Medicaid is replaced by a capitation system. The fee-for-service system usually covers ingredient costs plus a fixed professional dispensing fee. The capitation system provided a cash payment (which varied by aid category and season of the year) per Medicaid eligible the first of each month. We examined drug use and costs in two experimental rural counties during a 1-year preperiod in which the fee-for-service form of reimbursement was employed, as well as a 2-year postperiod in which the capitation system was used. We compared the results with use and cost patterns in two other rural counties which remained on the fee-for-service system during the same 3-year period.
Researchers at The Johns Hopkins University (JHU) developed two new diagnosis-oriented methodologies for setting risk-adjusted capitation rates for managed care plans contracting with Medicare. These adjusters predict the future medical expenditures of aged Medicare enrollees based on demographic factors and diagnostic information. The models use the Ambulatory Care Group (ACG) algorithm to categorize ambulatory diagnoses. Two alternative approaches for categorizing inpatient diagnoses were used. Lewin-VHI, Inc. evaluated the models using data from 624,000 randomly selected aged Medicare beneficiaries. The models predict expenditures far better than the Adjusted Average per Capita Cost (AAPCC) payment method. It is possible that risk-adjusted capitation payments could encourage health plans to compete on the basis of efficiency and quality and not risk selection.
This article addresses three issues related to capitation. First, the average adjusted per capita cost (AAPCC) fluctuates with the mix of risks in the fee-for-service system. More sensitive adjusters in the AAPCC are needed. Second, the AAPCC, as now estimated, exhibits large geographic variance; so-called shrinkage estimators may help. Third, the AAPCC requires new adjusters to yield more homogeneous risk classes. Otherwise, the portion of the Medicare population under capitation may experience access problems at alternative delivery systems: Until such adjusters are developed, it seems better to rely upon a blend of capitation and fee-for-service than the present AAPCC.
This article reviews the history of capitation in the Medicare program and examines issues and research findings related to Medicare capitation. Specific capitation issues and related research findings reviewed include: the feasibility and extent of health maintenance organization participation in Medicare; plan marketing; beneficiary choice behavior; quality of care; and the use and cost of services. In addition, areas requiring further study are noted, and the potential for extensions of capitation under Medicare are explored.
The purpose of this study is to conduct
a baseline survey on the cost and efficiency in Primary
Health Care (PHC) Centers in Serbia before the
implementation of the payment reforms. Results can be used
to inform the payment reform and to establish a baseline on
health sector performance including utilization, quality,
cost, and efficiency against which the impact of the reforms
can be assessed in a follow-up survey. Recommendations about
payment system design and capitation formula are beyond the
scope of this report and have been undertaken as a separate
activity. This study was conducted with the support of World
Bank health sector strategy funds. The rest of this report
is organized is follows. Chapter two presents the data and
methodology used in this survey to evaluate the cost and
efficiency performance in Dom Zdravlja (DZs). Results are
presented and discussed in chapter three. Based on findings,
chapter four concludes and proposes several reform measures
to support the effect of the provider payment reform. The
annex contains additional information including a technical
annex with an overview on the literature on cost and
This study, done at the request of the
Hungarian government, presents evidence on cost-sharing in
the health sector, and its application in Hungary. It
presents results on the impact of cost-sharing on revenues
in health facilities and insurance, financial
sustainability, informal payments, overall service use, and
equity in access. Five keyfindings emerge: cost-sharing
could lead to a reduction in unnecessary care provided to
insured patients who do not have to pay the full price of
care; cost-sharing could help reduce informal payments and
keep patient payments in the system; cost-sharing with
exemption policies are a prerequisite to provide equity in
access to care; cost-sharing could support cost containment
strategies; experience from OECD countries provides examples
of successful cost-sharing policies. Based on these
findings. the study recommends that Hungary continues to
monitor and evaluate the impact of cost-sharing on access,
to identify possible negative effects on equity in service
use. In Hungary...
In this paper, it is discuss methods to
allocate national health care funds to purchasers or
insurers of health care. For administrative reasons,
resources are usually allocated as they always have
been-which relates more closely to the existing structure
and demand than to need. Resource allocation through
capitation is needed to achieve equity in access to health
care or health outcome. Capitation should be based on
epidemiological or socio-demographic need factors. The
author discusses how to select and weight need factors and
provides examples from high and low income countries.
This thesis analyzed the effect capitation based resourcing has on the incentives for the commander of military treatment facilities (MTFs). Specifically, what incentives do MTF Commanders have to increase effectiveness and efficiency in a capitated system? In answering this question, factors such as the ability of the Commander to contract out services and the proper mix of services to maximize the value to patients while maintaining the quality of care within the capitated constraint were discussed. The mechanism for determining the capitated rate and how Bid Price Adjustment and transfer payments affect incentives were reviewed. These characteristics were analyzed to determine whether capitation in BUMED provides the necessary market incentives to achieve technical and allocative efficiency. After comparing the incentives in BUMED to the incentives in civilian sector capitation, it is unclear if BUMED will achieve similar results.
The purpose of this research is to develop a financial model for Naval Medical Center San Diego for the calculation of an appropriate capitation rate under capitation budgeting. The current cost accounting system at Naval Medical Center San Diego and records of the Military Expense and Reporting System and the Uniform Management Report were analyzed to determine their usefulness in providing the information for and implementing capitation budgeting. An accounting model based on the principles of activity-based costing was used to develop a financial model and was applied to the current accounting system at Naval Medical Center San Diego. The research showed the current accounting system used at Naval Medical Center San Diego and the Military Expense and Reporting System and the Uniform Management Report do not provide the needed financial information for the calculation of an appropriate capitation rate. The accounting system will need to be realigned to identify expenses by activities versus cost categories. The analysis done for this thesis indicates that activity-based costing can provide a more accurate measure of the cost of services (outputs) and facilitate in the calculation of an appropriate capitation rate for Naval Medical Center San Diego.
In 1994, DoD implemented managed care and a capitation-based resource allocation model within the Military Health Services System (MHSS). This study examines the evolution of DoD's model and its impact on resource managers. Personal and telephonic interviews were conducted with key individuals from the Office of the Secretary of Defense for Health Affairs (OASD(HA)), Bureau of Medicine and Surgery (BUMED), and at the Military Treatment Facility (MTF) level. A review of literature, including books, white papers, monographs, and journal articles were undertaken. The thesis concludes that the capitation methodology that OASD(HA) and the Services follow is a population-based model. BUMED allocates Defense Health Program (DHP) fluids on the basis of capitation categories down to the activity level. However, the MTF resource manager apportions DHP fluids to the departments based on historical and workload considerations. Due to a lack of a patient cost accounting module in the present accounting system, actual execution against a capitated resource allocation is not possible. Because of other limitations in the present structure, MTFs under BUMED still use traditional incremental budgeting in allocating fluids to their various departments. Thus...
Approved for public release; distribution is unlimited.; This thesis analyzes whether a capitation-based resource allocation system will provide the incentives necessary to pursue or provide quality, cost- effective care within the Military Medical Department. To answer this question, capitation budgeting and its salient characteristics were defined. Then, the risks and incentives associated with capitation budgeting were compared against other budgetary methods. Subsequently, the civilian sector's experience with prepaid, managed care plans was analyzed, focusing on the incentives to the various health care players. It also questioned whether the quality of care has been effected. Next, the study drew on civilian sector experience to evaluate the potential impact of incentives on various players in the Military Health Services System. The study concludes that a capitation-based resource allocation system will provide the various players in the military health care arena with the proper incentives to provide quality, cost-effective care.; Lieutenant, United States Naval Reserve
Fonte: Royal Australian College of General PractitionersPublicador: Royal Australian College of General Practitioners
Tipo: Artigo de Revista Científica
Publicado em //1992Português
Relevância na Pesquisa
Fee for service and capitation systems are usually regarded as different methods of medical remuneration, however, they can be seen to differ mainly in the degree to which they 'bundle' or 'package' medical services. A capitation system for general practice services in Australia could be established by the creation of a Medicare item and benefit for a year's general practice care. This would allow doctors to assess the benefits of capitation without a total and potentially traumatic commitment, and may encourage innovation in the efficient delivery of primary health care.; Oliver Frank
With the movement toward universal
health coverage gaining momentum, the global health research
community has made significant efforts to advance knowledge
about the impact of various schemes to expand population
coverage. The impacts on efficiency, quality, and gaps in
service utilization of reforms to provider payment methods
are less well studied and understood. The current paper
contributes to this limited knowledge by evaluating the
impact of a shift by Vietnam's social health insurance
agency from reimbursing hospitals on a fee-for-service basis
to making a capitation payment to the district hospital
where the enrollee lives. The analysis uses panel data on
hospitals over the period 2005-2011 and multiple
cross-section data sets from the Vietnam Household Living
Standards Surveys to estimate impacts on efficiency,
quality, and equity. The paper finds that capitation
increases hospitals' efficiency, as measured by
recurrent expenditure and drug expenditure per case, but has
no effect on surgery complication rates or in-hospital
deaths. In response to the shift to capitation...
OBJECTIVE: To evaluate the predictive accuracy of the Diagnostic Cost Group (DCG) model using health survey information. DATA SOURCES/STUDY SETTING: Longitudinal data collected for a sample of members of a Dutch sickness fund. In the Netherlands the sickness funds provide compulsory health insurance coverage for the 60 percent of the population in the lowest income brackets. STUDY DESIGN: A demographic model and DCG capitation models are estimated by means of ordinary least squares, with an individual's annual healthcare expenditures in 1994 as the dependent variable. For subgroups based on health survey information, costs predicted by the models are compared with actual costs. Using stepwise regression procedures a subset of relevant survey variables that could improve the predictive accuracy of the three-year DCG model was identified. Capitation models were extended with these variables. DATA COLLECTION/EXTRACTION METHODS: For the empirical analysis, panel data of sickness fund members were used that contained demographic information, annual healthcare expenditures, and diagnostic information from hospitalizations for each member. In 1993, a mailed health survey was conducted among a random sample of 15,000 persons in the panel data set...
This article documents the history and implementation of health-based capitation risk adjustment in Minnesota public health care programs, and identifies key implementation issues. Capitation payments in these programs are risk adjusted using an historical, health plan risk score, based on concurrent risk assessment. Phased implementation of capitation risk adjustment for these programs began January 1, 2000. Minnesota's experience with capitation risk adjustment suggests that: (1) implementation can accelerate encounter data submission, (2) administrative decisions made during implementation can create issues that impact payment model performance, and (3) changes in diagnosis data management during implementation may require changes to the payment model.