Capitation Agreements

An example of a capita model would be an IAP that negotiates a fee of $500 per year per patient with an authorized PCP. For an HMO group of 1,000 patients, the PCP would receive $500,000 per year and in return provide all authorized medical services for the 1,000 patients for this year. One of the main concerns about healthcare accountability (and a repeated complaint by many participants in HMOs) is that the practice encourages physicians to enroll as many patients as possible, leaving less and less time to see a patient. While the capita is designed to reduce costs and improve results, it has its own drawbacks. The capitation model of the payment is intended to support these objectives. In addition, this approach could provide a strong incentive for care groups to choose patients, conditions and treatments on the basis of financial returns and not on the basis of patient needs. It is not uncommon for large groups or physicians involved in primary care network models to also receive an additional capitance payment for diagnostic test shipments and outsourced treatment. The family doctor will use this extra money to pay for these transfers. It is obvious that this exposes the family doctor to a higher financial risk if the total cost of transfers exceeds the amount of capitation, but the potential financial rewards are also greater when diagnostic transfers and outsourcing services are controlled. In addition, some test recommendation plans and sub-services are paid through fee for service agreements, but are usually paid through contractual scales that are reduced by 10% to 30% compared to usual and usual local fees.

The last widespread use of capitation in the United States did not meet the last two criteria. In the late 1980s and 1990s, both public and private payers were looking for ways to reduce inflation in the health sector. The main mechanism they turned to were health organizations (HMOs), usually owned and managed by insurance companies. While employers typically paid HMOs on a capital basis, most HMOs continued to pay care groups with fee for service and pro-case methods. Most care groups now navigate through a complex mix of reduced fees for service (commercial insurance) and per case (Medicare, plus some commercial insurance). Population-based payments – capital payments directly to care groups – remain relatively rare. But if it were adopted more widely, groups that aggressively reduce waste, as Intermountain did, would benefit financially; the income they received for each patient`s treatment would remain stable, while their costs would decrease. The key is to identify and reach the inflection point: the share of a group`s total, which must be achieved by capitation so that the benefits from waste disposal under PBP outweigh the losses among other payment systems. In case of capitation, there is an incentive to take into account the cost of treatment. Simple capitation pays a fee set per patient, regardless of their degree of infirmity, which encourages doctors to avoid the most expensive patients. [3] Traditionally, paying agencies have reimbursed healthcare providers for the cost of services provided or the volume of services provided. .

. .

This entry was posted in Uncategorized. Bookmark the permalink.