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PubMed1996

Capitation: selecting the method, determining the rates. Can providers share risk without excessive financial exposure?

Healthcare providers in markets with a high degree of managed care penetration, such as western states, are aggressively pursuing capitated contracts that are comprehensive in scope and that assume a significant amount of risk sharing. Providers in other parts of the country, however, still are determining how much risk they can assume safely. Integral to this assessment is consideration of two factors: the form of the capitated payment and the capitation rate. Providers must understand the two forms of capitated payment--per member per month and percent of premium--and how each is affected by changes in market levels before they can choose the one best suited to the amount of risk they can assume. Findings from a study of capitation rates utilized by 10 large national or multiregional HMOs may serve as a point of reference for providers.

Capitation Fee↗
PubMed1996

How to choose the right capitalization option.

Physician group practices and networks must have ready access to capital to finance their working capital needs, capital equipment acquisitions, and real estate purchases, as well as to fund the acquisition of additional practices. At least three options for capitalization are available to group practices and networks: debt financing, equity financing, or a combination of the two. The best option for physician group practices and networks depends on the costs of capital and the impact the strategy will have on decision making and governance.

Capital Financing↗
PubMed1997

Prepaid capitation versus fee-for-service reimbursement in a Medicaid population.

Utilization of health resources by 37,444 Medicaid recipients enrolled in a capitated health maintenance organization was compared with that of 227,242 Medicaid recipients enrolled in a traditional fee-for-service system over a 1-year period (1983-1984) in the state of Kentucky. Primary care providers in the capitated program had financial incentives to reduce downstream costs like specialist referral, emergency room use, and hospitalizations. The average number of physician visits was similar for both groups (4.47/year in the capitated program; 5.09/year in the fee-for-service system). However, the average number of prescriptions (1.9 versus 4.9 per year), average number of hospital admissions per recipient (0.11 versus 0.22 per year), and average number of hospital days per 1,000 recipients (461 versus 909 per year) were 5% to 60% lower in the capitated group than in the fee-for-service group. The Citicare capitated program resulted in a dramatic reduction in healthcare resource utilization compared with the concurrent fee-for-service system for statewide Medicaid recipients.

Aid to Families with Dependent Children↗
PubMed1997

Specialist capitation improves specialty and primary care physician relationships.

Physicians involved in managed care contracting serve as gatekeepers to manage their patients' care and receive payments through capitation arrangements. In serving as gatekeepers, primary care physicians assume financial risk for patients' care. A growing number of specialists, however, are entering into specialist capitation contracts, thereby sharing financial risk and patient care responsibilities. Primary care and specialist physicians should understand the terms of capitation contracts and develop positive working relationships to coordinate efficient, cost-effective patient care. Capitation contracts should define roles and responsibilities of primary care physicians and specialists and should delineate capitated payment rates. When primary care physicians and specialists share financial risk and divide responsibilities, patient care can be managed to the satisfaction of providers, payers, and patients.

Capitation Fee↗
PubMedDate not supplied

How venture capital works.

The popular mythology surrounding the U.S. venture-capital industry derives from a previous era. Venture capitalists who nurtured the computer industry in its infancy were legendary both for their risk taking and for their hands-on operating experience. But today things are different, and separating the myths from the realities is crucial to understanding this important piece of the U.S. economy. Today's venture capitalists are more like conservative bankers than the risk takers of days past. They have carved out a specialized niche in the capital markets, filling a void that other institutions cannot serve. They are the linch-pins in an efficient system for meeting the needs of institutional investors looking for high returns, of entrepreneurs seeking funding, and of investment bankers looking for companies to sell. Venture capitalists must earn a consistently superior return on investments in inherently risky businesses. The myth is that they do so by investing in good ideas and good plans. In reality, they invest in good industries--that is, industries that are more competitively forgiving than the market as a whole. And they structure their deals in a way that minimizes their risk and maximizes their returns. Although many entrepreneurs expect venture capitalists to provide them with sage guidance as well as capital, that expectation is unrealistic. Given a typical portfolio of ten companies and a 2,000-hour work year, a venture capital partner spends on average less than two hours per week on any given company. In addition to analyzing the current venture-capital system, the author offers practical advice to entrepreneurs thinking about venture funding.

Capital Financing↗
PubMedDate not supplied

Efficiency, new equity capital enable systems to compete.

Because of limited cash, sponsors of some community and religious hospitals have sought to sell or lease their institutions to a not-for-profit (NFP) system or to a for-profit system. A number of national alliances address the capital formation problem of NFP institutions. Until now they have been almost exclusively concerned with acquiring less costly debt. Without new equity capital, market influence is difficult to obtain. Even well-managed voluntary systems face a serious threat from well-capitalized investor-owned systems. Increased competition among hospitals and physicians will force future advantages to those who have capital. It will also restrict funding of certain programs and services by voluntary enterprises. In anticipation of this, various forms of partnerships have developed with investor-owned systems. To regain the initiative as the premier sponsors of health care, religious and other voluntary systems must go beyond merely competing in their markets to acquiring weaker institutions. They also must revitalize private giving and excel in efficiency to offset threats from ambulatory, day-care operations and from high-technology hospitals. Structural changes in the industry can be predicted, including the following: The trend toward integration for production, financing, and marketing will continue. Public market equity capital will be increasingly used to finance medical practice. Hospitals that sell their equity values will establish service foundations. National alliances will continue, but strictly local systems will maintain operation. Investor-owned systems will move increasingly into high-technology tertiary care.

Capital Financing↗
PubMed1986

Inflation, risk, replacement, closure: concerns in capital budgeting.

Four problems can affect the capital budgeting process-inflation, replacement, risk, and closure. Therefore financial managers must consider these problems carefully when making capital budgeting decisions. This article is the second of a two-part series on capital budgeting in health care. It builds on the existing level of knowledge of capital budgeting to give the financial manager confidence in the use of capital budgeting techniques.

Budgets↗
PubMed1988

Approaches to primary care. Physician capitation.

The first author, as a consultant to the Office of Prepaid Health Care, reviewed the financial status of nine IPAs for federal qualification in 1987. He found little to suggest any methodology being used for constructing primary care physician (PCP) capitation reimbursement systems. This article draws upon statistical theory and presents hypothetical examples to structure better financial arrangements based on five criteria: stop-loss reinsurance deductible levels, capitation of services related to physician practice, minimum panel size (number of patients) for capitation, stratified capitation, and inclusion of all PCPs in the capitation arrangement.

Capitation Fee↗
PubMed1999

Using contact capitation to align payment incentives among specialists.

Contact capitation is a means of paying specialists based on the number of patients managed rather than on the number of services provided or procedures performed. Payments to physicians are disbursed from budgets, or risk pools, which are established by specialty and product line (e.g., commercial coverage, Medicare). Each specialist is credited with managing a patient for a specified time period (usually 12 months) following the patient's initial visit. To ensure payments are equitable to all physicians, regardless of specialty or subspecialty, the system may be adjusted by using different contact weights for certain diagnoses or procedures, creating subpools for selected subspecialties and/or procedures, establishing separate capitation rates for different age segments, and setting aside certain specialties as fee-for-service carve-outs. Contact capitation has advantages over traditional specialist capitation of removing physicians' financial incentives to overutilize and allowing for a broad physician specialty panel. Challenges to implementing contact capitation include getting physicians to alter habitual practice patterns and managing the system's administrative complexity.

Capitation Fee↗
PubMedDate not supplied

Capitated contracting roles and relationships in healthcare.

Capitated contracting of health providers has created substantial change in healthcare markets. This article assesses how capitation affects the roles and relationships of healthcare organizations. In-depth case studies were conducted of eight major hospital-led integrated health networks/systems and two large integrated medical groups. Types of capitated contracts employed, contract support capabilities developed, relationships among providers in the support services, and lessons learned about capitation were explored. The experiences of these organizations provide valuable guidance for health executives as they develop or refine capitated contracting strategies.

Capitation Fee↗
PubMed2002

Alcohol and juvenile justice contacts: a comparison of fee-for-service and capitated medicaid mental health services.

OBJECTIVE: This study examines whether youth with alcohol problems are especially vulnerable to juvenile justice contact when receiving public mental health services in fee-for-service versus capitated managed-care agencies. Capitation is a payment method often accompanying managed care; a fixed fee is paid per person enrolled, for a specific time period and range of services. METHOD: Youth services were studied in a statewide, quasi-experimental design from July 1994 to June 1997; subjects were 13,365 Medicaid-eligible youth (52% female) aged 10-17. Alcohol problems were measured using a clinician-generated psychiatric diagnosis and a subjective indicator of alcohol symptoms obtained from a psychometrically tested mental health treatment intake form. Analysis methods were hazard/survival rates, log-rank tests and Cox proportional hazards models. RESULTS: As measured by the presence of symptoms, alcohol-involved youth in capitated managed care were significantly less likely to have contact with the juvenile justice system, in uncontrolled analysis. In controlled analysis, they were also less likely; however, only at the level of a trend. CONCLUSIONS: Concerns regarding capitated managed mental health care (e.g., substitution of care or "cost-shifting") found no support. There was no evidence of a shifting of alcohol-involved youth receiving mental health services under capitated managed care to the juvenile justice system. If anything, such youth saw their likelihood of juvenile justice involvement decrease.

Adolescent↗
PubMed2004

Does capitation matter? Impacts on access, use, and quality.

Provider capitation may constrain costs, but it also may reduce access and quality of care. We examine the impacts of capitating the usual source of care of enrollees in health maintenance organizations (HMOs). We account for the endogeneity of capitation and other characteristics using generalized methods of moments (GMM) estimation on a sample from the Medical Expenditure Panel Survey for 1996 and 1997. Being organized as a group/staff HMO generally has stronger impact on access and quality than capitation. Capitation by itself may increase access to consumers' usual sources of care, improve primary preventive care, and reduce coordination, but estimates with GMM were not statistically significant.

Adult↗
PubMed1996

Capitation adjustment for pediatric populations.

OBJECTIVE: The objective of this study is to assess the predictive performance of current claims-based capitation adjustment methods for pediatric populations. Medicaid programs and other insurers may increasingly use these systems for capitation rate setting, physician profiling, and other purposes. METHODS: Five leading models, a demographic model, ambulatory care groups, ambulatory diagnostic groups, diagnostic cost groups, and payment amounts for capitated systems, were tested by using use and expenditure data for children enrolled in the Maryland Medicaid program and a private nonprofit health maintenance organization in Minnesota. The models were tested at the individual level by using multiple regression methods and at the group level by using split-half validation to create both random and nonrandom groups. One of the nonrandom groups was created to represent children with chronic conditions. RESULTS: The findings indicate that although each of the alternative methods offers an improvement over a demographic model, significant underpayment remained for high-risk children, regardless of the capitation adjustment method used. CONCLUSIONS: It is concluded that children with chronic conditions would probably remain at risk for discrimination in a competitive health care market under all models tested. Limitations associated with current alternatives suggest the need for further research in the area of pediatric capitation adjustment methods.

Adolescent↗
PubMed1996

Children's dental health under the capitation scheme.

A study was undertaken of the dental health of 7870 eight-year-old children resident in the City of Birmingham, using the standard British Association of Community Dentistry epidemiological procedures. There were variations in the dental health of children from different ethnic backgrounds. Asian children had the poorest dental health and Afro-Caribbean children, the best. There were also variations in the dental health of children from different ACORN Categories. Children from the highest ACORN Category 'Thriving' had better dental health than those from the lowest, 'Striving' Category. Positive consent was obtained from every parent or guardian to link the findings with the Dental Practice Board's records as to whether each child was registered under the NHS capitation scheme for the provision of primary dental care to children. The dental state of those who were registered in the capitation scheme, (54.5 per cent), was compared with those who were not, (45.5 per cent). The highest proportion of children registered with a dentist were Caucasian and from a high social class i.e. ACORN Category 'Thriving'. In order to ensure that differences were due to their capitation status and not to other differences within the groups, analyses were undertaken according to the ethnic background and ACORN Category of the children. Overall, there were only very small differences between the caries state of the registered and non registered children. However 32 per cent of those children registered in the scheme still had active decay which was not restricted to the primary dentition. The greatest reduction in the average number of decayed teeth together with the greatest increase in the average number of fillings in registered children when compared to their non registered colleagues was observed in the lowest ACORN Category. Unfortunately this group had the lowest proportion of children who were registered in the capitation scheme and 40 per cent of them, both registered and non registered, still had active decay. Overall, oral hygiene was good, and there was little difference between registered and non-registered children in the ACORN Category 'Thriving'. However, in the ACORN Category 'Striving', there was a higher proportion of children with good oral hygiene amongst those who were registered than amongst those who were not. Provision of preventive treatment was low in all registered and non registered groups, but lowest in those groups of children with the poorest dental health. It would appear that, for a proportion of children registered in the capitation scheme, the practitioners were failing to achieve the requirement of "securing and maintaining their oral health".

Africa↗
PubMed2006

The empirical relationship between community social capital and the demand for cigarettes.

We show that the proportion of community social capital attributable to religious groups is inversely and strongly related to the number of cigarettes that smokers consume. We do not find overall community social capital or the proportion of community social capital attributable to religious groups to be related to the overall prevalence of smoking. Using a new validated measure of community social capital, the Petris Social Capital Index and three years (1998-2000) of US data on 39 369 adults, we estimate a two-part demand model incorporating the following controls: community-level fixed effects, price (including excise taxes), family income, a smuggling indicator, nonsmoking regulations, education, marital status, sex, age, and race/ethnicity.

Adult↗
PubMed2006

Development and testing of the social capital scale for families of children with special health care needs.

The purpose of this study was to develop and psychometrically test the Social Capital Scale for families of children with special health care needs. Researchers have suggested a link between social capital and health, however, psychometrically tested measures of social capital are not described in the literature. The Social Capital Scale (SCS) demonstrated internal consistency, stability over time, and construct validity (as evaluated through factor analysis, correlation with existing measures, and hypothesis testing). Five subscales provide insight into family strengths and areas for improvement related to their investment in relationships that support health. Use of the SCS will contribute to the establishment of consensus and precision in communication about social capital's utility and measurement in the population of families of children with special health care needs.

Adult↗
PubMed1989

Evidence for four capital and six auxiliary cation-binding sites on calmodulin: divalent cation interactions monitored by direct binding and microcalorimetry.

Recently, Mills and Johnson [7] and our group [9] provided evidence that calmodulin contains, in addition to the four Ca2+-binding sites (capital sites), which are essential for drug- and enzyme-binding, a number of divalent cation-binding sites of different ion selectivity (auxiliary sites), which modulate drug-binding as well as the affinity of Ca2+ for the capital sites. In the present study, the number of auxiliary sites and their relationship to the capital sites were determined by equilibrium gel filtration and by flow microcalorimetry with Zn2+ and Mn2+ as selective probes for the auxiliary sites and with Cd2+ as a probe for both types of sites. In the absence of other divalent cations, 6 mol of Zn2+ bind to calmodulin with an identical affinity constant of 2,850 M-1 and a delta H0 of 106 kJ/mol calmodulin. In the presence of millimolar free Ca2+ calmodulin binds, in addition to four Ca2+, six Zn2+ with an affinity constant of 1,200 M-1 and a delta H0 of 47 kJ/mol calmodulin. The Zn2+-Ca2+ antagonism is governed by negative free energy coupling between the capital and auxiliary sites. In contrast, the Zn2+-Mg2+ antagonism follows the rule of straight competition at all six auxiliary sites. Mn2+ also binds exclusively to the auxiliary sites with affinity constants of 800 or 280 M-1 and delta H0 of 45 or 46 kJ/mol calmodulin in the absence and presence of saturating [Ca2+], respectively. Cd2+ binds to the capital sites with an affinity constant of 3.4 10(4) M-1 (delta H = 35 kJ/mol calmodulin) and to the auxiliary sites with ca. 100-fold lower affinity. The Zn2+ much greater than Mn2+ greater than or equal to Cd2+ greater than Mg2+ selectivity of the auxiliary sites corroborates the potencies of these cations in modulating drug binding. The auxiliary site-specific cations are unable to promote high-affinity complex formation between calmodulin and melittin.

Animals↗
PubMed2006

Maternal social capital and child nutritional status in four developing countries.

Social capital has been shown to be positively associated with a range of health outcomes, yet no studies have explored the association between maternal social capital and child nutritional status. Using data from the Young Lives study comprising 7242 1-year-old children from Peru, Ethiopia, Vietnam and the state of Andhra Pradesh in India, we find significant differences in the levels of, in particular, structural social capital (group membership and citizenship) between countries. While few associations were found between structural measures of social capital, support from individuals and cognitive social capital (e.g. trust, social harmony) displayed fairly consistent positive associations with child nutritional status across countries.

Adult↗