Case management in the context of capitation financing: an evaluation of the strengths model.
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Adult↗
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A community ability scale for chronically mentally ill consumers: Part II. Applications.
The authors describe uses for a 17-item instrument that efficiently measures the functioning level of chronically mentally ill persons living in the community. The Multnomah Community Ability Scale is designed to be completed by case managers who work with chronically mentally ill consumers. The instrument is sensitive to differences among individuals within this special population of consumers and is easy to complete. Community mental health program staff can be trained to use the scale reliably. The scale has been used to compare levels of severity between urban and rural community mental health program clients. The authors discuss the application of the Multnomah Community Ability Scale to a capitated payment system for severely mentally ill, involuntary clients.
Activities of Daily Living↗
HMOs and the seriously mentally ill--a view from the trenches.
The role of HMOs in health care policy, specifically in treating individuals with long-term persistent illness, is a matter of debate. The following is a response to a summary of the research to date entitled "Health Maintenance Organizations and Persons with Severe Mental Illness" previously published in this journal. The author argues that capitated pre-paid payment mechanisms can and should be considered separately from the decision of funding an HMO or other managed care structure. The argument is made that, with proper planning, the existing community mental health system can make capitated payment system changes, while avoiding dual health and social services systems. Savings in the expenses of dual systems and maintenance of the charitable missions with local oversight of CMHC can result.
Capitation Fee↗
The economic impact of capitated care for high utilizers of public mental health services: the Los Angeles PARTNERS program experience.
Los Angeles PARTNERS, or "people achieving rehabilitation together need empowering respectful support," is a treatment program that uses capitation to shift risk for treatment costs of high utilizers of public mental health services to private community-based treatment organizations. This analysis reveals two important findings from PARTNERS. First, the economic incentives created by capitation contributed to the dis-enrollment of PARTNERS clients; furthermore, factors such as not speaking English or Spanish or having schizophrenia increased the probability of dis-enrollment. Second, analyses of health costs for enrollees in the PARTNERS capitation program suggest that the program did not result in a change in total costs. However, the program increased the use of community-based care and increased treatment costs for clients with lower preprogram costs but decreased costs for the clients with high preprogram costs. These results suggest that future capitation programs for this severely ill population would benefit from using detailed clinical information to determine program eligibility and to set risk-adjusted capitation rates.
Capitation Fee↗
Comment on "Managed care in the public sector: lessons learned from the Los Angeles PARTNERS program".
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Budgets↗
Do adjusted clinical groups eliminate incentives for HMOs to avoid substance abusers? Evidence from the Maryland Medicaid HealthChoice program.
The adequacy of risk adjustment to eliminate incentives for managed care organizations (MCOs) to avoid enrolling costly patients had been questioned. This study explored systematic differences in expenditures between beneficiaries with and without substance disorders assigned to the same capitation rate group under the Maryland Medicaid HealthChoice program. The investigators used fiscal year (FY) 1995 to 1997 Medicaid data to assign beneficiaries to rate cells based on FY 1995 diagnoses and compared the distribution of expenditures for beneficiaries with and without substance disorders, defined using FY 1997 and FY 1995 diagnoses. Results showed that differences in FY 1997 expenditures between beneficiaries with and without FY 1995 substance disorders were negligible. However, MCOs could expect greater average losses and lower average profits on beneficiaries with FY 1997 substance disorders. Thus, the adjusted clinical groups methodology used to adjust capitation payments in the HealthChoice program attenuated, but did not eliminate, financial incentives for MCOs to avoid substance abusers.
Adolescent↗
Evaluating selection out of health plans for Medicaid beneficiaries with substance abuse.
In the absence of adequate risk adjustment, capitation for enrollees creates incentives for health plans to enroll and retain good risks and to avoid bad risks. This article examines whether Maryland Medicaid beneficiaries with histories of substance abuse disenroll from health plans more frequently than those without such histories. The findings indicate that enrollees with a history of substance abuse were more likely to switch plans than other enrollees, regardless of whether they chose the health plan or were randomly assigned to the plan. These results suggest that current risk-adjustment systems may fail to offset selection incentives in modern capitated health plans.
Adult↗
What happens when capitated behavioral health comes to town? The transition from the Fort Bragg demonstration to a capitated managed behavioral health contract.
Capitated managed care contracts for behavioral health services are becoming more prevalent across the country in both public and private sectors. This study followed the transition from a demonstration project for child mental health services to a capitated managed behavioral health care contract with a for-profit managed care company. The focus of the study was on the impact--at both the service system and the individual consumer level--pertaining to the start-up and maintenance of a capitated managed behavioral health program. A case study using multiple methods and multiple sources of information incorporated a program fidelity framework that examined micro to macro levels of program implementation. The findings of this study include the following: access to services decreased, the lengths of stay and average daily census in the more intensive levels of treatment declined, difficult-to-treat children were shifted to the public sector, and ratings of service system performance and coordination fell.
Adolescent↗
Implementing capitation of Medicaid mental health services in Colorado: is "readiness" a necessary condition?
Two consortia of community mental health centers in Colorado varied in their administrative readiness for changing to a capitated system and, ultimately, implemented capitation using different organizational arrangements. The objective was to assess the impact of this natural experiment on administrative change, costs, and utilization of services during the first two years postcapitation. Prior to capitation, one was rated as having greater "readiness" than the other and received a capitation contract from the state, while the other did not. A private, for-profit managed behavioral health organization was awarded a contract and formed a joint venture with the less "ready" consortium, providing managed care expertise to complement the consortium's expertise in delivering mental health services. Two years later, these consortia do not look different either administratively or in their patterns of service utilization and costs. These findings suggest alternative ways of successfully implementing a capitated public mental health system.
Capitation Fee↗
Medicaid chemical dependency patients in a commercial health plan: do high medical costs come down over time?
A cohort of 197 Medicaid-insured patients presenting for treatment in Kaiser Permanente's outpatient chemical dependency treatment program were observed the year prior to their program intake visit and followed for 3 years afterwards, to compare their medical costs and utilization to demographically matched commercially insured patients entering the same programs. The Medicaid-insured patients on average incurred medical costs 60% higher than non-Medicaid patients during the 12-month preintake period ($5402 vs $3377). [corrected] During the 3 years subsequently, however, both groups of chemical dependency patients displayed significant declines in medical costs, averaging 30% from the baseline period to the third year of follow-up. Cost trends reflected declines in use of hospital days, emergency department visits, and nonemergent outpatient visits. These results may help address concerns among Medicaid managed care providers and payers by giving a more realistic account of the long-term costs of this group of high-utilizing enrollees.
Adolescent↗
Institutionalized patients with hip fractures: characteristics associated with returning to community dwelling.
The authors sought to identify patient- and nursing home-specific characteristics associated with a return to community living among patients with hip fractures discharged initially to nursing homes. One hundred eighty-nine free-living elderly patients were admitted for hip fractures to a 1,120-bed community hospital during 1984-1986. At hospital discharge, 114 (60%) of these patients were institutionalized. One year later, 49/114 (43%) had returned to the community. Three factors independently correlated with patients' return to community living: being discharged to a nursing home with a large ratio of annual admissions to number of beds (RR = 2.51, 95% CI 1.65, 3.94), achieving any in-hospital ambulation (RR = 4.24, 95% CI 1.77, 8.14), and receiving conventional Medicare insurance (RR = 0.37, 95% CI 0.05, 0.53). These data suggest the existence of patient and nursing home features that identify those institutionalized patients with hip fractures who are more likely to return to community dwelling.
Age Factors↗
Mental health costs, other public costs, and family burden among mental health clients in capitated integrated service agencies.
This article explores the cost implications of the capitated integrated service agency (ISA) model for persons with severe and persistent mental illness. Two demonstration sites in California were chosen for a randomized comparison between an ISA model and usual care under the existing county service system. Each ISA demonstration program assumed fiscal and service responsibility for approximately 100 clients. Cost information was collected during a 3-year study period. The capitated ISAs reduced the previously skewed distribution of resources to clients and reduced family economic burden (in one site). However, they did not reduce law enforcement, health, and other nontreatment public costs. Although capitated funding enabled programmatic effectiveness and the shifting of services toward rehabilitation, it did not itself ensure such results.
California↗
The risk-adjusted vision beyond casemix (DRG) funding in Australia. International lessons in high complexity and capitation.
Hospitals throughout the world using funding based on diagnosis-related groups (DRG) have incurred substantial budgetary deficits, despite high efficiency. We identify the limitations of DRG funding that lack risk (severity) adjustment for State-wide referral services. Methods to risk adjust DRGs are instructive. The average price in casemix funding in the Australian State of Victoria is policy based, not benchmarked. Average cost weights are too low for high-complexity DRGs relating to State-wide referral services such as heart and lung transplantation and trauma. Risk-adjusted specified grants (RASG) are required for five high-complexity respiratory, cardiology and stroke DRGs incurring annual deficits of $3.6 million due to high casemix complexity and government under-funding despite high efficiency. Five stepwise linear regressions for each DRG excluded non-significant variables and assessed heteroskedasticity and multicollinearlity. Cost per patient was the dependent variable. Significant independent variables were age, length-of-stay outliers, number of disease types, diagnoses, procedures and emergency status. Diagnosis and procedure severity markers were identified. The methodology and the work of the State-wide Risk Adjustment Working Group can facilitate risk adjustment of DRGs State-wide and for Treasury negotiations for expenditure growth. The Alfred Hospital previously negotiated RASG of $14 million over 5 years for three trauma and chronic DRGs. Some chronic diseases require risk-adjusted capitation funding models for Australian Health Maintenance Organizations as an alternative to casemix funding. The use of Diagnostic Cost Groups can facilitate State and Federal government reform via new population-based risk adjusted funding models that measure health need.
Australia↗
Financing of health care services in Hungary.
In this paper we give a practical overview of the changes in the financing of health care in Hungary. We describe the financing system of general practitioners, home care (nursing), out-patient care and the acute and chronic care of hospitals. We show how the financial system has changed after the political changes of 1990. The global budget approach of the 1980s was replaced by performance-related financing methods including the ICPM (International Classification of Procedures in Medicine) code system of the WHO (World Health Organization) in out-patient care and the introduction of HBCS (Homogen Betegsegcsoportok, "Homogeneous Disease Groups") in in-patient care. We underline that the efforts made towards reforming health care financing resulted in an activity-related financing system.
Adolescent↗
Health care provider payment mechanisms in the new EU members of Central Europe and the Baltic states. Current reforms, incentives, and challenges.
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Baltic States↗
Primary care physicians and capitated reimbursement. Experience, attitudes, and predictors.
Given the explosive expansion of capitated reimbursement for the services of primary care physicians, we conducted a national survey of a random sample of these practitioners to measure attitudes toward capitated payment and identify predictors of important attitudes. Descriptive, factor analytic, and regression techniques were used. The response rate was 54%. As measured by scales derived from factor analysis, perceptions were strong that capitation was costly to professional and patient relationships. Patients' access to care was perceived as slightly reduced. Actual participation in capitation attenuated feelings of lack of access but not those of capitation's costly effects. Physicians' attitudes toward capitation remain negative, but participants perceive their patients' access to appropriate care as reasonable.
Attitude of Health Personnel↗
Managed care contracting/capitation.
Both the general approach for entering into a managed care contract and the subject of capitation are presented. The general approach section outlines the criteria that a physician group should apply in analyzing the feasibility of entering into a managed care contract with any insurer. The physician group's contracting process should be iterative and refined over time. The capitation section addresses issues revolving around the assessment of a capitated contract. The example assumes a typical health maintenance organization-primary care group contract. Not analyzed in this article are the exciting opportunities presented through specialty carveout capitation. Managing the transition to a more competitive environment will be the major challenge facing group practices. Survival in the tightening healthcare market will depend on sound strategic decisions regarding the physician group's mission as well as its relationship to its hospital partners and other delivery systems. To support these strategic decisions, a solid knowledge base and a thorough understanding of the terms and provisions regarding the formulation of these new relationships are necessary. The budget methodology is a relatively straightforward approach to establishing a capitation. Careful consideration will have to be given to the method of allocating the capitation among providers. A special concern is the risk-sharing arrangement with primary care physicians.
Budgets↗
Optimizing cardiothoracic surgery information for a managed care environment.
The rapid change occurring in American healthcare is a direct response to rising costs. Managed care is the fastest growing model that attempts to control escalating costs through limitations in patient choice, the active use of guidelines, and placing providers at risk. Managed care is an information intensive system, and those providers who use information effectively will be at an advantage in the competitive healthcare marketplace. There are five classes of information that providers must collect to be competitive in a managed care environment: patient satisfaction, medical outcomes, continuous quality improvement, quality of the decision, and financial data. Each of these should be actively used in marketing, assuring the quality of patient care, and maintaining financial stability. Although changes in our healthcare system are occurring rapidly, we need to respond to the marketplace to maintain our viability, but as physicians, we have the singular obligation to maintain the supremacy of the individual patient and the physician-patient relationship.
Capitation Fee↗