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PubMed1991

Taking a deep breath over capital payments.

As the Congressional deadline nears for incorporating Medicare payment for capital investments into the prospective payment system, a number of healthcare groups are renewing their opposition to the initiative. They insist that a payment method cannot be constructed to equitably account for geographic influences, different capital cycles among healthcare facilities, and other factors. Opponents of the initiative say this failure will impose further stress on hospitals already burdened by less than adequate Medicare payments for operating expenses.

Capital Expenditures↗

PubMed1991

Joint-venture, capitation model can strengthen market share.

As health maintenance organizations (HMOs) and preferred provider organizations (PPOs) control an increasingly larger percentage of the healthcare market, many hospitals are entering capitation contracts to capture and preserve market share. A joint-venture and capitation model may provide an additional mechanism for large referral centers and community hospitals to jointly maintain or increase market share through improved service delivery. While the model includes many benefits, hospitals should thoroughly consider ramifications. Only through substantial institutional commitment, careful planning, and ongoing management will the model prove successful.

Capitation Fee↗

PubMed1991

Complexity, caution mark start of PPS for capital.

The Health Care Financing Administration's revised and highly complex method of paying for inpatient capital costs includes broadened provisions for old capital, a series of payment "floors" for especially vulnerable facilities, and other changes meant to address industry criticism. But a villain known as budget neutrality inevitably led to reductions in some areas. During the system's 10-year transition, one prominent concern will center on how the Federal rate will be set and adjusted.

Budgets↗

PubMed1992

Capital PPS 10-year transition up and running.

Hospital financial officers must prepare themselves for the long stretch, as the 10-year transition to Medicare's new capital prospective payment system (PPS) gets underway. Documentation related to capital assets and their financing must be assembled and preserved throughout the transition period; audit procedures must be understood; crucial deadlines must be met; and calculations by Medicare fiscal intermediaries (FIs) must be verified by reference to a hospital's records. Most important, lines of communication with FIs must be established and maintained because rates set this year will determine a substantial portion of Medicare payment for the next decade.

Capital Expenditures↗

PubMed1993

Integrating technology assessment into the capital budgeting process.

Technology assessment can help hospitals rank the importance of capital requests by providing crucial information both about existing equipment and about new equipment that has been requested. Integrating technology assessment into the capital budgeting process is the best way for hospitals to determine what equipment should be purchased each year.

Budgets↗

PubMed1993

Retroactive reimbursement under HCFA's PPS for capital.

Most hospitals participating in a diagnosis related group-based prospective payment system (PPS) make the transition to HCFA's PPS for capital reimbursement much as they did to PPS for operating cost reimbursement. However, unlike the transition to a Federal rate of reimbursement for a hospital's operating cost, the initial years of the transition to a Federal rate for Medicare capital cost reimbursement may offer significant opportunities for retroactive reimbursement.

Capital Expenditures↗

PubMed1994

Third-party capital equipment management cuts costs.

In an effort to reduce maintenance, repair, and reorder costs associated with the wide range of capital equipment necessary for the operation of most healthcare facilities, some healthcare organizations are turning to third-party capital equipment management companies. These companies can help reduce costs by providing the high-level technical expertise many facilities lack, reducing response time when equipment servicing is necessary, and developing effective preventive maintenance programs.

Capital Expenditures↗

PubMed1996

Capitated contracting for emergency services.

As a way of gaining further control over the cost of healthcare delivery, more managed care organizations are seeking to negotiate capitated contracts for emergency department services. In many instances, these contracts do not include disincentives that would discourage primary care physicians from sending patients who require nonurgent care to emergency departments for treatment. Without such disincentives, emergency departments may have to bear a considerable financial burden for providing additional services. Prior to negotiating the terms of capitated contracts for emergency services, managers should analyze carefully how patients use emergency department resources. By negotiating with managed care organizations to include volume stop-loss provisions and other financial disincentives to curb overutilization by physicians, financial managers can help protect their organizations from the costs of overutilization.

Capitation Fee↗

PubMed1996

Capitating physician group practices.

To prepare for capitated payment, physician group practices must gather essential data on service utilization and cost of services, must develop appropriate compensation and incentive plans for physicians, and must analyze and, if necessary, modify their practices's clinical and business operations. Those group practices that take these steps will be positioned to profit from capitated payment.

Capitation Fee↗

PubMed1996

Modified capitation and treatment incentives for end stage renal disease.

This study developed a modified capitation payment method for the Medicare end stage renal disease (ESRD) program designed to support appropriate treatment choices and protect health plans from undue financial risk. The payment method consists of risk-adjusted monthly capitated payments for individuals on dialysis or with functioning kidney grafts, lump sum event payments for expected incremental costs of kidney transplantations or graft failures, and outlier payments for expensive patients. The methodology explained 25 percent of variation in annual payments per patient. Risk adjustment captured substantial variations across patient groups. Outlier payments reduced health plan risk by up to 15 percent.

Capitation Fee↗

PubMed1996

Risk-adjusted Medicare capitation rates using ambulatory and inpatient diagnoses.

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.

Aged↗

PubMed1996

Underwriting: a key to healthy capitation agreements.

In some markets, healthcare providers in integrated delivery systems have been assuming full-risk capitated contracts. Some of these contracts have been profitable, but others have produced inconsistent financial results. These results may reflect inadequate underwriting practices. For providers and HMO insurers to establish financially successful capitation agreements, they must develop and audit an underwriting process to evaluate the health risk of the population entering the managed care system.

Capitation Fee↗

PubMed1996

Key provisions strengthen hospital capitation contracts.

Hospitals that accept capitation payments can expect both risks and rewards. The rewards include a dependable revenue stream and economic incentives aligned with those of physicians. The risks are related to payment issues, provision of services, utilization projections, and contract disputes. By ensuring that capitation contracts adequately address these and other issues, hospitals can minimize their exposure to risk.

Actuarial Analysis↗

PubMed1997

Four techniques for managing the risk of capitation contracts.

Organizations that provide managed care must manage four major cost drivers if they are to achieve financial success under capitation. These cost drivers-number of lives covered, service frequency, service intensity, and cost per unit of service-represent risk factors that can be minimized using several insurance risk management strategies: bearing risk, sharing risk, transferring risk, and undertaking risk-reduction activities. No one strategy will be sufficient to ensure success under capitation; contracting organizations, therefore, should use a portfolio of strategies to manage risk.

Capitation Fee↗

PubMed1997

The power and potential of capitation.

Capitation creates a financial incentive to deliver care in the most appropriate setting. All major stakeholders in the health care industry (plan members, employers, practitioners, delivery systems, community organizations, and the government) share a common interest in managing risk sooner and better. Capitation can be a catalyst that encourages and reinforces this commonalty of purpose.

Attitude of Health Personnel↗

PubMed1997

Integrating payer and provider risk through capitation.

Capitation payment mechanisms promote conservative use of medical resources by transferring risk to the decision maker, the physician. However, there is another view of capitation: defining common risk between provider-driven organizations (i.e., physician/hospital organizations (PHOs) or integrated delivery systems (IDS), and risk-managing entities such as HMOs or insurance companies. This article discusses a strategy to align provider and risk manager incentives to share the risks and rewards for a total book of business or population.

Actuarial Analysis↗

PubMed1997

New capitation scenarios for HMO Medicare risk contracting.

Medicare's current method for setting capitation rates does not provide adequate financial incentives for HMOs to offer managed care products; more than 60 percent of the nation's HMOs still do not participate in Medicare risk contracts. Possible changes to the capitation calculation method could provide the necessary financial incentives for Medicare HMOs to proliferate and ease the strain on the Medicare trust fund. Managed care organizations need to prepare to enter the Medicare risk-contracting arena.

Capitation Fee↗

PubMed1997

Evaluating and negotiating a profitable capitation contract.

Evaluating the financial terms of capitation contracts and negotiating their nonfinancial provisions are becoming increasingly important responsibilities for healthcare financial managers. To evaluate the financial terms of a contract, financial managers must understand both incremental and replacement pricing strategies. They also must understand when strategic positioning objectives make a capitated plan attractive despite limited financial rewards. Before a contract is accepted, financial managers can take steps to increase its potential profitability by negotiating the nonfinancial provisions that can help control contract expenses. These provisions are related to services to be provided, payment terms, withholds and risk pools, access to data, provision of eligibility data, utilization review and quality assurance procedures, filing of grievances, contract renewal terms, and contract termination.

Capitation Fee↗