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PubMed1998

Mental health costs and outcomes under alternative capitation systems in Colorado: early results.

BACKGROUND: This study presents preliminary findings for the first nine months of the State of Colorado USA Medicaid capitation Pilot Project. Two different models of capitation (model I and model II) are compared with fee for service (FFS) in providing services to severely and persistently mentally ill adults. In model I the state's mental health authority contracts with community mental health centers (CMHCs) who both manage the care and deliver mental health services, while in model II the state contracted with a joint venture between a for-profit managed care firm who manage the care with either a single CMHC or an alliance of CMHCs who deliver the mental health services. AIMS: Our objective is to examine utilization, cost and outcomes of inpatient and outpatient (including community based) services before and after the implementation of a capitated payment system for Colorado's Medicaid mental health services compared to services that remained under FFS reimbursement. METHODS: The stratified, random sample includes 513 consumers (188 for model I, 179 for model II, and 146 for FFS). Consumer outcomes were collected by trained interviewers and include 17 measures of symptoms, health status, functioning, quality of life and consumer satisfaction. Utilization and cost of services are from the Medicaid claims data and a shadow billing data system (post-capitation) designed by Colorado. The first step of the two-step regression procedure adjusts for the presence of individuals with use or no service use during the specified time while the second step, ordinary least-squares regression, is applied to the sample who utilized services. RESULTS: These preliminary findings indicate consistent reductions in inpatient user costs and probability of outpatient use under capitation. Combining all services, there are consistent reductions in the probability of use in both models: model I had significantly higher initial probability of use for any service. Only model II showed a statistically significant decrease in post-capitation overall user costs, but they were initially higher than model I or FFS. Estimated total cost per person for model I suggests virtually no change from the pre- to post-capitation period. Model II had the highest pre-capitation and the lowest post-capitation estimated cost per person. Examination of pre measures of outcomes across capitated areas suggest that samples drawn from the FFS, model I and model II areas were comparable in severity of psychiatric symptoms, functioning, health status and quality of life. No changes were found in outcomes. DISCUSSION: These early findings are consistent with the limited literature on capitation. Both studies of capitation integrated with medical care and those specific to mental health settings did not find adverse changes in outcomes compared to FFS. Limitations include the short follow-up period, lack of detail and possible under-reporting of outpatient services provided by the shadow billing data system. CONCLUSIONS: For the short term, it is concluded that capitation can reduce service cost per person without significant change in clinical status. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Implications are unclear until we can determine whether (i) reductions in the numbers receiving service indicates favorable consumer outcomes or reductions in access and (ii) lack of change in consumer outcomes is due to the benefits of capitation or the lack of sensitivity of the outcome measures. IMPLICATIONS FOR HEALTH CARE POLICY FORMULATION: Implications are premature for these early findings. IMPLICATIONS FOR FUTURE RESEARCH: Future research should include longer follow-up as well as analysis of long-term consequences for both cost savings and clinical outcomes.

Journal Article↗
PubMed2003

The M-C-M' cycle and social capital.

Social capital has become a popular term over the past two decades amongst researchers, policy makers and practitioners from varied disciplines. This popularity, however, has resulted in a great deal of confusion over the nature and application of social capital in different contexts. This confusion has made it difficult to identify and measure social capital within the evaluation of specific social and health programmes, one of the aims of which may be to stimulate social capital. This paper identifies a theoretical model that seeks to capture the dynamic nature of social capital to assist in the development of research methods that will facilitate its measurement and exploration within such programmes. The model reported in the paper identifies the key components of social capital and expresses the relationship between those components in a dynamic system based on Marx's description of the process of capital (economic) exchanges expressed in the M-C-M' cycle. The M-C-M' cycle is the transformation of money (M) into commodities (C), and the change of commodities back again into money (M') of altered value. The emphasis within the paper is on the capital element of the concept and its transactional nature with the aim of avoiding the pitfall of attributing social capital in relation to social behaviours in isolation of context and interaction. Importantly, the paper seeks to distinguish the central elements of social capital from some of the antecedent factors and outcomes often attributed to and confused with social capital adding to the problem of providing valid measurement. The model is presented as the basis for the measurement of social capital within a transactional process involving the investment of social resources in a cyclical process, which may result in net gains or losses. This process is described as the R-C-R' cycle following Marx's model of economic capital, with the focus being on the transfer of social resources (R) rather than money (M). R represents an internal resource held by individuals, C the external resource or commodity they obtain from the network and the R' the internal resource of altered value. The possibilities of the model in assisting in the measurement of social capital specifically in assessing formal networks are explored.

Commerce↗
PubMed2000

How much does social capital add to individual health? A survey study of Russians.

Some Russians are healthier than others. To what extent does their health vary with involvement or exclusion from social capital networks? The first section reviews alternative theories: human capital as the primary determinant; social capital, whether generic, situation-specific or simply a new label for old measures of social integration; or a composite theory--both human and social capital are major determinants of health. The evidence to test hypotheses consists of individual-level data about self-assessed physical and emotional health from the special-purpose social capital questionnaire used in the 1998 New Russia Barometer survey, a nationwide representative sample of the adult Russian population. Multiple regression analysis shows that on their own human capital and social capital each account for a notable amount of variance in health. When both forms of capital are combined in a composite model, each retains major influence, demonstrating that social capital does make an independent contribution to health. Significant social capital influences include involvement or exclusion from formal and informal networks; friends to rely on when ill; control over one's own life; and trust. Significant human capital influences besides age include subjective social status, gender and income. Regression-based estimates of impact show that social capital increases physical and emotional health more than human capital; together they can easily raise an individual's self-reported health from just below average on a five-point scale to approaching good health.

Adolescent↗
PubMed2006

Bonding versus bridging social capital and their associations with self rated health: a multilevel analysis of 40 US communities.

STUDY OBJECTIVE: Few studies have distinguished between the effects of different forms of social capital on health. This study distinguished between the health effects of summary measures tapping into the constructs of community bonding and community bridging social capital. DESIGN: A multilevel logistic regression analysis of community bonding and community bridging social capital in relation to individual self rated fair/poor health. SETTING: 40 US communities. PARTICIPANTS: Within community samples of adults (n = 24 835), surveyed by telephone in 2000-2001. MAIN RESULTS: Adjusting for community sociodemographic and socioeconomic composition and community level income and age, the odds ratio of reporting fair or poor health was lower for each 1-standard deviation (SD) higher community bonding social capital (OR = 0.86; 95% = 0.80 to 0.92) and each 1-SD higher community bridging social capital (OR = 0.95; 95% CI = 0.88 to 1.02). The addition of indicators for individual level bonding and bridging social capital and social trust slightly attenuated the associations for community bonding social capital (OR = 0.90, 95% CI = 0.84 to 0.97) and community bridging social capital (OR = 0.96, 95% CI = 0.89 to 1.03). Individual level high formal bonding social capital, trust in members of one's race/ethnicity, and generalised social trust were each significantly and inversely related to fair/poor health. Furthermore, significant cross level interactions of community social capital with individual race/ethnicity were seen, including weaker inverse associations between community bonding social capital and fair/poor health among black persons compared with white persons. CONCLUSIONS: These results suggest modest protective effects of community bonding and community bridging social capital on health. Interventions and policies that leverage community bonding and bridging social capital might serve as means of population health improvement.

Adult↗
PubMed2000

Academic health systems management: the rationale behind capitated contracts.

OBJECTIVE: To determine why hospitals enter into "capitated" contracts, which often generate accounting losses. The authors' hypothesis is that hospitals coordinate contracts to keep beds full and that in principal, capitated contracts reflect sound capacity management. SUMMARY BACKGROUND DATA: In high-overhead industries, different consumers pay different prices for similar services (e.g., full-fare vs. advanced-purchase plane tickets, full tuition vs. financial aid). Some consumers gain access by paying less than total cost. Hospitals, like other high-overhead business enterprises, must optimize the use of their capacity, amortizing overhead over as many patients as possible. This necessity for enhanced throughput forces hospitals and health systems to discount empty beds, sometimes to the point where they incur accounting losses serving some payors. METHODS: The authors analyzed the cost accounting system at their university teaching hospital to compare hospital and intensive care unit (ICU) lengths of stay (LOS), variable direct costs (VDC), overhead of capitated patients, and reimbursement versus other payors for all hospital discharges (n = 29,036) in fiscal year 1998. The data were analyzed by diagnosis-related groups (DRGs), length of stay (LOS), insurance carrier, proximity to hospital, and discharge disposition. Patients were then distinguished across payor categories based on their resource utilization, proximity to the hospital, DRG, LOS, and discharge status. RESULTS: The mean cost for capitated patients was $4,887, less than half of the mean cost of $10,394 for the entire hospitalized population. The mean capitated reimbursement was $928/day, exceeding the mean daily VDC of $616 but not the total cost of $1,445/day. Moreover, the mean total cost per patient day of treating a capitated patient was $400 less than the mean total cost per day for noncapitated patients. The hospital's capitated health maintenance organization (HMO) patients made up 16. 0% of the total admissions but only 9.4% of the total patient days. Both the mean LOS of 3.4 days and the mean ICU LOS of 0.3 days were significantly different from the overall values of 5.8 days and 1 day, respectively, for the noncapitated population. For patients classified with a DRG with complication who traveled from more than 60 miles away, the mean LOS was 10.7 days and the mean total cost was $21,658. This is in contrast to all patients who traveled greater than 60 miles, who had an LOS of 7.2 days and a mean total cost of $12,569. CONCLUSION: The capitated payor directed the bulk of its subscribers to one hospital (other payors transferred their sicker patients). This was reflected in the capitated group's lower costs and LOS. This stable stream of relatively low-acuity patients enhanced capacity utilization. For capitated patients, the hospital still benefits by recovering the incremental cost (VDC) of treating these patients, and only a portion of the assigned overhead. Thus, in the short run, capitated patients provide a positive economic benefit. Other payors' higher-acuity patients arrive more randomly, place greater strains on capacity, and generate higher overhead costs. This results in differential reimbursement to cover this incremental overhead. Having a portfolio of contracts allows the hospital to optimize capacity both in terms of patient flows and acuity. One risk of operating near capacity is that capitated patients could displace other higher-paying patients.

Capitation Fee↗
PubMed2003

Investments in social capital--implications of social interactions for the production of health.

This paper develops a theoretical model of the family as producer of health- and social capital. There are both direct and indirect returns on the production and accumulation of health- and social capital. Direct returns (the consumption motives) result since health and social capital both enhance individual welfare per se. Indirect returns (the investment motives) result since health capital increases the amount of productive time, and social capital improves the efficiency of the production technology used for producing health capital. The main prediction of the theoretical model is that the amount of social capital is positively related to the level of health; individuals with high levels of social capital are healthier than individuals with lower levels of social capital, ceteris paribus. An empirical model is estimated, using a set of individual panel data from three different time periods in Sweden. We find that social capital is positively related to the level of health capital, which supports the theoretical model. Further, we find that the level of social capital (1) declines with age, (2) is lower for those married or cohabiting, and (3) is lower for men than for women.

Age Factors↗
PubMed1997

Managing the strategic capital cycle.

A healthcare organization's financial strategy should be defined within the context of the capital cycle and provide for the management of three critical components that will ensure the expansion and renewal of capital capacity--the design and implementation of the financial plan, the design and implementation of an appropriate capital structure, and a means to strategically utilize capital and reinvest it in the organization. The capital cycle comprises two parts--strategic planning and implementation, and the development of the support infrastructure that includes financial planning, capital structure, and capital allocation. The financial plan positions an organization within an area of financial equilibrium and defines its organizational capabilities. The financial infrastructure gives integrity and momentum to the capital cycle. Capital structure addresses critical funding and financing questions and is best defined as the combination of debt and equity that funds the strategic plan. In regard to capital allocation, healthcare organizations should follow a corporate "best practices" approach for such areas as financial objectives and policies, project review, and the capital expenditures approval process.

Capital Expenditures↗
PubMed1999

Does a year make a difference? Changes in physician satisfaction and perception in an increasingly capitated environment.

BACKGROUND: Although capitation has become an increasingly common method of payment for heath care, little is known about changes in physician satisfaction as they become more experienced working in a capitated environment. METHODS: We surveyed the members of a physician hospital organization at an urban teaching hospital in the summers of 1996 and 1997. In 1996, fully capitated contracts covered <5% of patients under 65 years of age, but that figure increased to nearly 25% by 1997. We assessed physicians' satisfaction with their practice, compared satisfaction under fee-for-service and capitated payment, and evaluated ethical issues related to capitation. RESULTS: In 1996, we surveyed 587 physicians with direct patient care responsibilities, of whom 62% responded; 51% of 520 physicians responded in 1997. Overall satisfaction was 57% in 1996 and 71% in 1997. Among physicians who responded in both years, overall satisfaction was unchanged, but increases in satisfaction were noted for patient load (an increase of 0.5 points on a five-point scale, P <0.01), time to discuss patient needs (an increase of 0.3 points, P <0.01), and helpfulness of care coordination (an increase of 0.5 points, P = 0.02). In a direct comparison between fee-for-service and capitation, physicians were more satisfied with both methods of payment in 1997 than they were in 1996, but they were much more satisfied with fee-for-service in both years. For many individual indicators, the difference in satisfaction between fee-for-service and capitation increased between 1996 and 1997. CONCLUSION: When introduced to capitation, physicians had strong negative perceptions about it. After a year's experience, satisfaction with capitation improved, but perceived differences between capitation and fee-for-service grew even larger. Thus, physicians have serious concerns about capitation that may not be alleviated by experience with it.

Attitude of Health Personnel↗
PubMed2005

The impact of capitated financing on psychiatric emergency services.

OBJECTIVE: Studies of capitated financing of mental health services have generally focused on the cost and utilization of services. Relatively little research has addressed whether capitation has an impact on the effectiveness of the mental health system as a whole. This study examined the impact of capitation on hospital emergency department visits, a widely cited indicator of the effectiveness of the other components of the system. METHODS: In 1995 Colorado's Medicaid program instituted capitation for mental health services in two areas of the state, one in which reimbursement of not-for-profit providers was directly capitated and another in which not-for-profit providers partnered with a for-profit managed behavioral health organization. The analysis examined variation over time in the number of emergency department visits by adults who had a primary mental or substance use disorder. Using interrupted time-series methods, visits in areas where reimbursement was capitated were compared with visits in areas where providers continued to be reimbursed on a fee-for-service basis. A total of 105 weeks for each area was examined; capitation was implemented at week 53. RESULTS: The number of psychiatric emergencies treated in capitated areas declined by 814 (28 percent) below the 2,908 psychiatric emergencies expected from trends, cycles, and levels in fee-for-service areas. Findings were similar for for-profit and not-for-profit areas. The decrease persisted through the end of the first year after capitation. CONCLUSIONS: In Colorado the implementation of capitation was associated with a sustained decrease in utilization of psychiatric emergency services provided by hospital emergency departments. Our findings suggest that capitation does not necessarily reduce the quality of care provided to clients.

Capitation Fee↗
PubMed2006

A multilevel analysis of key forms of community- and individual-level social capital as predictors of self-rated health in the United States.

Communities may be rich or poor in a variety of stocks of social capital. Studies that have investigated relations among these forms and their simultaneous and combined health effects are sparse. Using data on a sample of 24,835 adults (more than half of whom resided in core urban areas) nested within 40 U.S. communities from the Social Capital Benchmark Survey, correlational and factor analyses were applied to determine appropriate groupings among eight key social capital indicators (social trust, informal social interactions, formal group involvement, religious group involvement, giving and volunteering, diversity of friendship networks, electoral political participation, and non-electoral political participation) at each of the community and individual levels. Multilevel logistic regression models were estimated to analyze the associations between the grouped social capital forms and individual self-rated health. Adjusting the three identified community-level social capital groupings/scales for one another and community- and individual-level sociodemographic and socioeconomic characteristics, each of the odds ratios of fair/poor health associated with living in a community one standard deviation higher in the respective social capital form was modestly below one. Being high on all three (vs. none of the) scales was significantly associated with 18% lower odds of fair/poor health (odds ratio = 0.82, 95% confidence interval = 0.69-0.98). Adding individual-level social capital variables to the model attenuated two of the three community-level social capital associations, with a few of the former characteristics appearing to be moderately significantly protective of health. We further observed several significant interactions between community-level social capital and one's proximity to core urban areas, individual-level race/ethnicity, gender, and social capital. Overall, our results suggest primarily beneficial yet modest health effects of key summary forms of community social capital, and heterogeneity in some of these effects by urban context and population subgroup.

Adolescent↗
PubMed2004

Social capital is associated with decreased risk of hunger.

This article explores whether social capital-a measure of trust, reciprocity and social networks-is positively associated with household food security, independent of household-level socioeconomic factors. Interviews were conducted in 330 low-income households from Hartford, Connecticut. Social capital was measured using a 7-item Likert scale and was analyzed using household- and community-level scores. Household food security and hunger were measured using the US Household Food Security Module. chi2 tests were used to examine associations between social capital, food security and household demographic characteristics. Logistic regression was used to examine whether household- and community-level social capital decreases the odds of household hunger, and to estimate which household characteristics increase the likelihood of having social capital. Consistent with our hypotheses, social capital, at both the household and community levels, is significantly associated with household food security in these data. Community-level social capital is significantly associated with decreased odds of experiencing hunger (adjusted odds ratio (AOR)=0.47 [95% CI 0.28, 0.81], P<0.01), while controlling for household socioeconomic status. Results show that households with an elderly member are over two and a half times as likely to have high social capital (AOR=2.68 [1.22, 5.87], P<0.01) than are non-elderly households, after controlling for socioeconomic status. Having a household member who participates in a social or civic organization is also significantly associated with having higher levels of social capital. Social capital, particularly in terms of reciprocity among neighbors, contributes to household food security. Households may have similarly limited financial or food resources, but households with higher levels of social capital are less likely to experience hunger.

Confidence Intervals↗
PubMed2005

Social capital and mental health: an interdisciplinary review of primary evidence.

An interdisciplinary interrogation of primary evidence linking social capital and mental health sought to establish: (1) 'quality of evidence' (assessed in terms of study design, methods used to address stated questions, rigor of data analysis, and logic and clarity of interpretation of results), and (2) applicability of the evidence to public health policy and practice with respect to mental health. It is found that social capital, a complex and compound construct, can be both an asset and a liability with respect to mental health of those in receipt of and those providing services and other interventions. The most meaningful assessment of social capital or components thereof may examine individual access to rather than possession of social capital, a property of groups, and therefore an ecological variable. Theoretical advances in research on social capital serve to identify mainly two types of social capital: bonding (between individuals in a group) and bridging (between groups). Each type of social capital has cognitive and/or structural component(s) and may operate at micro and/or macro level(s). Effective mental health policy and service provision may build or strengthen bridging social capital and benefit from both bonding and bridging social capital where either or both exist. Established indicators of social capital are amenable to quantitative and qualitative assessment, preferably in tandem. However studies that employ combined research design are rare or non-existent. Interdisciplinary multi-method investigations and analyses are called for in order to unravel mechanisms whereby social capital and mental health might be meaningfully associated.

Behavioral Research↗
PubMed2002

Social capital and violence in the United States, 1974-1993.

Social capital is a characteristic of communities. Cross-sectional studies have shown that social capital is inversely associated with homicide and violent crime. We hypothesized that variations in social capital in US states over time can predict variations in regional homicide mortality both across and within time periods. We analyzed serial cross-sectional data for measures of social capital and age-adjusted homicide rates between 1974 and 1993. We used perception of social trust and per capita membership in voluntary associations, obtained from responses to the General Social Surveys, as the principal measures of social capital. We controlled for potential confounding by mean levels of income, urbanization, and region. Measures of perceived trust were strongly inversely correlated with homicide rates in an aggregate cross-sectional analysis (r=-0.51, p<0.001) and also within each time period. Social capital was an independent predictor of rates of violence when controlling for income, region, and urbanization (p<0.001). Homicide rates also predicted levels of social capital in adjusted models (p<0.001). To investigate directionality of this relationship we developed Markov transition matrices that described the change in the states' levels of social capital and homicide across time intervals. Analysis of the transitional probabilities confirmed that a simple unidirectional association between social capital and violence was not sufficient to describe this association. There is likely an impact of violence on levels of perceived trust in communities that complements the hypothesized effect of social capital on homicide. We conclude that the relationship between social capital and violence over time is non-linear and dynamic. More complex analytic models describing the relationship between violence and ecological social determinants need to be considered.

Adult↗
PubMedDate not supplied

Choices of ecosystem capital without discounting and prices.

In the last decade, neo-classical economists have used the Consumption-Growth Based Utility (CGBU) framework to suggest an appropriate discount rate for eco-system capital. The CGBU framework, being based on the simplicity and single-valued nature of man-made capital, is subject to many limitations. Three general limitations of the framework, irrespective of its use for man-made capital or ecosystem capital, paradox of consumption growth, expectations' insensitive utility specification, and insensitivity to the nature of returns, are discussed. With respect to its use for ecosystem capital, the framework has two limitations: ecosystems cannot be commoditized and ecosystem capital satisfies differentiated needs, and, hence, gross substitution between different components of ecosystem capital or between ecosystem capital and man-made capital is not possible. Therefore, the rate of discount for ecosystem capital suggested on the basis of the framework is arbitrary. In the context of international security, choices of ecosystem capital are similar to the choices of military decisions. Similar to military decisions, ecosystem choices should be made without discounting and prices. The neo-classical framework does not have appropriate tools for such decision analyses, and other streams of economics, specifically post-Keynesian economics, may assist decision-makers in analysing ecosystem choices without prices and discounting.

Conservation of Natural Resources↗
PubMed1998

Children who prosper in unfavorable environments: the relationship to social capital.

OBJECTIVE: Social capital describes the benefits that are derived from personal social relationships (within families and communities) and social affiliations. This investigation examined the extent to which social capital is associated with positive developmental and behavioral outcomes in high-risk preschool children. DESIGN: A cross-sectional case-control analysis of young children "doing well" and "not doing well" at baseline in four coordinated longitudinal studies. PARTICIPANTS: A total of 667 2- to 5-year-old children (mean age, 4.4 years) and their maternal caregivers who are participating in the Longitudinal Studies of Child Abuse and Neglect Consortium. At recruitment, all children were characterized by unfavorable social or economic circumstances that contributed to the identification of the children as high risk. MEASURES: Social capital was defined as benefits that accrue from social relationships within communities and families. A social capital index was created by assigning one point to each of the following indicators: 1) two parents or parent-figures in the home; 2) social support of the maternal caregiver; 3) no more than two children in the family; 4) neighborhood support; and 5) regular church attendance. Outcomes were measured with the Child Behavior Checklist, a widely used measure of behavioral/emotional problems, and with the Battelle Developmental Inventory Screening Test, a standardized test that identifies developmental deficits. Children were classified as doing well if their scores on these instruments indicated neither behavioral nor developmental problems. RESULTS: Only 13% of the children were classified as doing well. The individual indicators that best discriminated between levels of child functioning were the most direct measures of social capital-church affiliation, perception of personal social support, and support within the neighborhood. The social capital index was strongly associated with child well-being, more so than any single indicator. The presence of any social capital indicator increased the odds of doing well by 29%; adding any two increased the odds of doing well by 66%. CONCLUSIONS: Our findings suggest that social capital may have an impact on children's well-being as early as the preschool years. In these years it seems to be the parents' social capital that confers benefits on their offspring, just as children benefit from their parents' financial and human capital. Social capital may be most crucial for families who have fewer financial and educational resources. Our findings suggest that those interested in the healthy development of children, particularly children most at risk for poor developmental outcomes, must search for new and creative ways of supporting interpersonal relationships and strengthening the communities in which families carry out the daily activities of their lives.

Case-Control Studies↗
PubMed2002

Patient protection and risk selection: do primary care physicians encourage their patients to join or avoid capitated health plans according to the patient's health status?

BACKGROUND: Individual physicians who are paid prospectively, as in capitated health plans, might tend to encourage patients to avoid or to join these plans according to the patient's health status. Though insurance risk selection has been well documented among organizations paid on a prospective basis, such physician-level risk selection has not been studied. OBJECTIVE: To assess physician reports of risk selection in capitated health plans and explore potentially related factors. DESIGN AND PARTICIPANTS: National mailed survey of primary care physicians in 1997-1998, oversampling physicians in areas with more capitated health plans. RESULTS: The response rate was 63% (787 of 1,252 eligible recipients). Overall, 44% of physicians reported encouraging patients either to join or to avoid capitated health plans according to the patients' health status: 40% encouraged more complex and ill patients to avoid capitated plans and 23% encouraged healthier patients to join capitated plans. In multivariable models, physicians with negative perceptions of capitated plan quality, with more negative experiences in capitated plans, and those who knew at each patient encounter how they were being compensated had higher odds of encouraging sicker patients to avoid capitated plans (odds ratios, 2.0, 2.2, and 2.0; all confidence intervals >1). CONCLUSIONS: Many primary care physicians report encouraging patients to join or avoid capitated plans according to the patient's health status. Although these physicians' recommendations might be associated primarily with concerns about quality, they can have the effect of insulating certain health plans from covering sicker and more expensive patients.

Adult↗
PubMed2005

Variation in outpatient mental health service utilization under capitation.

BACKGROUND: To improve the financing of Colorado's public mental health system, the state designed, implemented, and evaluated a pilot program that consisted of three reimbursement models for the provision of outpatient services. Community mental health centers (CMHCs), the primary providers of comprehensive mental health services to Medicaid recipients in Colorado, had to search for innovative ways to provide cost-effective services. STUDY AIMS: This study assessed outpatient service delivery to Medicaid-eligible consumers under this program. This paper is among the first to study variations in the delivery of specific types of outpatient mental health services under capitated financing systems. METHODS: This study uses claims data (1994-1997) from Colorado's Medicaid and Mental Health Services Agency. The fee-for-service (FFS) model served as the comparison model. Two capitated models under evaluation are: (i) direct capitation (DC), where the state contracts with a non-profit entity to provide both the services and administers the capitated financing, and (ii) managed behavioral health organization (MBHO), which is a joint venture between a for-profit company who manages the capitated financing and a number of non-profit entities who deliver the services. A sample of severely mentally ill patients who reported at least one inpatient visit was included in the analysis. Types of outpatient services of interest are: day-treatment visits, group therapy, individual therapy, medication monitoring, case management, testing, and all other services. Comparisons were set up to examine differences in service utilization and cost between FFS and each of the two capitated models, using a two-part model across three time periods. RESULTS: Results showed differences in service delivery among reimbursement models over time. Capitated providers had higher initial utilization in most outpatient service categories than their FFS counterparts and as a result of capitation, outpatient services delivered under these providers decreased to converge to the FFS pattern. Findings also suggest substitution between group therapy and individual psychotherapy. Overall, more service integration was observed and less complex service packages were provided post capitation. IMPLICATION FOR HEALTH CARE PROVISION AND POLICIES: Financing models and organizational arrangements have an impact on mental health service delivery. Changes in utilization and costs of specific types of outpatient services reflect the effects of capitation. Understanding the mechanism for these changes may lead to more streamlined service delivery allowing extra funding for expanding the range of cost-effective treatment alternatives. These changes pose implications for improving the financing of public mental health systems, coordination of mental health services with other healthcare and human services, and provision of services through a more efficient financing system.

Adolescent↗
PubMed2000

Capitated payments for mental health patients: a comparison of potential approaches in a public sector population.

BACKGROUND: Both private and public health care systems have embraced capitated reimbursement as a method of controlling costs. AIMS OF THE STUDY: This study explores the financial implications of using reimbursement models based on clinically based patient classification schemes to distribute funds for the treatment of mental health patients in the Department of Veterans Affairs (VA). METHODS: We identified 53700 veterans treated in VA specialty mental health outpatient clinics during the first 2 weeks of fiscal year (FY) 1991 for whom relevant clinical data were available. We calculated total utilization and costs for this sample during the remainder of FY 1991 using VA administrative databases and simulated hypothetical distributions of funds based on seven alternative capitation models. The resulting distributions of funds across service networks and facility types were compared to actual expenditures. RESULTS: Approximately 8% of overall VA budget was redistributed under a simple capitated scheme, and some individual networks and facility types experienced changes in funding of over 30%. Models based on clinical data resulted in only minor differences from average-cost reimbursement. Substantial variation in practice style was observed across Veterans Integrated Service Networks (VISNs), which was significantly associated with funding shifts under capitation. DISCUSSION: A simple capitated payment scheme would result in large changes in funding for some VISNs. Adjustments for case mix did not substantially affect patterns of redistribution. Patterns of redistribution appear to reflect large differences in practice style across VISNs. Although a capitated system will create incentives to reduce such variation, the effect of such shifts on patient well-being is unknown. IMPLICATIONS FOR HEALTH POLICIES: Any capitated system will create incentives to provide a uniform standard of care. In our analyses, the capitation rate was based on the average cost per treated patient in each category; however rates could be set higher or lower as policy makers deem necessary. The standard of care associated with the average cost is not necessarily the "correct" level of care. IMPLICATIONS FOR FURTHER RESEARCH: Our analyses explore the implications of capitated systems for mental health patients in the absence of behavioral change. Further research is needed to determine how providers actually respond to the different incentives created by capitation and what impact these changes have on patient well-being. lems.

Journal Article↗