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Capitation financing for the delivery of mental health care under public programs is receiving increasing attention from policymakers. Most initiatives in this respect are in the planning or early implementation stages. This paper describes five years of experience with capitated financing for mental health care in the state of Rhode Island. It discusses the motivation for the programs, their design, and the issues that have arisen with respect to their operation. The Rhode Island experience demonstrates that capitated financing for mental health care is feasible and that Community Mental Health Centers can operate effectively as providers of care under these arrangements. It also suggests that capitated programs can have unanticipated impacts on the operation of community-based mental health service delivery programs.
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Worldwide health systems are faced with additive and complex problems: a cost containment willingness, growing expenses for the health care budgets particularly in relation with the new technologies, questioning about true quality of provided care from results indicators. Health care financing is one of the major determinants of the nature and the comprehensive quality of the system: its aim to promote suitable processes and behaviors, to dissuade inadequate ones, in a context of efficiency (efficacy with minimal cost), as for politic decidors, as for the patients, as for the providers, as for the insurers/funders. A comparative and critical approach of the international scientific literature shows that partial fixed capitation payment is an interesting alternative for the total fee for service. Taking into account many experiences, a proposal for a cumulated financing for the practices is made: a structural part, a fixed capitation payment (the most important), a fee for service one, a target payment one, and a patient personal participation.
To successfully obtain capital financing, a group practice should develop a business plan that is tailored to the needs and objectives of the targeted investors. When evaluating possible funding sources, healthcare financial managers need to consider the group practice's growth objectives, geographic scope, intended use of the funding, and cash-flow potential and/or assets. Potential capital sources include internal funding; investments by healthcare organizations, health plans, private investors, and venture capitalists; borrowing from lenders; and public offerings.
Internet-related health care firms have accelerated through the life cycle of capital finance and organizational destiny, including venture capital funding, public stock offerings, and consolidation, in the wake of heightened competition and earnings disappointments. Venture capital flooded into the e-health sector, rising from $3 million in the first quarter of 1998 to $335 million two years later. Twenty-six e-health firms went public in eighteen months, raising $1.53 billion at initial public offering (IPO) and with post-IPO share price appreciation greater than 100 percent for eighteen firms. The technology-sector crash hit the e-health sector especially hard, driving share prices down by more than 80 percent for twenty-one firms. The industry now faces an extended period of consolidation between e-health and conventional firms.
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Small hospitals must explore as many sources of capital financing as possible to select ones that are most appropriate for their special capital needs.
This analysis of "neoliberalism" and its economic and social consequences is presented in six sections. Section I begins by describing the impact of neoliberal public policies on economic growth and inflation, on business profits and business investments, on productivity, on business credit, on unemployment and social inequalities, on social expenditures, and on poverty and family debt. The author shows that, except in the area of business profits and control of inflation, neoliberal policies have not proved superior to those they replaced. Section II deals with unemployment and social polarization in the developed capitalist countries. The author criticizes some of the theories put forward to explain these social problems, such as the introduction of new technologies and globalization of the economy, and suggests that a primary reason for these problems is the implementation of neoliberal policies. Section III challenges the widely held neoliberal perception that the U.S. economy is highly efficient and the E.U. economies are "sclerotic" due to their "excessive" welfare states and "rigid" labor markets. The author shows that the U.S. economy is not so dynamic, nor the E.U. economies so sclerotic. Some developed countries with greater social protection and more regulated labor markets are shown to be more successful than the United States in producing jobs and lowering unemployment. The reasons for the growing polarization in developed capitalist countries, rooted in political rather than economic causes, are discussed in section IV--especially the enormous power of the financial markets and their influence on international agencies and national governments, and the weakness of the labor movements, both nationally and internationally. Section V questions the major theses of globalization. The author shows that rather than globalization of commerce and investments, we are witnessing a regionalization of economic relations stimulated by political considerations. He also analyzes the globalization of capital finance, criticizing the thesis that capital markets are determining public policies. The economic determinism that underlies the globalization position is questioned, uncovering the importance of political explanations for understanding major social problems such as unemployment. Finally, section VI shows that neoliberal public policies on the deregulation of labor markets are creating enormous instability in the labor force, worsening the living conditions of the majority of the populations.
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Using the collective financial strength of a group of not-for-profit health care institutions to finance capital needs has become an increasingly popular concept. This article discusses the significant advantages and disadvantages of the concept, provides an overview of the development of multi-institutional financing arrangements, and describes the generic forms of credit poolings. It also outlines three broad areas of inquiry to be explored by potential participants before entering a pooled credit arrangement: the relationships among participants, the availability of assets to support debt, and corporate planning and strategy.
The provision and utilization of health care services in rural areas are tied directly to the structure of financing. The model of rural health care shaped by federal policies over three decades was significantly altered by changes during the 1980s. With reactions of third-party payers to health care costs rising faster than inflation, the difficulty of accommodating access to care and cost efficiency in provision became evident. This review begins with the literature on patient services and capital financing of rural hospitals, then continues with the financing of clinics, community centers, and other supply forms. Research during the 1980s provides insight into the effects of various financing policies on the supply of services. The demand for health care in rural areas is characterized by less generous third-party coverage, leaving residents paying a larger share of their incomes for care than do urban residents. As a consequence, access to care is especially difficult for low-income and elderly people, heavily dependent upon government financing. Third-party payers have severely reduced cost shifting as a mechanism for taking care of the health care needs of a sizable share of the population, thereby placing providers in an uncomfortable position. Several potential and more formalized financing options for replacing cost shifting are discussed. Several important changes will take place with rural-focused legislation enacted in the late 1980s. These are used to present a rural financing research agenda for the 1990s.
Financing the Future is a yearlong project to help hospitals take advantage of growth opportunities. Led by HFMA in partnership with GE Healthcare Financial Services, the project provides information, insights, strategies, and tools designed to help hospitals finance their future. The findings of Financing the Future are based on research conducted by HFMA and PricewaterhouseCoopers. To access the first four Financing the Future reports, visit www.financingthefuture.org.
A financially struggling hospital in New York's Harlem section is turning financial distress into an opportunity for economic recovery with the help of private grants, state rate relief and an innovative capital financing program. North General Hospital will move into a new, $65 million facility in December--five months ahead of schedule and $9 million under budget.
CONTEXT: Medical groups are growing and merging to improve efficiency and bargaining leverage in the competitive managed care environment. An increasing number are affiliating with physician practice management (PPM) firms that offer capital financing, expertise in utilization management, and global capitation contracts with health insurance entities. These physician organizations provide an alternative to affiliation with a hospital system and to individual physician contracting with health plans. OBJECTIVE: To describe the growth, structure, and strategy of PPM organizations that coordinate medical groups in multiple markets and contract with health maintenance organizations (HMOs). DESIGN: Case studies, including interviews with administrative and clinical leaders, review of company documents, and analysis of documents from investment bankers, the Securities and Exchange Commission, and industry observers. SETTING: Medical groups and independent practice associations (IPAs) in California and New Jersey affiliated with MedPartners, FPA Medical Management, and UniMed. OUTCOME MEASURES: Growth in number of primary care and specialty care physicians employed by and contracting with affiliated medical groups; growth in patient enrollment from commercial, Medicare, and Medicaid HMOs; growth in capitation and noncapitation revenues; structure and governance of affiliated management service organizations and professional corporations; and contracting strategies with HMOs. RESULTS: Between 1994 and 1996, medical groups and IPAs affiliated with 3 PPMs grew from 3787 to 25763 physicians; 65% of employed physicians provide primary care, while the majority of contracting physicians provide specialty care. Patient enrollment in HMOs grew from 285503 to 3028881. Annual capitation revenues grew from $190 million to $2.1 billion. Medical groups affiliated with PPMs are capitated for most professional, hospital, and ancillary clinical services and are increasingly delegated responsibility by HMOs for utilization management and quality assurance. COMMENT: Physician practice management organizations and their affiliated medical groups face the challenge of continuing rapid growth, sustaining stock values, and improving practice efficiencies while maintaining the loyalty of physicians and patients.
One strategy employed by healthcare organizations to increase their market presence is the construction of new facilities. Accessing capital to fund such construction, however, has become more of a challenge. One relatively untapped source of building capital is real-estate-based financing. Nonrecourse mortgages, turnkey net leases, and synthetic leases can provide several advantages to healthcare organizations seeking capital, assuming issues related to building ownership, debt and balance sheet effects, and tax-exempt status have been thoroughly explored first.