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PubMedDate not supplied

[Physician payment mechanisms. An instrument of health policy].

Payment mechanisms for physicians have always been subject of debate. The profession tends to prefer fee-for-services, while health care institutions prefer to pay doctors by salary or capitation. The definition of the payment mechanism is not an administrative decision, it is frequently the output of an intense political negotiation. Recently an increase in salaried physicians has been observed, even in countries where the profession is powerful. In nations like Mexico, where the State is the dominant actor, salary or capitation can be used as an instrument to encourage quality of care and better geographic distribution. In this paper, several country cases are reviewed.

Capitation Fee↗
PubMedDate not supplied

A simplified analysis to determine the impact of surgical procedure time on pediatric anesthesia productivity.

With fee-for-service (FFS) reimbursement, anesthesiologists benefit financially from cases that take longer than expected. Capitation, or fixed anesthesia reimbursement (FAR), might result in financial losses for such inefficient cases. In this investigation, we used the Centers for Medicare and Medicaid Services' average anesthesia times as benchmarks for efficiency and examined case time characteristics for three surgical services: otorhinolaryngology, general surgery, and orthopedics. Our model demonstrated that some inefficient cases would be better billed FAR rather than FFS.

Anesthesia Department, Hospital↗
PubMed1994

Transforming a hospital facility company into an integrated medical care organization.

This article outlines the steps a major integrated health delivery system in Chicago has undertaken to transition from a primarily hospital-based fee-for-service organization to an integrated medical care organization operating under full-risk capitation. The focus is on vision setting, building a foundation for change, structural building blocks, network building steps, and lessons learned to date.

Capitation Fee↗
PubMed2001

Correlates of family burden under medicaid managed mental health care.

This study examined predictors of family burden (assistance in daily living, supervision, and subjective concern) for family members of Medicaid recipients with severe mental illness in two regions of Virginia. In the Richmond area, mental health services were provided on a no-risk fee-for-service basis, while in Tidewater these services were provided through a risk-based capitated contract with a managed care organization. No differences in family burden were attributable to the risk-based payment system. Predictors of increased family burden were (a) more reported client symptoms and disruptive behaviors, (b) status as a parent, and (c) living with the client.

Adult↗
PubMedDate not supplied

Financial applications using the cost per RBRVS methodology.

In this article, the resource-based relative value scale (RBRVS) is used as a basis to allocate physician salaries, malpractice insurance and practice expense to determine the cost of providing physician services. With this information, practice administrators can readily apply this cost accounting methodology to fee schedule analysis and managed care contract evaluation. Other applications of this method include determining floor capitation rates, allocating the capitation payment among the group and third party payer profitability analysis.

Capitation Fee↗
PubMedDate not supplied

Funding mechanisms for depression care management: opportunities and challenges.

OBJECTIVE: Inconsistent third-party reimbursement for depression care management is a significant economic barrier to the utilization and sustainability of the chronic illness care model in primary care practice settings. We review common mechanisms used to procure payment for depression care management services, discuss obstacles encountered and suggest future directions. METHOD: We describe several extant models for funding depression care management services in use at the demonstration sites of the Robert Wood Johnson Foundation funded "Depression in Primary Care" project and similar programs. We derived this information from ongoing discussions with the sites' project directors and through an extensive electronic literature search on "care management, funding mechanisms and depression." RESULTS: Funding mechanisms include (a) practice-based care management on a fee-for-service basis, (b) practice-based care management under contract to health plans, (c) global capitation, (d) flexible infrastructure support for chronic care management, (e) health-plan-based care management, (f) third-party-based care management under contract to health plans and (g) hybrid models. CONCLUSIONS: While substantial obstacles remain in the way of fully implementing these depression care management funding mechanisms (e.g., variations in care managers' credentials and work locations and third-party payer concerns about overutilization and transaction costs), several recent policy advances provide some optimism for the potential adoption of financial mechanisms to support and disseminate these evidence-based practices.

Capitation Fee↗
PubMed1997

The role of financial incentives in shaping clinical practice patterns and practice efficiency.

The US healthcare system is evolving from one in which most providers have been paid on some variation of a fee-for-service basis to one in which many or most providers will be paid on a capitated basis. Will this change in financial incentives make a difference in how coronary artery disease and heart failure are treated and managed? Although the evidence is equivocal and limited, two recent studies suggest that capitation and other global payment incentives may dramatically alter clinical practice patterns in treating cardiovascular disease and substantially reduce cardiac-care costs. Clinical cost-effectiveness research efforts must be intensified. Thought leaders in the field of cardiology must move forcefully in developing, disseminating, and encouraging cardiac-care providers to accept and implement evidence-based clinical practice guidelines. The alternative may be ill-advised tradeoffs decided in a decentralized, competitive marketplace, with algorithms being developed de facto by individual practitioners or groups in response to capitated reimbursement constraints. The resulting practice could reduce healthcare use and spending without being cost-effective. Unexpected and undesirable health outcomes could ensue.

Capitation Fee↗
PubMed1997

Family physician perception of economic incentives for the provision of office procedures.

BACKGROUND AND OBJECTIVES: The influence of capitation versus fee-for-service reimbursement for services provided by primary care physicians is an important topic as capitation becomes increasingly prevalent. This study ascertained whether family physicians perceive an economic incentive to perform flexible sigmoidoscopy, colposcopy, and vasectomy under capitated versus fee-for-service payment structures. METHODS: In May 1995, questionnaires were mailed to 592 randomly selected physician "diplomates" of the American Board of Family Practice in California, Florida, Texas, Virginia, and Minnesota. Nonrespondents received an additional mailing in July 1995. RESULTS: The return rate was 62%. Of 336 responses: 1) 177 (52%) provide flexible sigmoidoscopy; 68 (20%) think capitation and 173 (51%) think fee for service provide sufficient reimbursement to make this procedure profitable. 2) 69 (20%) provide colposcopy; 50 (16%) think capitation and 99 (30%) think fee for service provide sufficient reimbursement to make this procedure profitable. 3) 91 (27%) provide flexible sigmoidoscopy; 36 (11%) think capitation and 84 (25%) think fee for service provide sufficient reimbursement to make this procedure profitable. CONCLUSIONS: A significant number of family physicians provide these three procedures in their offices. Most physicians view fee-for-service payment as providing an economic incentive to provide these procedures. Capitation was less frequently perceived as providing sufficient reimbursement to make the provision of these procedures profitable.

Capitation Fee↗
PubMedDate not supplied

Should fee-for-service group practices develop a prepaid component?

Many fee-for-service group practices are considering the advantages of developing activities using health maintenance organization concepts. In some cases, the decision to become involved with an HMO as an addition to current fee-for-service activities may become essential because of competition with other medical groups who are also considering an HMO alternative. There are a number of different ways or models for fee-for-service groups to become involved with an HMO.

Capitation Fee↗
PubMed2001

Theory and practice in the design of physician payment incentives.

Combining the economic literature on principal-agent relationships with examples of marketplace innovations allows analysis of the evolution of methods for paying physicians. Agency theory and the economic principles of performance-based compensation are applied in the context of imperfect information, risk aversion, multiple interrelated tasks, and team production efficiencies. Fee-for-service and capitation are flawed methods of motivating physicians to achieve specific goals. Payment innovations that blend elements of fee-for-service, capitation, and case rates can preserve the advantages and attenuate the disadvantages of each. These innovations include capitation with fee-for-service carve-outs, department budgets with individual fee-for-service or "contact" capitation, and case rates for defined episodes of illness. The context within which payment incentives are embedded, includes such non-price mechanisms as screening and monitoring and such organizational relationships as employment and ownership. The analysis has implications for health services research and public policy with respect to physician payment incentives.

Capitation Fee↗
PubMed1987

HMO physician reimbursement. The case for fee-for-service IPAs.

Individual Practice Association (IPA)-model HMOs use two methods of physician reimbursement: capitation and fee-for-service (FFS). Advantages and disadvantages of these two systems are explored. The author describes the organization of his group's IPA and gives the reasons for its adoption of FFS payment. An inherent problem of this system--minimal incentive for participating physicians to limit provision of medical services--now requires his group to identify the small percentage of its members who engage in overly expensive practice styles. Alternatives are discussed for dealing with those physicians who incur costs that exceed the norm for their specialties. Finally, the author gives basic recommendations for physicians who are interested in organizing their own FFS-model IPA.

Capitation Fee↗
PubMed2004

Milwaukee-based employer group may bring back risk contracting.

Milwaukee's health care prices are higher than the national average because hospitals and physician groups consolidated to a point that they control the market and demanded fee-for-service payments, according to a new study by the U.S. General Accounting Office.

Capitation Fee↗
PubMedDate not supplied

Subcapitation arrangements for specialists.

As group practices begin to change from fee-for-service to managed care/capitated contracts, one of the major issues they will face is how to divide up the revenue from capitated contracts. Single specialty primary care groups traditionally have utilized a method that takes into account the panel size of covered lives for revenue distribution. Multispecialty group practices have different and more complicated issues that need to be dealt with. It is important that medical groups understand the implications of capitated contracting. Not only will compensation formulas need to be revised, but utilization management, management information and referrals systems will all need to be reviewed in light of changing payment methodologies. This article will review some of the decisions that need to be carefully considered before a multi-specialty medical group should sign a capitated contract.

Capitation Fee↗
PubMed1997

Defining the practice population in fee-for-service practice.

OBJECTIVE: To develop and validate a technique for defining a practice population of discrete individuals based on multiyear family practice fee-for-service billings data. DATA SOURCES/STUDY SETTING: Nineteen family physicians in Ontario, Canada who converted from fee-for-service to capitation payment. Data sources were fee-for-service billings data for the three-year period prior to the conversion from fee-for-service to capitation payment and the rosters of enrolled patients for the first and third years after the change to capitation payment. STUDY DESIGN: The billings-based definition of the physician's practice population was compared against the Year 1 roster. We also compared the billings-based practice population and the Year 1 roster to the physician's Year 3 roster to identify patients who might have been missed during the roster development process. Our principal analyses were an assessment of the sensitivity of the billings-based definition of the practice population (EPP), the positive predictive value of EPP, and the agreement between EPP and the rostered patient population (RPP). We also examined the ratio between EPP and RPP to determine EPP's accuracy in estimating the practice denominator. DATA COLLECTION/EXTRACTION METHODS: The practice population for each physician at the time of conversion from fee-for-service to capitation payment was defined as (a) all persons for whom the physician billed the provincial health insurance plan for at least one visit during the year immediately prior to joining the capitation-funded program; and (b) all additional patients for whom the physician billed the plan for at least one service in each of the two preceding years. Data extraction was carried out within the Ministry of Health in order to preserve the anonymity of patients and physicians. Data were provided to the investigators stripped of patient and physician identifiers. PRINCIPAL FINDINGS: The mean sensitivity and positive predictive value of EPP were 95.3 percent and 87.4 percent, respectively. The level of agreement between EPP and RPP averaged 84.4 percent. The mean ratio of EPP to RPP was 1.21 (95 percent C.I. 1.030-1.213). Correction for roster false-negatives increased the sensitivity, positive predictive value, and agreement between EPP and the practice population, and reduced the mean ratio of EPP to the practice population to 1.068 (95 percent C.I. 1.010-1.127). CONCLUSIONS: The practice population can usefully be defined in fee-for-service family practice on the basis of multiyear fee-for-service billings data. Further research examining alternative encounter-based practice population definitions would be valuable.

Adolescent↗
PubMed1990

Prepaid versus traditional Medicaid plans: effects on preventive health care.

Prepaid, case managed systems have been proposed as a method of controlling costs in Medicaid populations. We investigated the utilization of preventive services in two prepaid Medicaid Competition Demonstration programs in Santa Barbara County, Calif., and Jackson County, Mo. (containing the city of Kansas City). Care in the demonstration sites was compared with care given in similar counties functioning under a traditional fee-for-service Medicaid system--Ventura County, Calif., and St Louis, Mo. We tested the hypothesis that preventive care would be less in the capitated demonstrations. 2735 Children's and 3389 adult's charts were abstracted for care received during the calendar year 1985, after the prepaid demonstration had been in place for more than 1 year. No significant differences were found between the demonstration and comparison counties in the proportion of children with complete DPT or OPV immunizations at 1 year of age, with 56% complete in both California counties and 69 and 65% complete in Jackson County and St Louis, respectively. Regression analysis demonstrated a slight, but statistically significant trend towards more immunizations in the demonstration counties. Pap smear use in women of 15-44 years of age was little different in the California counties, but significantly greater in the Jackson County demonstration in Missouri (64 vs 45%). Physician breast examinations were somewhat more likely to occur in the prepaid, case managed demonstration counties. Capitated, case managed systems for the AFDC Medicaid population appear to result in no diminution of preventive services. Substantial problems exist in this, as in other poor populations, in childhood immunizations.

Adolescent↗