ESSENTIALS OF CAPITATION PAYMENTS IN HEALTHCARE
The United States of America currently ranks highest among developed nations in per-capita healthcare spending. This concerning information came out of a 2019 paper in Health Affairs by a team from the Johns Hopkins Bloomberg School of Public Health Research.According to the study’s lead author, Gerard F. Anderson, PhD, the U.S. “remains the most expensive because of the prices the U.S pays for health services.”
It’s not surprising that in the setting of skyrocketing prices, both U.S. government and private payers are implementing and adopting alternatives to the fee-for-service (FFS) care model. FFS has faced increasing criticism as a costly and wasteful payment model for healthcare that encourages providers to deliver more services so that they can be paid more.
In the FFS model, providers are paid on a per-piece basis – and each individual procedure, visit, test (such as laboratory and imaging) as well as other treatments and services, are all billed to a payer. The concern is that in this model there is a tendency for providers to deliver more services in order to maximize their income – and some of these services might be unnecessary or inappropriate, thus resulting in inflated costs without improving the quality of care or the patient’s health outcome.
One payment model that is considered a favorable alternative to FFS is Capitation or Capitated Insurance.
What is Capitation?
Capitation is a healthcare payment model in which physicians and other healthcare providers such as clinics and hospitals receive an agreed-upon fixed amount per patient over a defined timeframe. The payment is the same for each patient during that period, regardless whether they seek medical services and treatment or not.
In the capitation model, providers are paid for each enrolled patient, or per member per month (PMPM). This is called the capitated rate or capitation premium, which is sometimes referred to as the “cap”.
The components of capitation are:
- The advance payment of a flat fee
- For the delivery of a specific set of services in a given period
- For an agreed-upon number of enrolled members
- Whether or not patients seek care during that period
The amount of capitation payment per person is based on various factors, including average expected healthcare utilization of the members as well as the local costs of medical services.
Some payers also establish something called a “risk pool”. This is a percentage of the overall payment withheld until the end of the year. If healthcare providers performed well in the previous year (that is, they do not use up more than the total capitation amount), payers may release the extra amount to physicians at the end of the year. However, if the services provided ends up costing much more than the total of the agreed-upon amount, the payer may withhold the money in the “risk pool” to make up for the loss.)
For example, a health maintenance organization (HMO) may enter into an agreement with a primary care physician (PCP) or medical group for a year, with a negotiated rate of $50 per patient per month. The HMO may ask to withhold 10% of this amount, or $5 per patient per month, and place it in the “risk pool”. In this scenario, the actual payment that the PCP/medical group receives per member per month is $45.
If the HMO in this example has 500 patients, the PCP/medical group will be paid a guaranteed amount of $22,500 per month (or $270,000 per year) with $30,000 in the “risk pool”.
Capitation agreements or contracts are entered into by the healthcare provider and the payer to establish rates and other details. These agreements may also include a list of services that will be provided by the health plan to the patient, such as preventive services, medications and immunizations, lab tests, routine screenings, and other diagnostic and treatment services.
Types of Capitation Agreements
Generally speaking, there are three types of capitation agreements, depending on the relationship of the paying entity and the receiver of the payment:
- Primary – this type of agreement happens when a managed care organization such as an HMO pays a physician (or physician group) directly for care to be provided to the HMO’s members.
- Secondary – this type is created when an HMO arranges a contract involving primary care physicians and a “secondary” healthcare service provider such as a diagnostic or imaging service provider or a specialist, among others.
- Global – this type can be taken to mean a couple of different arrangements.
It can mean “a fixed payment made to health care professionals or organizations for the care their patients may require during a contract period regardless of how many services are provided to patients and that can be adjusted to account for severity of illness.” This is how it is defined by the American Academy of Family Physicians (AAFP). This definition is similar to the basic definition of capitation.
On the other hand, an article in PBS defines global capitation as an arrangement “in which whole networks of hospitals and physicians band together to receive single fixed monthly payments for enrolled health plan members; under global capitation, the providers sign a single contract with a health plan to cover the care of groups of members, and then must determine a method of dividing up the capitated check among themselves.”
Services Covered by Capitation
According to the American College of Physicians, the following are covered by most capitation plans:
- Preventive, diagnostic, and treatment services
- Injections, immunizations, and medications administered in the office
- Outpatient laboratory tests done either in the office or at a designated laboratory
- Health education and counseling services performed in the office
- Routine vision and hearing screening
Advantages of Capitation
Capitation offers several benefits to payers, physicians and patients.
- In the capitation system, healthcare providers are usually paid in advance; they do not have to wait for the billing cycle to be completed before they paid. This means that from the outset they have an idea of the cash flow coming in and can plan accordingly.
- Healthcare providers won’t need to spend as much money and time on billing and accounting staff.
- Payers benefit because the costs of medical services can be kept under control.
- Patients may see an improvement in their overall health in situations where providers offer preventative care and wellness programs as part of their services. Prevention and wellness initiatives are seen as a means for providers to control costs because they can potentially decrease the volume of services needed by patients.
- Patients can avoid the inconvenience and cost of medically unnecessary procedures since providers are encouraged to be conscientious about providing appropriate services and treatment rather than increasing the number of these services and treatments as a means to increase fees.
Disadvantages of Capitation
While capitation is designed to decrease costs and improve outcomes, it does come with its own disadvantages.
- Whereas FFS laid the burden of financial risk on the payer, capitation presents an increased financial risk for healthcare providers. This is because the payment to the provider is a fixed amount, regardless of the time, effort, and other resources required to provide care to the patient. This risk is increased for providers who enroll a larger percentage of patients with complex medical issues. This may potentially lead providers to avoid enrolling patients whom they think will need more services, such as those with complicated issues or multiple comorbidities.
- Another situation than can arise is one in which providers may not order or provide necessary treatment or services in an effort to optimize their income, resulting in “underutilization” of needed health services, which is a form of healthcare rationing.
- In certain locations where capitation payments are low, providers may not have the funding to offer preventive care or wellness programs which help improve patient outcomes.
- The capitation model might also encourage providers to enroll a large amount of patients to maximize their expected payment. This situation can backfire for both patients and providers if it results in longer wait times and decreased amount of time for patient care. This could result in increased risk of patient safety issues as well decreased patient satisfaction, and can also potentially contribute to provider burnout when providers are trying to see more patients than they can reasonably provide care for.
Some of the above drawbacks may potentially lead into a vicious cycle that eventually results in providers losing money when participating in a capitation payment model. This could push them to go back to the FFS model with its attendant challenges and shortcomings.
Capitation: Then and Now
Capitation in the U.S. initially gained widespread adoption in the 1990s. At that time, however, the adoption was driven more by commercial, private payers. This time, Medicare and Medicaid are more involved and spearheading change away from FFS to more value- and performance-driven models of payment and reimbursement.
Under the capitated model, the Centers for Medicare & Medicaid Services (CMS), a state, and a health plan enter into a three-way contract to provide comprehensive, coordinated care.
On April 22, 2019, CMS announced the Primary Cares Initiative (PCI). According to CMS, the “Primary Care First Model Options is a set of voluntary five-year payment options that reward value and quality by offering an innovative payment structure to support delivery of advanced primary care.”
The general Primary Care First payment model option is designed for primary care practices with advanced primary care capabilities that are prepared to accept increased financial risk in exchange for flexibility and potential rewards based on practice performance. Eligible applicants are primary care practices that:
- Are located in one of the selected Primary Care First regions.
- Include primary care practitioners (MD, DO, CNS, NP, and PA), certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine.
- Provide primary care health services to a minimum of 125 attributed Medicare beneficiaries at a particular location
- Have primary care services account for at least 70% of the practices’ collective billing based on revenue. In the case of a multi-specialty practice, 70% of the practice’s eligible primary care practitioners’ combined revenue must come from primary care services.
- Have experience with value-based payment arrangements or payments based on cost, quality, and/or utilization performance such as shared savings, performance-based incentive payments, and episode-based payments, and/or alternative to fee-for-service payments such as full or partial capitation.
- Use 2015 Edition Certified Electronic Health Record Technology (CEHRT), support data exchange with other providers and health systems via Application Programming Interface (API), and connect to their regional health information exchange (HIE).
- Attest via questions in the Practice Application to a limited set of advanced primary care delivery capabilities, such as 24/7 access to a practitioner or nurse call line and empanelment of patients to a practitioner or care team.
- Can meet the requirements of the Primary Care First Participation Agreement
Previously, providers faced a huge challenge related to monitoring how often patients use services both individually and as an aggregate. The use of paper charts in the past made it difficult for providers to track both the utilization of services as well as patient outcomes.
One of the key developments in the U.S. healthcare industry is the passing of the HITECH Act of 2009. This landmark legislation resulted in widespread use of electronic health records (EHRs), which gives healthcare providers the ability to track patient and payment data more accurately and more easily than before. The use of an EHR enables providers to better manage and control the financial risk that they take on within the capitated payment model.
The triple aim of healthcare framework designed by IHI and embraced by CMS aspires for better care for individuals, better health for populations, and lower cost of healthcare.
The capitation model of payment intends to support these goals. While capitation may never be the only payment structure in healthcare, it holds the promise of supporting the above aims by encouraging greater control of healthcare costs and reducing waste in terms of unnecessary medical treatments and services. Proponents claim it effectively increases cost savings, and has the potential to improve patients’ experience as well as their overall health outcomes.
RevenueXL Inc. provides best value comprehensive solutions to medical practices, including solutions for Practice Management or Medical Billing software – such as PrognoCIS EHR Software which can be enabled to automatically differentiate between capitation claims and fee-for-service claims. PrognoCIS also has reports that can help users see anticipated capitation payment from private insurance compared with expected Medicare payment, which helps them assess their expected cash flow in a more timely and accurate manner.
CMS Value-Based Primary Care: https://www.cms.gov/newsroom/press-releases/hhs-news-hhs-deliver-value-based-transformation-primary-care
Primary Care First Model Options: https://innovation.cms.gov/initiatives/primary-care-first-model-options/
Health Affairs Article on Why The U.S. Spends So Much on Healthcare: https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05144