Capitation (healthcare)

Capitation is a payment arrangement for health care service providers. It pays a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care. The amount of remuneration is based on the average expected health care utilization of that patient, with payment for patients generally varying by age and health status. There are differing arrangements in different healthcare systems. Primary capitation is a relationship between a managed care organization and primary care physician, in which the physician is paid directly by the organization for those who have selected the physician as their provider. Secondary capitation is a relationship arranged by a managed care organization between a physician and a secondary or specialist provider, such as an X-ray facility or ancillary facility such as a durable medical equipment supplier whose secondary provider is also paid capitation based on that PCP's enrolled membership. Global capitation is a relationship based on a provider who provides services and is reimbursed per-member per-month for the entire network population. Between 1948 and 1968, NHS financial allocations were essentially based on sequential inflation uplifts. The Resource Allocation Working Party devised a formula which operated from 1977 to 1989, based on population adjusted for age and sex, weighted for morbidity by standardized mortality ratio. Under capitation there is an incentive to consider the cost of treatment. Pure capitation pays a set fee per patient, regardless of their degree of infirmity, giving physicians an incentive to avoid the most costly patients. Providers who work under such plans focus on preventive health care, as there is a greater financial reward in the prevention of illness than in the treatment of the ill. Such plans divert providers from the use of expensive treatment options. The financial risks providers accept in capitation are traditional insurance risks. Provider revenues are fixed, and each enrolled patient makes a claim against the full resources of the provider.

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Concepts associés (6)

Pay for performance (healthcare)

In the healthcare industry, pay for performance (P4P), also known as "value-based purchasing", is a payment model that offers financial incentives to physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures. Clinical outcomes, such as longer survival, are difficult to measure, so pay for performance systems usually evaluate process quality and efficiency, such as measuring blood pressure, lowering blood pressure, or counseling patients to stop smoking.

Fee-for-service

Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. However evidence of the effectiveness of FFS in improving health care quality is mixed, without conclusive proof that these programs either succeed or fail. Similarly, when patients are shielded from paying (cost-sharing) by health insurance coverage, they are incentivized to welcome any medical service that might do some good.