In weighted analyses, about 9% (95% confidence interval [CI] 6.311.1%) of visits were to practices with majority capitation revenue; 76% (72.978.5%) were to those with majority FFS revenue, and 16% (13.617.5%) to practices with another reimbursement mix. Healthcare systems and providers focus on population-level issues to reduce their expenses. Wanner C, Tonelli M. KDIGO clinical practice guideline for lipid management in CKD: summary of recommendation statements and clinical approach to the patient. We first compared patient and physician/practice characteristics for visits by patients with chronic disease by practice reimbursement type: 1) majority capitation, 2) majority FFS, and 3) other reimbursement mix. As part of this management there is a continued focus on the ability to accurately forecast expenses and to manage the risk associated with high-cost care events. Fee-for-service, while much maligned, remains the dominant payment method for physician visits. This can allow providers to invest in quality improvements to increase their efficiency, and give them the opportunity for financial rewards while sharing in the risk of potential losses. There are several types of capitation: The Association of Reimbursement Composition and Hypertension and Diabetes Quality Indicators, CKD chronic kidney disease, BP blood pressure, aOR adjusted odds ratio, CI confidence interval, HbA1c Hemoglobin A1c, ACEi Angiotensin converting enzyme inhibitor, ARB angiotensin receptor blocker, NSAID nonsteroidal anti-inflammatory drug, Differences in the unadjusted prevalence of quality indicators across reimbursement types were assessed using unadjusted logistic regression, Model 1 adjusted for patient characteristics: age, sex, race, comorbidities, total number of chronic conditions, and patient payor type, Model 2 adjusted for Model 1+physician/practice characteristics: United States Census Region, metropolitan statistical area, solo practice, physician specialty, physician compensation, practice ownership, and physician employment status, aHypertension and nonmissing blood pressure reading. About 9% of visits were to practices with majority capitation revenue. Emerging alternative payment models, which incorporate incentives for high-quality, cost-efficient care, aim to address quality of care gaps and rising expenditures in chronic disease management. Kidney Care Choices (KCC) Model Request for Applications (RFA). Relationship between number of medical conditions and quality of care. An insurer enters a one-year capitation contract with a healthcare provider to secure coverage for its members. In this model, practices achieve higher revenue with more patients and procedures each day. Capitated practices had distinctively different patient and practice characteristics, when compared with FFS practices, but capitated reimbursement was not associated with consistent differences in hypertension, diabetes, and CKD quality indicators. First, practice reimbursement is separate from physician compensation. While the associations found in this study do not necessarily indicate causation, we find important differences in chronic disease quality of care by reimbursement type that complements prior literature. Centers for Disease Control and Prevention . A global capitation model is also commonly known as full capitation. Recommended statin use was also low across capitated, FFS, and other practices (37% vs. 40% vs. 32%). All data are publicly available on the Centers for Disease Control & Prevention website: https://www.cdc.gov/nchs/ahcd/index.htm. ), Katie Porter (D-Calif.), and Lloyd Doggett (D . Therefore, its up to the healthcare provider and insurer to predict the resources and utilization that will be used under this capitation payment model to better manage spend. The hypertension quality indicator was controlled hypertension with systolic blood pressure (BP) <140mmHg and diastolic BP <90mmHg, according to guidelines during the study period [17, 18]. We performed diagnostics using the Stata command midiagplots which showed good fitness of the generated data sets [26]. In Ontario, Canada, a blended capitation model called the Family Health Network was introduced in 2001-2002. James PA, Oparil S, Carter BL, et al. Dr. Ibrahim is supported in part by a K24 Mid-Career Development Award from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (grant K24AR055259). Pay-for-Performance Model Careers, Unable to load your collection due to an error. A leading question in primary care is whether practices can shift towards delivering better preventive and proactive health services. Dr. Tummalapalli receives consulting fees from Bayer AG, unrelated to this work. Capitation reimbursement was assessed by asking The following questions are about your practice revenueRoughly, what percent of your patient care revenue comes from capitation? FFS reimbursement was assessed by the question Roughly, what percent of your patient care revenue comes from usual, customary, and reasonable fee-for-service? Case rates was asked by the question Roughly, what percent of your patient care revenue comes from case rates (e.g. Therefore, qualitative and quantitative methodologies will be crucial to evaluate the effectiveness of care delivery changes under PCF and KCC. In addition to a flat FFS primary care visit fee, PCF provides a capitated per beneficiary per month payment, tiered according to the average level of comorbidities in the practice. Contemporary evidence from a population-based primary care system in Hawaii demonstrated that capitated payments were associated with improvements in a Healthcare Effectiveness Data and Information Set (HEDIS) composite quality measure score, as well as a reduction in number of visits [33]. Other potential drawbacks, or concerns regarding capitation, include that it can: Capitated care strives to control healthcare costs and the use of healthcare resources while creating incentives for preventative healthcare and the provision of quality care. The prevalence of controlled hypertension, controlled diabetes, ACEi/ARB use, and statin use was suboptimal across practice reimbursement types. The primary new payment models include the following: 1. The provider payment is not directly tied to the services performed and the patient is not put in a position where cost becomes a determining factor in the provisions of their care. What is a capitated risk-sharing model of care? So Stanford Health Policys Sanjay Basu, MD, PhD, and colleagues set out to figure out whether, and to what degree, a capitation payment model could help a primary care practice shift from the traditional fee-for-service system to one based on population health management. Full capitation models are typically associated with entities or care that is being provided by an organization. Second, we identified CKD using ICD-9 and ICD-10 diagnosis codes which are insensitive for CKD [42]. It is used by physician associations or insurers to. In this article, we will address providers' most Frequently Asked Questions regarding BPCC with the goal of empowering PCPs to take advantage of capitation in the new CMS DC model. In theory, the more primary care providers turn toward team and non-visit-based care such as visits to a nurse practitioner or seeking telephone or online advice the more overhead costs would go down and the number of patients would go up. External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. The prevalence of controlled hypertension (BP <140/90mmHg) was similar across capitated, FFS, and other reimbursement types in unadjusted analyses (71% vs. 74% vs. 75%, Table3). Stone NJ, Robinson JG, Lichtenstein AH, et al. In the fully adjusted model, the odds of controlled hypertension in capitated practices was not statistically significantly different than for FFS practices, adjusting for both patient and physician/practice characteristics. Under this approach, providers receive a fixed per person (or "capitated") payment that covers all health care services over a defined time period, adjusted for each patient's expected needs, and. Comorbidities were defined by physician-reported diagnoses in the medical chart, except for obesity, which was defined as a body mass index of 30kg/m2 or greater. 11. The common thread is that the models incentivize providers to deliver not only top quality care, but also low-cost care. The prevalence of controlled diabetes (HbA1c <7%) was similar across capitated, FFS, and other practices in unadjusted analyses (57% vs. 59% vs. 63%, Table Table3).3). Our results have policy implications for the upcoming new capitation models, PCF and KCC. How Healthcare Organizations Overcome Barriers to APIs & Interoperability, Improving Health Outcome through Patient Experience Management Software, CareClouds Practice Management Software: Achieving Value for Healthcare Providers, Insights from CEO A. Hadi Chaudhry, Staff Shortages are Becoming Commonplace How RPM Can Help, Defining the Role of Healthcare Data Analytics, CareClouds CEO A. Hadi Chaudhry Shortlisted as Finalist for Entrepreneur of the Year 2023. Prior research on the effect of capitated payments on chronic disease management has shown mixed results. Theres been a long-term controversy about this issue and about what level of capitation is right, as well as financial sustainability during a period of transition, Basu told me. This is a departure from the traditional fee-for-service model which utilizes a set fee for each service. Bethesda, MD 20894, Web Policies Up until now, theyve had to guess, Basu said. Including those in the U.S., Canada, and the European Union. Hear from HRS' Vice President of Revenue Cycle Management on the 2023 updates to telehealth reimbursement rates and how HRS can support your reimbursement efforts. The use of EHR can be beneficial to assist in identifying services, patient populations, and a better understanding of the costs and approved reimbursements. For example, analyses of the National Health and Nutrition Examination Survey showed that only 43.7% of participants with hypertension had controlled blood pressure<140/90mmHg, and only 50.5% of participants with diabetes had controlled Hemoglobin A1c (HbA1c) values <7% [5, 6]. the contents by NLM or the National Institutes of Health. CKD quality indicators were 1) controlled hypertension (systolic BP <130mmHg and diastolic BP <80mmHg) among those with hypertension and CKD [17]; 2) controlled diabetes (Hemoglobin A1c [HbA1c] <7%) among persons with diabetes and CKD [19]; 3) ACEi/ARB use in those with hypertension and CKD [20]; and 4) statin use if age50 and CKD [22]. The effects of capitation on health and functional status of the Medicaid elderly: a randomized trial. There are quite a few challenges that still need to be ironed out. package pricing/episode of care), or other sources. Quality-based payment for medical groups and individual physicians. Fee-for-service (FFS) means that providers bill and are paid for each medical service delivered - physician visit, test or intervention, hospital day.. Capitation means that providers are paid a monthly amount per beneficiary for all services or just some (e.g., primary care).. Let's start with the claim that capitation is better than fee-for-service . Smalls BL, Ritchwood TD, Bishu KG, Egede LE. Capitation rates are developed using local costs and average utilization of services and therefore can vary from one region of the country to another. Whereas an HMO managed care arrangement will typically reimburse based on a capitation arrangement, a PPO's reimbursement model may be a discounted fee-for-service. The .gov means its official. Quality monitoring and management in commercial health plans. Lurie N, Christianson J, Finch M, Moscovice I. Medicare Payment Advisory Commission. Copyright 2023 Health Recovery Solutions. Casalino L, Gillies RR, Shortell SM, et al. First, our findings provide a detailed picture of patient and practice characteristics where capitation is currently implemented. 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. Another systematic review found that FFS care, compared with capitation, was associated with more patient visits and greater continuity; however, the review was limited by study heterogeneity and the low number of eligible studies [13]. PMID: 1538613. Practices already familiar with capitated arranagements may more readily elect into the PCF and KCC models, and have infrastructure in place to support practice changes. Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, Sergison M, Pedersen L. Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians. The NAMCS dataset was fully de-identified and therefore was not subject to Institutional Review Board review, in accordance with 45 CFR 46. Data on patient and visit characteristics were abstracted and recorded by field representatives from electronic or paper medical charts using a standardized data collection form, available on the Centers for Disease Control and Prevention website [16]. An official website of the United States government. We then assessed the variation in quality of chronic disease care by practice reimbursement type. National diabetes statistics report, 2020. Payers, whether they are private insurance companies or government entities, are continually looking for ways to better manage healthcare costs. Capitation is a payment arrangement for health care services in which an entity (e.g., a physician or group of physicians) receives a risk adjusted amount of money for each person attributed to . Second, many population health management strategies incentivized under PCF and KCC, such as panel management or care coordination activities, will not be readily measurable from claims data. In either multivariable model, there were no statistically significant associations between reimbursement type and controlled diabetes or ACEi/ARB use, among visits for diabetes. Lastly, KCC is a Medicare-only model, and lack of participation from other payors may limit care delivery changes [11], particularly in practices with predominantly commercially insured or Medicaid populations. The outcomes we analyzed align with the hypertension and diabetes quality measures incentivized in PCF, and the hypertension control measure in KCC. Why is that ok in healthcare. Muntner P, Hardy ST, Fine LJ, et al. Categorical variables reported as percentages. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the eighth joint National Committee (JNC 8). Practices with predominantly capitated payments are less incentivized toward in-person visits, which may result in fewer opportunities to provide care and thus lower quality care [14, 15]. If the annual capitation fee comes up to $500 per person, then the insurer would pay out $1.5 million to the healthcare provider to cover all treatment expenses for the 3,000 members. Fang M, Wang D, Coresh J, Selvin E. Trends in Diabetes Treatment and Control in U.S. We performed a cross-sectional analysis of visits in the United States National Ambulatory Medical Care Survey (NAMCS) for patients with hypertension, diabetes, or chronic kidney disease (CKD). This leads to a care model that moves towards a monopoly within the area and has been one of the most significant drivers in the merger and acquisition activity for the U.S. in recent years. In capitated payments, healthcare providers are paid based on how many patients they see over a period of time. The resulting financial uncertainty has limited practices participation in non-visit-based care initiatives, the researchers wrote. A total of 27% of visits for patients with hypertension, diabetes, or CKD had missing reimbursement information. First, our assessment of hypertension control was limited to a single office BP reading, as home BP readings were not available in the dataset. Our finding that practices with majority capitation reimbursement served more Black and Hispanic patients likely represents a greater enrollment of these patients in managed Medicaid plans. All analyses incorporated patient visit weights and accounted for the ultimate cluster sampling in NAMCS, as described in NAMCS micro-data file documentation (Appendix 1). On top of this, things like patient satisfaction levels and process compliance receive less focus that they should. The transition from a fee-for-service model to value-based care has spurred healthcare leaders to reevaluate and realign their current payment models to meet organizational goals. An insurer enters a one-year capitation contract with a healthcare provider to secure coverage for its members. Furthermore, in the context of the Coronavirus Disease 2019 (COVID-19) pandemic, capitated payments provide a consistent revenue stream, leaving physician practices less financially vulnerable to decreases in visit volumes [10]. The odds of controlled hypertension in visits to capitated practices did not differ significantly from those to FFS practices in multivariable analyses adjusted for patient characteristics. Liddy C, Singh J, Hogg W, Dahrouge S, Taljaard M. Comparison of primary care models in the prevention of cardiovascular disease-a cross sectional study. 1992;30(3):252-61. There are two types of capitation that may be. In this nationally representative sample of US outpatient visits, we found that about 9% of patients with chronic disease visited practices that receive the majority of their revenue from capitated payments. First, our findings provide a detailed picture of patient and practice characteristics where capitation is currently implemented. This way to pay for health care is working, and expanding rapidly. Patients visiting practices with majority capitated reimbursement were seen fewer times in the past 12months (3.7 vs. 5.2 vs. 5.2, p=0.006), compared with practices with majority FFS revenue or other reimbursement mix. Chronic diseases, including hypertension, diabetes, and chronic kidney disease (CKD), cause a tremendous disease burden and increase the risk of cardiovascular events, kidney failure, and mortality [1, 2]. Capitated practices, compared with FFS and other practices, had lower visit frequency (3.7 vs. 5.2 vs. 5.2, p=0.006), were more likely to be located in the West Census Region (55% vs. 18% vs. 17%, p<0.001), less likely to be solo practice (21% vs. 37% vs. 35%, p=0.005), more likely to be owned by an insurance company, health plan or HMO (24% vs. 13% vs. 13%, p=0.033), and more likely to have private insurance (43% vs. 25% vs. 19%, p=0.004) and managed care payments (69% vs. 23% vs. 26%, p<0.001) as the majority of revenue. Payment systems that leverage capitation can be incredibly complex but overall there are four general types to be aware of. NAMCS is a federally funded survey conducted by the National Center for Health Statistics within the Centers for Disease Control and Prevention. Zhang X, Sweetman A. Blended capitation and incentives: fee codes inside and outside the capitated basket. As a value-based reimbursement strategy, capitation payments include quality measures and standards to deter withholding treatment for financial gain. In many plans, a risk pool is established as a percentage of the capitation payment. However, there is a lack of evidence about their ultimate impact on patient outcomes. Capitated payments were first introduced in the 1980s to control costs [9], and are now making a resurgence as a method to increase flexibility in care delivery and emphasize outcomes rather than volume. In my last blog post on the FFS payment model, it became clear that reimbursement was directly tied to volume. It pays the doctor, known as the primary care physician (PCP), a set amount for each enrolled patient whether a patient seeks care or not.
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