HCPro.com: Capitation Rates and Data

Each issue of this monthly newsletter is jam-packed with PMPM rates, benchmark capitation and comparative information-from determining appropriate physician panel sizes and stop-loss attachment points to evaluating your PMPM rates and withholds.

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April 2008 (Volume 13, Issue 4)	view entire issue

Blue's model may breathe new life into global cap
In a move that's surely being watched by payers in other states, Blue Cross Blue Shield of Massachusetts (BCBSMA) in Boston plans to stop paying certain doctors and hospitals in its statewide network for each patient visit or treatment and return to capitation. BCBSMA's alternative quality contract (AQC) represents a new spin on traditional capitation, marrying a global PMPM rate for all physician and hospital services with annual inflation increases and performance incentives linked to nationally accepted measures of quality, effectiveness, and patient satisfaction. Rather than focusing exclusively on cost control-a payer-imposed goal that drove scores of ill-prepared physician practices out of business during the 1990s-the model is designed to help align payment reform, performance measurement, provider and member incentives, and increased cost and quality transparency.

Go back to basics when negotiating new cap contracts
Considering the renewed interest in capitation that's likely to be prompted by Blue Cross Blue Shield of Massachusetts' (BCBSMA) alternative quality contract (AQC) (see "Blue's model may breathe new life into global cap" on p. 1), provider organizations should revisit the assumptions they make when they negotiate cap contracts and accept PMPM rates, says Robin Fisk, Esq., principal at the Fisk Law Office in Ashland, NH. A decade ago, Fisk represented payers during cap contract negotiations. Frequently, providers didn't do the math before they accepted capitation deals, she says, so they learned too late that their PMPMs resulted in payments that sometimes translated into just 20%-30% of charges.

Hospitalist care reduces LOS in various inpatient settings
Two recent studies seem to confirm that hospitalists reduce patient LOS-a finding that many capitated groups using these clinicians have already discovered. In a paper published in Archives of Internal Medicine,1 researchers at New York City's Montefiore Medical Center examined data collected between July 1, 2002, and June 30, 2004, and compared the records of 2,913 patients treated by hospitalists at Montefiore's Weiler Hospital, a 381-bed teaching facility, to those of 6,124 patients treated by nonhospitalist teams. Patients were similar in age, sex, race, prior admission, and mix of acute diagnoses.

Other recently-published articles from Capitation Rates and Data:

Do the math before taking capitation risk for vaccines

Guided Care plan reduces costs for chronically ill seniors

Coordinated care benefits children with special needs

Social media provide cost-effective route to patient care

Coordinated care program cuts costs for members with chronic illness

Dartmouth Atlas: Overtreatment still common

PROMETHEUS payment model aims to top capitation

Managed Medicare may help seniors avoid preventable hospitalizations through better coordination of care

Weigh the balance between healthcare quality and costs

Benchmark your cap rates against this profitable IPA

Examine underlying community trends as one factor in the cost of care

Use predictive modeling to improve case management

Evaluate 2009 payment rates for MA plans

Mine your data to target high-risk members

Drug cost data suggest patient copays, compliance linked

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