The impact of capitated payment on preventive care utilization in community health clinics

Association Between Capitated Payments and Preventive Care Among U.S. Adults

Introduction

There is increasing interest in using capitation rather than fee for service to promote primary care and population health. The goal of this study was to examine the association between practice reimbursement mix (majority fee for service versus majority capitation versus other) and receipt of common preventive screening examinations and health counseling from 2012 to 2018.

Methods

Using the National Ambulatory Medical Care Survey, a retrospective cross-sectional study of 24,864 visits with primary care clinicians among patients aged 18-75 years without a cancer diagnosis was conducted. The main dependent measures were age- and sex-appropriate receipt of breast cancer screening, osteoporosis screening, cervical cancer screening, chlamydia testing, colon cancer screening, diabetes screening, and hyperlipidemia screening as well as 3 health counseling items. Multivariable logistic regression was performed to assess the association between reimbursement mix and receipt of preventive care, adjusted for patient, visit, and practice characteristics.

Results

Majority capitation reimbursement was associated with a greater likelihood of receiving breast cancer screening (AOR=2.11, 95% CI=1.16, 3.84, p=0.014) and osteoporosis screening (AOR=4.34, 95% CI=1.74, 10.8, p=0.0017) than majority fee-for-service or other reimbursement mixes. Reimbursement mix was not associated with the likelihood of receiving 9 other preventive care or health counseling services.

Conclusions

Larger amounts of capitation reimbursement may improve some but not all aspects of preventive care compared with fee for service.

Managing Urban Stroke Health Expenditures in China: Role of Payment Method and Hospital Level

BACKGROUND

Stroke is one of the leading public health issues in China and imposes a heavy financial burden on patients and the healthcare system. This study assess which payment method provides the lowest hospital costs for China's healthcare system and the lowest out-of-pocket (OOP) expense for insured patients.

METHODS

This is a 4-year cross-sectional study. From the China Health Insurance Research Association (CHIRA) database, a 5% random sample of urban health insurance claims was obtained. Descriptive analysis was conducted and a generalized linear model (GLM) with a gamma distribution and a log link was estimated.

RESULTS

For outpatients, capitation payment had the lowest hospital cost (RMB180.9/US$28.8) and lowest OOP expenses (RMB75.6/US$12.0) per patient visit in primary hospitals compared with fee-for-service (FFS) payments. The global budget (GB) displayed the lowest total hospital costs (RMB344.7/US$54.8) in secondary hospitals, and was 27.4% (95% CI=-0.32, -0.29) lower than FFS. FFS had the lowest OOP expenses (RMB123.4/US$19.6 vs. RMB151.8/US$24.1) in secondary and tertiary hospitals. For inpatients, FFS had the lowest total hospital costs (RMB5918.7/US$941.1) per visit and capitation payments had the lowest OOP expenses (RMB876.5/US$139.4, 40.1% lower than FFS, 95% CI=-0.58, -0.15) in primary hospitals. Capitation payment had both the lowest hospital costs (RMB7342.9/US$1167.5 vs. RMB17 711.7/US$2816.2) and the lowest OOP expenses (RMB1664.2/US$264.6 vs. RMB3276.3/US$520.9) for both secondary and tertiary hospitals.

CONCLUSION

For outpatients in primary hospitals and inpatients in secondary and tertiary hospitals, the capitation payment was the most money-saving payment method delivering both the lowest OOP expenses for patients and the lowest hospital total costs for hospitals. We recommend that health policymakers prioritize the implementation of the payment method with the lowest OOP expenses when the payment method does not deliver both the lowest hospital costs for the health system and lowest OOP expenses for patients.

Health Centers and Value-Based Payment: A Framework for Health Center Payment Reform and Early Experiences in Medicaid Value-Based Payment in Seven States

Policy Points As essential access points to primary care for almost 29 million US patients, of whom 47% are Medicaid enrollees, health centers are positioned to implement the population health management necessary in value-based payment (VBP) contracts. Primary care payment reform requires multiple payment methodologies used together to provide flexibility to care providers, encourage investments in infrastructure and new services, and offer incentives for achieving better health outcomes. State policy and significant financial incentives from Medicaid agencies and Medicaid managed care plans will likely be required to increase health center participation in VBP, which is consistent with broader state efforts to expand investment in primary care.

CONTEXT

Efforts are ongoing to advance value-based payment (VBP), and health centers serve as essential access points to comprehensive primary care services for almost 29 million people in the United States. Therefore, it is important to assess the levels of health center participation in VBP, types of VBP contracts, characteristics of health centers participating in VBP, and variations in state policy environments that influence VBP participation.

METHODS

This mixed methods study combined qualitative research on state policy environments and health center participation in VBP with quantitative analysis of Uniform Data System and health center financial data in seven vanguard states: Oregon, Washington, California, Colorado, New York, Hawaii, and Kentucky. VBP contracts were classified into three layers: base payments being transformed from visit-based to population-based (Layer 1), infrastructure and care coordination payments (Layer 2), and performance incentive payments (Layer 3).

FINDINGS

Health centers in all seven states participated in Layer 2 and Layer 3 VBP, with VBP participation growing from 35% to 58% of all health centers in these states from 2013 to 2017. Among participating health centers, the average percentage of Medicaid revenue received as Layer 2 and Layer 3 VBP rose from 6.4% in 2013 to 9.1% in 2017. Oregon and Washington health centers participating in Layer 1 payment reforms received most of their Medicaid revenue in VBP. In 2017, VBP participation was associated with larger health center size in four states (P <.05), and higher average number of days cash on hand (P <.05) in three states.

CONCLUSIONS

A multilayer payment model is useful for implementing and monitoring VBP adoption among health centers. State policy, financial incentives from Medicaid agencies and Medicaid managed plans, and health center-Medicaid collaboration under strong primary care association and health center leadership will likely be required to increase health center participation in VBP.