Assessing care integration for dual-eligible beneficiaries: a review of quality measures chosen by states in the financial alignment initiative.

Caring for the 9 million low-income elderly or disabled adults who are eligible for full benefits under both Medicare and Medicaid can be extremely costly. As part of the federal Financial Alignment Initiative, states have the opportunity to test care models for dual-eligibles that integrate acute care, behavioral health and mental health services, and long-term services and supports, with the goals of enhancing access to services, improving care quality, containing costs, and reducing administrative barriers. One of the challenges in designing these demonstrations is choosing and applying measures that accurately track changes in quality over time­essential for the rapid identification of effective innovations. This brief reviews the quality measures chosen by eight demonstration states as of December 2013. The authors find that while some quality domains are well represented, others are not. Quality-of-life measures are notably lacking, as are informative, standardized measures of long-term services and supports.

Success with capitation doesn't always parlay into increased membership.

Ochsner Clinic Foundation is preparingfor life without capitation after selling its health plan to Humana. Like a growing number of integrated physician organizations, Ochsner found it hard to compete with the growing consumer-driven health care movement.

Capitated contracting roles and relationships in healthcare.

Capitated contracting of health providers has created substantial change in healthcare markets. This article assesses how capitation affects the roles and relationships of healthcare organizations. In-depth case studies were conducted of eight major hospital-led integrated health networks/systems and two large integrated medical groups. Types of capitated contracts employed, contract support capabilities developed, relationships among providers in the support services, and lessons learned about capitation were explored. The experiences of these organizations provide valuable guidance for health executives as they develop or refine capitated contracting strategies.

Capitation funding in Australia: imperatives and impediments.

Health service funding mechanisms are pivotal in the pursuit of health system objectives, as they provide strong financial incentives for actors in the system to achieve policy goals. Underpinning funding mechanisms is a set of key economic principles, or objectives, that should guide their design and use: efficiency, equity, and accountability. The Australian health system has historically performed relatively poorly in relation to these objectives, with evidence of inefficiencies, inequities, and poor accountability in many areas of health services. The primary cause of these shortcomings may lie in the complex set of funding and delivery arrangements at the State and Federal levels of government. Potentially significant improvements in the performance of the health system would be available from the integration of the funding and delivery of services within a single tier of government, coupled with the development of a national weighted capitation approach to funding. To develop a national capitation funding model a number of unique factors require consideration, including the current fragmentation of services, the role of the private sector, the needs of indigenous populations, and the effects of rurality. The data available to develop a capitation model is of a level of detail and quality not readily found elsewhere. If policy statements promoting efficiency, accountability, and particularly equity are to be actively pursued, a national capitation model based on robust methods should become a cornerstone of Australian health system reform.

Capitated contracting of integrated health provider organizations.

This paper examines global capitation of integrated health provider organizations that link physicians and hospitals, such as physician-hospital organizations and management service organizations. These organizations have proliferated in recent years, but their contracting activity has not been studied. We develop a conceptual model to understand the capitated contracting bargaining process. Exploratory multivariate analysis suggests that global capitation of these organizations is more common in markets with high health maintenance organization (HMO) market share, greater numbers of HMOs, and fewer physician group practices. Additionally, health provider organizations with more complex case mix, nonprofit status, more affiliated physicians, health system affiliations, and diversity in physician organizational arrangements are more likely to have global capitation. Finally, state regulation of provider contracting with self-insured employers appears to have spillover effects on health plan risk contracting with health providers.

A capitated model for a cross-section of severely mentally ill clients: hospitalization.

Hospitalization outcomes are examined in a three year random assignment controlled study of two capitated Integrated Service Agencies (ISAs) in California. Study participants were a cross-section of severely mentally ill clients. Using the flexibility of capitated funding, the urban ISA reduced inpatient length of stay and days, but not admissions. Elements of the capitated ISA model worked together to produce clinically appropriate and less costly use of inpatient services. At the rural ISA, admissions were reduced substantially during the first two years of the demonstration but not costs.

Mandatory high-risk pooling: an approach to reducing incentives for cream skimming.

Risk-adjusted capitation payments (RACPs) to competing health insurers are an essential element of market-oriented health care reforms in The Netherlands. Crude RACPs are inadequate, especially because they encourage insurers to select against people expected to be unprofitable--a practice called cream skimming. However, implementing improved RACPs does not appear to be straightforward. This paper analyzes an approach that, given a system of crude RACPs, reduces insurers' incentives for cream skimming in the market for individual health insurance, while preserving incentives for efficiency and cost containment. Under the proposed system of Mandatory High-Risk Pooling (MHRP), each insurer would be allowed to periodically predetermine a small fraction of its members whose costs would be (partially) pooled. The pool would be financed with mandatory, flat-rate contributions. The results suggest that MHRP is a promising supplement to RACPs.

Capitation revisited: integrated systems learn how to manage care and risk.

Caught in the middle of HMO price wars, integrated delivery systems are tightening their belts and demanding a greater share of what they save from delivering good outcomes more efficiently. Quality isn't endangered yet, leaders agree, but could be unless employers start to incorporate outcomes measures into their choice of health plans.

The trend towards capitation: the basis for the movement.

With the trend towards integrated health delivery systems gaining momentum, more health plans and joint ventures are considering capitation as the payment method of choice to physicians, specialty contractors, and other suppliers of health care services. This first article of a two-part series examines the basis for the capitation movement.

Risk-adjusted capitation: recent experiences in The Netherlands.

The market-oriented health care reforms taking place in the Netherlands show a clear resemblance to the proposals for managed competition in U.S. health care. In both countries good risk adjustment mechanisms that prevent cream skimming--that is, that prevent plans from selecting the best health risks--are critical to the success of the reforms. In this paper we present an overview of the Dutch reforms and of our research concerning risk-adjusted capitation payments. Although we are optimistic about the technical possibilities for solving the problem of cream skimming, the implementation of good risk-adjusted capitation is a long-term challenge.