Relationship between general practice capitation funding and the quality of primary care in England: a cross-sectional, 3-year study.

OBJECTIVE: To explore the relationship between general practice capitation funding and quality ratings based on general practice inspections. DESIGN: Cross-sectional study pooling 3 years of primary care administrative data. SETTING: UK primary care. PARTICIPANTS: 7310 practices (95% of all practices) in England which underwent Care Quality Commission (CQC) inspections between November 2014 and December 2017. MAIN OUTCOME MEASURES: CQC ratings. Ordered logistic regression methods were used to predict the relationship between practice capitation funding and CQC ratings in each of five domains of quality: caring, effective, responsive, safe and well led, together with an overall practice rating. RESULTS: Higher capitation funding per patient was significantly associated with higher CQC ratings across all five quality domains: caring (OR 1.14, 95% CI 1.04 to 1.23), effective (OR 1.08, 95% CI 1.00 to 1.16), responsive (OR 1.09, 95% CI 1.02 to 1.17), safe (OR 1.11, 95% CI 1.05 to 1.18), well led (OR 1.13, 95% CI 1.06 to 1.20) and overall rating (OR 1.13, 95% CI 1.06 to 1.19). CONCLUSION: Higher capitation funding was consistently associated with higher ratings across all CQC domains and in the overall practice rating. This study suggests that measured dimensions of the quality of care are related to the underlying capitation funding allocated to each general practice, implying that additional capitation funding may be associated with higher levels of primary care quality.

Responding to policy makers' evaluation needs: combining experimental and quasi-experimental approaches to estimate the impact of performance based financing in Burkina Faso.

BACKGROUND: The last two decades have seen a growing recognition of the need to expand the impact evaluation toolbox from an exclusive focus on randomized controlled trials to including quasi-experimental approaches. This appears to be particularly relevant when evaluation complex health interventions embedded in real-life settings often characterized by multiple research interests, limited researcher control, concurrently implemented policies and interventions, and other internal validity-threatening circumstances. To date, however, most studies described in the literature have employed either an exclusive experimental or an exclusive quasi-experimental approach. METHODS: This paper presents the case of a study design exploiting the respective advantages of both approaches by combining experimental and quasi-experimental elements to evaluate the impact of a Performance-Based Financing (PBF) intervention in Burkina Faso. Specifically, the study employed a quasi-experimental design (pretest-posttest with comparison) with a nested experimental component (randomized controlled trial). A difference-in-differences approach was used as the main analytical strategy. DISCUSSION: We aim to illustrate a way to reconcile scientific and pragmatic concerns to generate policy-relevant evidence on the intervention's impact, which is methodologically rigorous in its identification strategy but also considerate of the context within which the intervention took place. In particular, we highlight how we formulated our research questions, ultimately leading our design choices, on the basis of the knowledge needs expressed by the policy and implementing stakeholders. We discuss methodological weaknesses of the design arising from contextual constraints and the accommodation of various interests, and how we worked ex-post to address them to the best extent possible to ensure maximal accuracy and credibility of our findings. We hope that our case may be inspirational for other researchers wishing to undertake research in settings where field circumstances do not appear to be ideal for an impact evaluation. TRIAL REGISTRATION: Registered with RIDIE (RIDIE-STUDY-ID- 54412a964bce8 ) on 10/17/2014.

Payment models in primary health care: A driver of the quantity and quality of medical laboratory utilization.

Physician payment models' incentives regarding many aspects of primary health care are not well understood. We focus on the case of medical laboratory utilization and examine how physicians' laboratory test ordering patterns change following a switch to a blended capitation payment model from one with fee for service enhanced with pay for performance. Also, within blended capitation, we examine differences between traditional staffing and interdisciplinary teams. Using a propensity score weighted fixed-effects specification to address selection, it is estimated that the switch to capitation leads to a short-run average of 3% fewer laboratory requisitions per patient. Patients' laboratory utilization also becomes more concentrated with the rostering physician. More importantly, using diabetes-related laboratory tests as a case study, after joining the blended model, physicians order 3% fewer inappropriate/redundant tests, and the addition of an interdisciplinary care team makes the reduction about 9%. Advances in both continuity and quality seem to be associated with blended capitation.

The ongoing evolution of capitation funding for primary care: the December 2018 PHO capitation funding changes for Community Services Card holders.

AIM: To 1) consider the possible impact on equity of the recent policy to support people on low incomes to access primary care using the Community Services Card (CSC), and 2) identify questions that will need to be answered in order for the policy and funding changes to be evaluated. METHODS: Review of publicly accessible reports, papers, media releases and websites to detail and examine the funding changes made in December 2018 to implement the CSC policy. RESULTS: CSC possession is an important new determinant of eligibility to low-cost access to primary care for many people. As the funding changes are complex, the equity effects cannot be fully understood until further detailed modelling is carried out, and specific questions are answered. CONCLUSIONS: The December 2018 PHO capitation funding policy changes represent a further step towards universal low-cost primary healthcare. The effects of those funding changes should now be evaluated in order to understand their effects on equity. It is the responsibility of the Ministry of Health to ensure that an evaluation of the changes takes place.

Effect of risk-based payment model on caries inequalities in preschool children assessed by geo-mapping.

BACKGROUND: To describe, with aid of geo-mapping, the effects of a risk-based capitation model linked to caries-preventive guidelines on the polarization of caries in preschool children living in the Halland region of Sweden. METHODS: The new capitation model was implemented in 2013 in which more money was allocated to Public Dental Clinics surrounded by administrative parishes inhabited by children with increased caries risk, while a reduced capitation was allocated to those clinics with a low burden of high risk children. Regional geo-maps of caries risk based on caries prevalence, level of education and the families purchasing power were produced for 3-6-year-old children in 2010 (n = 10,583) and 2016 (n = 7574). Newly migrated children to the region (n = 344 in 2010 and n = 522 in 2016) were analyzed separately. A regional caries polarization index was calculated as the ratio between the maximum and minimum estimates of caries frequency on parish-level, based on a Bayesian hierarchical mapping model. RESULTS: Overall, the total caries prevalence (dmfs > 0) remained unchanged from 2010 (10.6%) to 2016 (10.5%). However, the polarization index decreased from 7.0 in 2010 to 5.6 in 2016. Newly arrived children born outside Sweden had around four times higher caries prevalence than their Swedish-born peers. CONCLUSIONS: A risk-based capitation model could reduce the socio-economic inequalities in dental caries among preschool children living in Sweden. Although updated evidence-based caries-preventive guidelines were released, the total prevalence of caries on dentin surface level was unaffected 4 years after the implementation.

Evidence for capitation reform in a New Rural Cooperative Medical Scheme in Pudong New Area, Shanghai: A longitudinal study.

Currently, China has been experiencing rapid growth of medical costs, serious waste of medical resources, increasing disease burden for residents, and a medical insurance fund deficit. Therefore, an urgent problem that needs to be solved is to choose a rational payment for the insurance system. To empirically evaluate the long-term effects of capitation reform in a New Rural Cooperative Medical Scheme in Pudong New Area, we collected and analysed data regarding financing, fund operation, medical service cost, and medical care-seeking behaviour from 2011 to 2015, a duration that includes data before and after reform. The data for financing and behaviours were compared year by year, and the monthly data for inpatient and outpatient costs were evaluated in a retrospective time series study. The capitation reform in Pudong New Area showed strong evidence of the power of medical cost control in the long run, while it was weak in reversing the number of patients flowing into secondary and tertiary hospitals. To make the payment of capitation play a bigger role in cost control in China, a tighter alignment of capitation with the general practitioner system and achieving dual referral is critical for future studies.

Claims-shifting: The problem of parallel reimbursement regimes.

Parallel reimbursement regimes, under which providers have some discretion over which payer gets billed for patient treatment, are a common feature of health care markets. In the U.S., the largest such system is under Workers' Compensation (WC), where the treatment workers with injuries that are not definitively tied to a work accident may be billed either under group health insurance plans or under WC. We document that there is significant reclassification of injuries from group health plans into WC, or "claims shifting", when the financial incentives to do so are strongest. In particular, we find that injuries to workers enrolled in capitated group health plans (such as HMOs) see a higher incidence of their claims for soft-tissue injuries (which are hard to classify specifically as work related) under WC than under group health, relative to those in non-capitated plans. Such a pattern is not evident for workers with traumatic injuries. Moreover, we find that such reclassification is more common in states with higher WC fees, once again for soft tissue but not traumatic injuries. Our results imply that a significant shift towards capitated reimbursement, or reimbursement reductions, under GH could lead to a large rise in the cost of WC plans.

NRCMS capitation reform and effect evaluation in Pudong New Area of Shanghai.

The Rural Cooperative Medical Scheme (RCMS) had played an important role in guaranteeing the acquisition of basic medical healthcare of China's rural populations, being an innovative model of the medical insurance system for so many years here in China. Following the boom and bust of RCMS, the central government rebuilt the New Rural Cooperative Medical Scheme (NRCMS) in 2003 across the whole country. Shanghai, one of the developed cities in China, has developed its RCMS and NRCMS as an advanced and exemplary representative of Chinese rural health insurance. But in the past 10 years, its NRCMS has encountered such challenges as a spiral of medical expenditures and a decrease of insurance participants. Previous investigations showed that the capitation and general practitioner (GP) system had great effect on medical cost containment. Thus, the capitation reform combined with GP system reform of NRCMS, based on a system design, was implemented in Pudong New Area of Shanghai as of 1 August 2012. The aim of the current investigation was to present how the reform was designed and implemented, evaluating its effect by analyzing the data acquired from 12 months before and after the reform. This was an empirical study; we made a conceptual design of the reform to be implemented in Pudong New Area. Most data were derived from the institution-based surveys and supplemented by a questionnaire survey, qualitative interviews and policy document analysis. We found that most respondents held an optimistic attitude towards the reform. We employed a structure-process-outcome evaluation index system to evaluate the effect of the reform, finding that the growth rate of the insured population's total medical costs and NRCMS funds slowed down significantly after the reform; that the total medical expenditure of the insured rural population decreased by 3.60%; and that the total expenditure of NRCMS decreased by 3.99%. The capitation was found to help the medical staff build active cost control consciousness. Approximately 2.3% of the outpatients flowed to the primary hospitals from the secondary hospitals; and farmers' annual medical burden was relieved to a certain degree. Meanwhile, it did not affect farmers' utilization and benefits of healthcare. However, further reform still faces new challenges: The capitation reform should be well combined with the primary healthcare system to realize the "dual gatekeeper" of GPs; a variety of payment methods should be mixed on the basis of capitation to avoid possible mistakes by one single approach; and the supervision of medical institutions should be strengthened. A long-term follow-up study need to be carried out to evaluate the effects of the capitation reform so as to improve the design of the program. Copyright © 2015 John Wiley & Sons, Ltd.

Realigning demand and supply side incentives to improve primary health care seeking in rural China.

China's recent and ambitious health care reform involves a shift from the reliance on markets to the reaffirmation of the central role of the state in the financing and provision of services. In collaboration with the Government of the Ningxia province, we examined the impact of two key features of the reform on health care utilisation using panel household data. The first policy change was a redesign of the rural insurance benefit package, with an emphasis on reorientating incentives away from inpatient towards outpatient care. The second policy change involved a shift from a fee-for-service payment method to a capitation budget with pay-for-performance amongst primary care providers. We find that the insurance intervention, in isolation, led to a 47% increase in the use of outpatient care at village clinics and greater intensity of treatment (e.g. injections). By contrast, the two interventions in combination showed no effect on health care use over and above that generated by the redesign of the insurance benefit package.

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.

Patient-reported access to primary care in Ontario: effect of organizational characteristics.

OBJECTIVE: To describe patient-reported access to primary health care across 4 organizational models of primary care in Ontario, and to explore how access is associated with patient, provider, and practice characteristics. DESIGN: Cross-sectional survey. SETTING: One hundred thirty-seven randomly selected primary care practices in Ontario using 1 of 4 delivery models (fee for service, established capitation, reformed capitation, and community health centres). PARTICIPANTS: Patients included were at least 18 years of age, were not severely ill or cognitively impaired, were not known to the survey administrator, had consenting providers at 1 of the participating primary care practices, and were able to communicate in English or French either directly or through a translator. MAIN OUTCOME MEASURES: Patient-reported access was measured by a 4-item scale derived from the previously validated adult version of the Primary Care Assessment Tool. Questions were asked about physician availability during and outside of regular office hours and access to health information via telephone. Responses to the scale were normalized, with higher scores reflecting greater patient-reported access. Linear regressions were used to identify characteristics independently associated with access to care. RESULTS: Established capitation model practices had the highest patient-reported access, although the difference in scores between models was small. Our multilevel regression model identified several patient factors that were significantly (P = .05) associated with higher patient-reported access, including older age, female sex, good-to-excellent self-reported health, less mental health disability, and not working. Provider experience (measured as years since graduation) was the only provider or practice characteristic independently associated with improved patient-reported access. CONCLUSION: This study adds to what is known about access to primary care. The study found that established capitation models outperformed all the other organizational models, including reformed capitation models, independent of provider and practice variables save provider experience. This suggests that the capitation models might provide better access to care and that it might take time to realize the benefits of organizational reforms.

Risk selection and cost shifting in a prospective physician payment system: evidence from Ontario.

We study the risk-selection and cost-shifting behavior of physicians in a unique capitation payment model in Ontario, using the incentive to enroll and care for complex and vulnerable patients as a case study. This incentive, which is incremental to the regular capitation payment, ceases after the first year of patient enrollment and may therefore impact on the physician's decision to continue to enroll the patient. Furthermore, because the enrolled patients in Ontario can seek care from any provider, the enrolling physician may shift some treatment costs to other providers. Using longitudinal administrative data and a control group of physicians in the fee-for-service model who were eligible for the same incentive, we find no evidence of either patient 'dumping' or cost shifting. These results highlight the need to re-examine the conventional wisdom about risk selection for physician payment models that significantly deviate from the stylized capitation model.

Knowledge, perceptions and expectations of capitation payment system in a health insurance setting: a repeated survey of clients and health providers in Kumasi, Ghana.

BACKGROUND: Health insurance is improving access to quality health care in Ghana. However, there are implementation challenges which call for reform of the current health insurance system. There is no doubt that reforming the current health insurance in Ghana is besieged with a myriad of problems due to misconceptions and misinformation. This study explored the perceptions and understanding of clients and health providers on the capitation payment system in the Kumasi metropolis. METHODS: The study employed a cross - sectional design and repeated surveys were conducted with a cohort of 422 NHIS policy holders aged 18-69 years in each survey. The surveys were conducted in every three months. Health service providers and clients from thirteen (13) Hospitals, seven (7) Maternity homes and twenty (20) Clinics were also interviewed. Data was collected with interviewer-administered questionnaires. STATA software (version 11) was used for cleaning, standardizing and analysing data. RESULTS: A majority, 97.9% of the clients interviewed had heard of capitation payment although this did not translate into their level of understanding. About two-thirds, 61.2% disclosed that capitation was not important to them as clients are restricted to one Preferred Primary Provider (PPP) for a long period of time. About 94% of health providers also believed that people did not like the capitation payment system due to their misconception that it has been politicized (34%); does not give clients free choice of providers (26%) and capitation not covering most drugs (17%). CONCLUSION: Although awareness of the capitation was high among clients, attitudes towards the capitation payment system were somewhat poor. A good understanding of the capitation payment system is key to ensuring client and provider acceptance and smooth implementation of the system.

Early experiences with accountable care in Medicaid: special challenges, big opportunities.

Accountable care organizations (ACOs) and the more general movement toward accountable care, in which payments are aligned directly with improvements in quality and cost, are intended to increase the incentives and support for higher value in health care. As of mid-2013, there are over 4 million beneficiaries covered by Medicare ACOs, and large private payers continue to enter new ACO arrangements with providers in all parts of the country. An increasing number of states have approved and are implementing accountable care models for their Medicaid programs. A review of some of these early state adopters demonstrates how the features of Medicaid populations, Medicaid providers, and Medicaid financing create some distinct issues for implementing ACOs in Medicaid. Many states that have relied on Medicaid managed care plans are moving to accountable care through these private plans. Some states also are implementing accountable care reforms through direct reforms in their payments to Medicaid providers, both through specific providers and regionally-based contracts. Others are implementing a mixture of private plan and public management approaches. States are moving toward more comprehensive accountable care payments through patient-centered medical homes, episode-based payments, and patient-level accountable care payment reforms; these payment reforms can be sequential and synergistic. Accountable care in Medicaid involves some distinct considerations such as performance measures, additional complications in shared savings related to the federal-state Medicaid funding structure, and potential antitrust issues in cases where states are pursuing reforms with implications for most or all providers in a geographic area. The evidence on the impact of the various early approaches to accountable care in Medicaid is just beginning to emerge, and it is likely that the best course for states will continue to depend on the distinctive institutional features of their Medicaid programs and health care delivery systems. As in other parts of the health care system, accountable care in Medicaid is likely to continue to expand and to evolve.

[How does the Regional Psychiatry Budget (RPB) work in an area with initially low capacity of psychiatric hospital beds?]. / Wie wirkt das Regionale Psychiatriebudget (RPB) in einer Region mit initial niedriger Bettenmessziffer?

OBJECTIVE: To analyze the impact of a capitated multi-sector-financing model for psychiatric care (RPB) in the model region Rendsburg-Eckernförde on costs and effectiveness of care. METHODS: In a prospective controlled cohort study 244 patients with a diagnosis according to ICD-10: F10, F2 or F3 were interviewed in the model region (MR) and compared to 244 patients from a control region (CR) financed according to the fee-for-service principle. At baseline, 1.5 years and 3.5 years follow-up patients were interviewed using measures of psychopathology (CGI-S, HONOS, SCL-90 R/GSI, PANSS, BRMAS/BRMES), functioning (GAF, SOFAS), quality of life (EQ-5 D) and service use/costs (CSSRI). RESULTS: Subjective symptom severity (GSI) and functioning (GAF) developed more favourably in the MR than in the CR, the HONOS score developed slightly worse in the MR. The latter effect occurred mainly in ICD-10: F10 patients, while patients with F2/3 rather did benefit under RPB conditions. The development of total costs of care was not different between MR and CR. The potential to reduce costs of in-patient care was low due to the initially low capacity of inpatient beds. CONCLUSIONS: The RPB did not reduce the total costs of mental health care, but certain diagnosis groups may benefit from improved trans-sectoral treatment flexibility.

CAPITATION IN HEALTHCARE FINANCING IN GHANA.

OBJECTIVE: To analyse implementation of the pilot study of the per capita system of healthcare financing in Ghana in 2012 for a determination of the likelihood of realising the inherent theoretical benefits when the system is rolled out nationally. DESIGN AND SETTING: First, publicly available information on how the pilot unfolded is presented, followed by the reaction of the health authorities to these developments. We then analysed accrued evidence on costs and developments vis-à-vis the theoretical benefits. RESULTS: It would appear that preparation for the pilot exercise could have been handled better. Concerns include i) the low level of both education and awareness of the capitation system among healthcare subscribers and primary care providers; ii) confusion about service provider to whom subscribers had been assigned for the capitation period; and iii) service providers not understanding differences between capitation financing and financing under the Ghana diagnostic Related Grouping; and iv) some indication of cost savings. CONCLUSION: Cost savings may be available nationally. This is important because cost containment is the driving force behind the introduction of the capitation system.

Accountable care organizations and kidney disease care: health reform innovation or more same-old, same-old?

The conceptual model for an accountable care organization imagines that care will be rendered to a defined population by an entity that receives bundled payment for that care, coordinates the individual services involved in that care, provides measures of outcomes and quality, and divides the bundled payment among those who supply services. How does this concept differ from earlier efforts, and what, if anything, does it mean for the care of patients with end-stage renal disease? The concept is similar to the largely abandoned integrated delivery networks of the 1990s. The support from Medicare may make a difference, but Medicare's need to constrain spending growth will pose a challenge. Kidney disease care is already much more coordinated than health care for the rest of the population. There are some potential gains from greater coordination, especially with care for comorbid conditions associated with hospitalization. However, economic analysis suggests that the absence of large populations of patients in given geographic sites and the relatively smaller gain from incremental improvements in coordination might mean that the accountable care organization model are not ideal for the dialysis market.

The return of capitation preparing for population-based health care.

To succeed under population-based health care, organizations need to understand thoroughly how this approach differs from traditional fee-for-service health care. To manage care under capitation, the contracting organization should have a population of sufficient size and a clear means of assigning patients to that population. To assess performance, the organization requires metrics that view performance in terms of per member per month, while avoiding common pitfalls of misapplying such metrics.

Impact of remuneration and organizational factors on completing preventive manoeuvres in primary care practices.

BACKGROUND: Several jurisdictions attempting to reform primary care have focused on changes in physician remuneration. The goals of this study were to compare the delivery of preventive services by practices in four primary care funding models and to identify organizational factors associated with superior preventive care. METHODS: In a cross-sectional study, we included 137 primary care practices in the province of Ontario (35 fee-for-service practices, 35 with salaried physicians [community health centres], 35 practices in the new capitation model [family health networks] and 32 practices in the established capitation model [health services organizations]). We surveyed 288 family physicians. We reviewed 4108 randomly selected patient charts and assigned prevention scores based on the proportion of eligible preventive manoeuvres delivered for each patient. RESULTS: A total of 3284 patients were eligible for at least one of six preventive manoeuvres. After adjusting for patient profile and contextual factors, we found that, compared with prevention scores in practices in the new capitation model, scores were significantly lower in fee-for-service practices (ß estimate for effect on prevention score = -6.3, 95% confidence interval [CI] -11.9 to -0.6) and practices in the established capitation model (ß = -9.1, 95% CI -14.9 to -3.3) but not for those with salaried remuneration (ß = -0.8, 95% CI -6.5 to 4.8). After accounting for physician characteristics and organizational structure, the type of funding model was no longer a statistically significant factor. Compared with reference practices, those with at least one female family physician (ß = 8.0, 95% CI 4.2 to 11.8), a panel size of fewer than 1600 patients per full-time equivalent family physician (ß = 6.8, 95% CI 3.1 to 10.6) and an electronic reminder system (ß = 4.6, 95% CI 0.4 to 8.7) had superior prevention scores. The effect of these three factors was largely but not always consistent across the funding models; it was largely consistent across the preventive manoeuvres. INTERPRETATION: No funding model was clearly associated with superior preventive care. Factors related to physician characteristics and practice structure were stronger predictors of performance. Practices with one or more female physicians, a smaller patient load and an electronic reminder system had superior prevention scores. Our findings raise questions about reform initiatives aimed at increasing patient numbers, but they support the adoption of information technology.