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Capitation Problem

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Capitation, Risk Sharing, Pay for Performance and Consumer-Directed Health Plans

All America HMO pays its primary care physicians (PCPs) by capitation, but a percentage of the total capitated amount is withheld and distributed to individual PCPs based on aggregate PCP performance. The financial goal of importance to All America is to achieve total actual specialty care and hospital costs less than budgeted. To this end, All America provides a financial incentive to its PCPs to encourage careful referral of patients to these services. The financial incentive is based on the referral gain or loss, defined as the difference between the actual and budgeted specialty care and hospital cost. More specifically, all America uses the following risk sharing rules:

If a total referral gain, then all of the total withhold is returned to the PCPs.
If a total referral loss < total withhold, then the difference (withhold - referral loss) is
returned to the PCPs based on the number of patients per PCP.
If a total referral loss > total withhold, then none of the withhold is returned to the PCPs.

Last year, All America's capitation payment to the PCPs was $20 PMPM, but 15 percent of this amount was placed into the PCP risk pool. The budgeted amount for specialty and hospital costs was $50 PMPM. At the end of the year, the following data were recorded for the four All America PCPs:

Dr Smith Dr Barney Dr Wells Dr Fargo
Number of patients 600 800 1,000 1,600
Actual referral costs $504,000 $470,000 $590,000 $880,000

a. Calculate the total compensation of each PCP at the end of the year.
b. Were each of the PCPs fairly compensated? What incentives does this single risk pool based on aggregate PCP performance present to the individual PCPs? What should be investigated to assess the fairness of the PCP compensation?

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Chapter 17 -- Capitation, Rate Setting, and Risk Sharing

Families First is a managed care plan that has been asked to submit a premium bid to ABC Company, a large
manufacturer in its service area. The premium bid includes the primary care for all of the ABC employees.
ABC has provided information about the age and gender of its employees, and Families First has identified
average primary care utilization rates from its own databases. This information is shown below:

ABC Company Average Primary Care
Number of Number of Visits per Year
Age Band Males Females Males Females
20-29 285 325 2.10 3.18
30-39 96 100 2.60 3.52
40-49 53 57 3.28 3.93
50-59 36 36 4.14 4.43
60+ 7 5 4.98 5.04

Each primary care physician can handle about 3,000 patient visits per year, for which he or she is paid
$180,000. What primary care rate (PMPM) will Families First propose to ABC Company?

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