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Understanding Changes in Medical Payment Delivery Models
Dr. David Edward Marcinko; MBA CMP™
[Publisher-in-Chief
]
As healthcare insurance payments have shifted from the older fee for service model, to the newer managed care capitation models, the following characteristics may be observed
Shifting from Retail to Wholesale Medical Models
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Full fee for service rendered as medical payment
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Illnesses and diseases treated retroactively
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Individual patients were treated
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Active and acute diagnoses were made
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Medical care rendered in the office or hospital setting
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Referrals to specialist were made in difficult cases.
Contemporary (Managed Care-Capitation) Methodology
A Per Member/Per Month medical capitation model requires the payment of a fixed sum of money to a medical provider to cover a defined set of health care services for an individual enrollee, over a defined period of time.
Under PM/PM capitation, the doctor assumes the risk for the incidence (utilization rate) of medical conditions requiring procedures specified in the MCO contract.
PM/PM Characteristics:
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Discounted payment from HMO’s and MCO’s
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Illnesses are prevented proactively
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Population cohorts are treated collectively, not individually
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Chronic diseases are intervened before acute disease exacerbates
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Care rendered in networks, the home or other sub-acute care facility
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Outcomes are evaluated based on results, not specialty care.
Assessment
Under PM/PM capitation, the MD is at risk for: (a) utilization and acuity (b) actuarial accuracy (c) cost of delivering medical care, and (d) adverse patient selection.
Conclusion
Do you participate in any capitated health insurance plans which have been making a comeback, of late? What has been your experience with them?
More info: http://www.springerpub.com/prod.aspx?prod_id=23759
Terms: www.HealthDictionarySeries.com
Speaker: If you need a moderator or a speaker for an upcoming event, Dr. David Edward Marcinko; MBA – Editor and Publisher-in-Chief – is available for speaking engagements. Contact him at: MarcinkoAdvisors@msn.com
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Filed under: Managed Care | Tagged: Health Care Finance | 3 Comments »
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