Great video. I'm trying to educate myself before starting a role in health insurance payments and your clear, simple explanations are just enough to get me started without being overwhelmed with too much details.
The risk adjustment process in Medicare and ACA products balances out the disadvantages of the capitation system described. In fact, the risk adjustment process has actually made it possible for emerging primary care groups (Oak Street Health, VillageMD, CenterWell Primary Care) to establish a business model centered around seeking out the most medically complex patients, taking well care of them in a primary care setting (and thus avoid expensive hospital or specialty care) and then "pocketing" the unspent dollars. In this environment, the physicians are incentivized to spend more time with their patients and see them more frequently to drive better patient outcomes (ie: less hospitalizations) rather than volume of service or "holding back" needed service.
Good explanation. Capitation rarely works out for the physician. Carriers have so much more information on actuarial data and sickness of patients, they know these agreements win out for their side. There are also carve outs for physicians, a healthcare provider can and SHOULD negotiate in a capitation arrangement. Carve outs are certain CPT's (Charges) they can be reimbursed on top of the flat cap payment. There are also bonuses/incentives physicians can negotiate into these cap agreements. Sadly, most healthcare providers just see a nice guaranteed paycheck but don't realize the utilization of their services, overall health and needs of the patient and a bunch of others factors eat into that flat fee payment and accept the first offer they get.
OMG I love your videos... as you are explaining how it works I am here thinking about all the ways a Doctor could take advantage of this by pushing away non-healthy patients and THEN... you talk about it and answer my questions. Are you reading my mind? lol
Capitation is a payment arrangement for health care service providers. It pays a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care. The amount of remuneration is based on the average expected health care utilization of that patient, with payment for patients generally varying by age and health status.
As a medical student I don't like capitation payment models. I would prefer to take an actual interest in my patients rather than just collect a pay check. Capitation is not practicing medicine in my opinion.
What happens to the professional fees for the physician if the hospital gets the capitated payments? Long story short, the physician is getting the capitated service denial because the hospital has already been paid for it. Would this then be a write off for the physician?
That is an interesting query, I think capitation contract applies separately for hospitals and physician groups. Also I am not sure if hospitals are offered capitation agreement by the insurance companies.
Forgot to add I got a bill that I owe an amount for capitaiton adjustment. Which brought me to your video, I don’t see why as a patient I would need to pay. I could be wrong, but will keep researching and calling my insurance
Thank you! This was a very helpful and easy to understand explanation!!
Great video. I'm trying to educate myself before starting a role in health insurance payments and your clear, simple explanations are just enough to get me started without being overwhelmed with too much details.
It's so educative,I now understand how the capitation works now
Studying for CEBS and didn't understand this concept until I watched your video, thank you!
Hi Ashley, This is Dave Nguyen from your grad school days! Just came across your video. Very informative!
The risk adjustment process in Medicare and ACA products balances out the disadvantages of the capitation system described. In fact, the risk adjustment process has actually made it possible for emerging primary care groups (Oak Street Health, VillageMD, CenterWell Primary Care) to establish a business model centered around seeking out the most medically complex patients, taking well care of them in a primary care setting (and thus avoid expensive hospital or specialty care) and then "pocketing" the unspent dollars. In this environment, the physicians are incentivized to spend more time with their patients and see them more frequently to drive better patient outcomes (ie: less hospitalizations) rather than volume of service or "holding back" needed service.
Thank you so much. Plz do more videos about fee for service and bundle payments
Good explanation. Capitation rarely works out for the physician. Carriers have so much more information on actuarial data and sickness of patients, they know these agreements win out for their side. There are also carve outs for physicians, a healthcare provider can and SHOULD negotiate in a capitation arrangement. Carve outs are certain CPT's (Charges) they can be reimbursed on top of the flat cap payment. There are also bonuses/incentives physicians can negotiate into these cap agreements. Sadly, most healthcare providers just see a nice guaranteed paycheck but don't realize the utilization of their services, overall health and needs of the patient and a bunch of others factors eat into that flat fee payment and accept the first offer they get.
OMG I love your videos... as you are explaining how it works I am here thinking about all the ways a Doctor could take advantage of this by pushing away non-healthy patients and THEN... you talk about it and answer my questions. Are you reading my mind? lol
Perfect ❤
Thanks queen u slayed
Thanks!
thank you
Great explanation! You would think this should be done by public insurance not the private sectors!
Capitation is a payment arrangement for health care service providers.
It pays a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.
The amount of remuneration is based on the average expected health care utilization of that patient, with payment for patients generally varying by age and health status.
Great explanation👍🏾
As a medical student I don't like capitation payment models. I would prefer to take an actual interest in my patients rather than just collect a pay check. Capitation is not practicing medicine in my opinion.
What happens to the professional fees for the physician if the hospital gets the capitated payments? Long story short, the physician is getting the capitated service denial because the hospital has already been paid for it. Would this then be a write off for the physician?
That is an interesting query, I think capitation contract applies separately for hospitals and physician groups. Also I am not sure if hospitals are offered capitation agreement by the insurance companies.
At 1:28 $200000, not $200. Cut, cut, cut. Take 2.
This explains so much why I’ve gotten some rude doctors that I’ve chosen not to go back to.
Forgot to add I got a bill that I owe an amount for capitaiton adjustment. Which brought me to your video, I don’t see why as a patient I would need to pay. I could be wrong, but will keep researching and calling my insurance