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PubMed1994

Understanding capitation and at-risk contracting.

New payment methods are driving the formation of integrated systems, but how do these payment plans really work? HSL researched capitation and other forms of at-risk contracting with primary care practices, specialty groups, and hospitals in both second and third generation managed care. Our story clarifies the complexities underlying capitation so leaders can identify the implications for their systems.

Capitation Fee↗
PubMed1995

Open-ended options in Medicare risk contracts with HMOs.

The open-ended option has achieved broad acceptance in the health maintenance organization (HMO) industry. Permitting HMOs that enter into risk contracts with Medicare to offer open-ended products would expand the number of managed care options available to Medicare beneficiaries. The attractiveness of this option to HMOs depends in part on how issues are addressed relating to tracking and managing of out-of-plan use, education of Medicare beneficiaries, interface with peer review organizations (PROs), payment of nonnetwork providers, and use of medical screening. Perhaps most importantly, changes in the Medicare supplementary insurance market probably would be necessary before an open-ended product would be offered by HMOs under Medicare risk contracts.

Contract Services↗
PubMedDate not supplied

Key state legislative provisions on purchasing alliances.

In order to function effectively in post-reform healthcare markets, behavioral healthcare professionals must understand and interact with health purchasing alliances. Healthcare reform initiatives based upon the principles of managed competition envision an important role for cooperative health purchasing organizations, or "health alliances," that collect premiums and contract with health plans for the provision of comprehensive health services delivered within the framework of a standardized benefit package. Health purchasing alliances have already been implemented in eight states, and this trend is expected to grow. The following article illustrates the structure and authority of the health alliances that are already in operation, and is presented here to give Behavioral Healthcare Tomorrow journal readers an up-to-date overview of reforming healthcare markets. This matrix arrays recent state laws which we identify as clearly including components of managed competition or purchasing alliances. Other states undoubtedly have elements of reform that include some aspects of these concepts. For example, under legislation, a Vermont health care authority was established and, among other things, charged with developing two comprehensive reform proposals, one of which will involve multipayors and the other a single-payor system. Options will likely embody many of the activities of alliances. Vermont is not included in this matrix because these provisions are still in the developmental stage.

Group Purchasing↗
PubMed1995

Health care financing reform in the United States: the community equity model.

The paper discusses the practical structural aspects required for implementing 'managed competition' reform policy which are often overlooked by policy designers of change. Namely, without fundamentally new organisational structures to mediate among the parties of interest, the policies for change will not be sufficient to meet the future. The paper discusses in some detail an organisational mediating structure called the Community Equity Model which organises care at the local neighbourhood or community level using the community as actual fundsholder. This puts the critical stakeholders in a practical mutual ownership relationship by making allocation, services and resource accountability a local act. The paper briefly discusses the organisational and information technology for this type of health care system redesign.

Community Health Planning↗
PubMedDate not supplied

Improving the state of reform.

If health reform is going to work, lawmakers need to recognize that states will play a central role in reforming the health system. In doing so, reformers must address the varying health systems and stop viewing complex solutions as a poor choice. To ignore these facts is to dim the future prospects for reforming the nation's health care system.

Group Purchasing↗
PubMed1995

Capitation.

As managed care increases its presence in the home care industry, providers need to take a good look at capitation, the reimbursement method that some managed care users. This article explores the issues involved in this new payment method.

Capitation Fee↗