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PubMed1997

Integrating payer and provider risk through capitation.

Capitation payment mechanisms promote conservative use of medical resources by transferring risk to the decision maker, the physician. However, there is another view of capitation: defining common risk between provider-driven organizations (i.e., physician/hospital organizations (PHOs) or integrated delivery systems (IDS), and risk-managing entities such as HMOs or insurance companies. This article discusses a strategy to align provider and risk manager incentives to share the risks and rewards for a total book of business or population.

Actuarial Analysis↗
PubMed1990

Medicare program; Medicare secondary payer for disabled active individuals--HCFA. Proposed rule.

This proposal sets forth the rules that limit Medicare payment for services furnished to disabled "active individuals" who are covered under a large group health plan (LGHP), and prohibit discrimination by an LGHP against such individuals. These rules are necessary to implement section 1862(b)(1)(B) of the Social Security Act (the Act), and related provisions, which make Medicare benefits secondary to LGHP benefits.

Deductibles and Coinsurance↗
PubMedDate not supplied

Minimally invasive surgery: a payer's point of view.

For insurers, the decision to provide coverage for a new technology sets in motion a series of events that can cause real dilemmas. Ordinarily, a new technology, once covered as a benefit, expands in utilization, sometimes dramatically. The trick for the insurer is too determine how much of this new utilization is appropriate and how much is not. Failure to gain control of the technology can contribute to further cost increases.

Diffusion of Innovation↗