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MANAGEMENT OF CAPITATION UNDER THE NATIONAL HEALTH INSURANCE SCHEME. BEING A PRESENTATION BY Dr HOPE UWEJA Gen. Manager ( Accr .& Insp ). MODE OF PAYMENTS UNDER MANAGED CARE. PER DIEM

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management of capitation under the national health insurance scheme
MANAGEMENT OF CAPITATION UNDER THE NATIONAL HEALTH INSURANCE SCHEME

BEING A PRESENTATION

BY

Dr HOPE UWEJA

Gen. Manager (Accr.& Insp)

mode of payments under managed care
MODE OF PAYMENTS UNDER MANAGED CARE
  • PER DIEM
  • PER CASE
  • FEE FOR SERVICE
  • CAPITATION
  • ON RETAINERSHIP BASIS
definition
DEFINITION

Capitation is a fixed amount of money

Per unit of time paid in advance to the Physician, Clinic or Hospital for the delivery of Healthcare Services

what determines the rate of capitations
WHAT DETERMINES THE RATE OF CAPITATIONS

Actual amount of money paid is determined by

Range of Services provided

The number of Patients involved

Period of time during which the services

are provided

Note that Capitation rates are developed using local costs and average utilisation of services

how it really works
HOW IT REALLY WORKS
  • A Critical feature of this mode of payment is
  • The shifting of financial risk from the payer to the Providers
  • Because it offers Health Plans the maximum risk reduction and is administratively simple
  • It has become the most prospective method of contracting Primary care worldwide
pros and cons of capitation
PROS AND CONS OF CAPITATION

PROVIDERS

  • Individual Physicians may find himself at a disadvantage when compared to those in Group or Multispecialty Practice
  • Improved cash flow planning

PATIENTS

  • Fraud is minimized
  • There is no longer any financial incentive for unnecessary surgery or Clinical intervention
capitation payment in nhis
CAPITATION PAYMENT IN NHIS
  • PRIMARYCARE
  • Capitation is used to pay for care to Primary Providers
  • SECONDARY CARE
  • Capitation is used to pay the HMOs for Secondary care
uses of capitation in managed care programmes
USES OF CAPITATION IN MANAGED CARE PROGRAMMES

Capitations are used to control use of Health resources by putting the Physician at Financial risk for Services provided to the patient

disadvantage of capitation payment system in managed care
DISADVANTAGE OF CAPITATION PAYMENT SYSTEM IN MANAGED CARE

The possibility of Providers giving Suboptimal Care through under utilisation of Care Services

management of capitation for primarycare in nhis formal sector program
MANAGEMENT OF CAPITATION FOR PRIMARYCARE IN NHIS FORMAL SECTOR PROGRAM

A function of the individual Primary Providers only.

The Providers are paid according to the number of enrolees attached to the facility

The Capitation is to be used for providing Primary healthcare services only.

management of capitation for secondary care under the nhis
MANAGEMENT OF CAPITATION FOR SECONDARY CARE UNDER THE NHIS
  • Strictly a function of the HMOs
  • The HMOs are the custodians of this
  • Capitation which is used to pay for
  • Secondary and Tertiary care from Primary
  • Care Providers.