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Capitation, Primary Care

I need some help understanding this : 

 

Definition: 

Capitation is a payment arrangement for health care service providers such as physicians. Under capitation, a physician or group of physicians receives a rish adjusted set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.

 

Now, my question is how does this control the PCP, to the point that they will not give referrals to my existing specialist but only to the " doctors of their choice"  this is causing great trouble in getting the treatment I am in need of. I have been using the same specialest for 12 yrs. now all of sudden the PCP says no more! you will either do it my way or not at all. .....some guidence here would be great

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@AnthonyR624223 wrote:

I need some help understanding this : Capitation is a payment arrangement for health care service providers such as physicians. Under capitation, a physician or group of physicians receives a rish adjusted set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care. Now, my question is how does this control the PCP, to the point that they will not give referrals to my existing specialist but only to the " doctors of their choice"  this is causing great trouble in getting the treatment I am in need of. I have been using the same specialest for 12 yrs. now all of sudden the PCP says no more! you will either do it my way or not at all. .....some guidence here would be great


Not sure if you feel you got this question answered already (some of the answers seemed to go to another topic) or perhaps you no longer care but... (and given the AARP Topic, I'm assuming you mean to ask this question in the context of Medicare)...

 

1. Most risk adjusted capitated fees go to the sponsor, not the PCP. In managed care Medicare (Part C), most sponsors are non-profit integrated health delivery systems (Kaiser Permanente being the biggest example) or spin out charities formerly linked to integrated health delivery systems (e.g., Tufts Medicare in New England which spun out of the Tufts New England Medical Center about 20 years ago)

2. Where it is a closed relationship like with Kaiser Permanente, you would be most likely to get the situation you describe in your question. In that situation, the PCP and others are most likely salaried employees of the integrated health system getting the fee from the Trust Funds

3. Where the relationship is looser as with Tufts (or an actual insurance company such as Humana), it all depends on what your Evidence of Coverage booklet says and what the arrangment is between the sponsor and the various providers the sponsor has under contract

4. There are also different types of such Managed Care plans in terms of how much flexibility the PCP has for referrals:

-- HMOs (most restrictive in terms of referrals),

-- HMO-POSs (less restrictive),

-- PPOs (even less restrictive but still restrictive)

-- These three types comprise about 80% of Part C plans but there are also some other types

 

As with all things in life, in your situation it depends on what it says in the small print

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@AnthonyR624223 wrote:

I need some help understanding this : 

 

Definition: 

Capitation is a payment arrangement for health care service providers such as physicians. Under capitation, a physician or group of physicians receives a rish adjusted set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care.

 

Now, my question is how does this control the PCP, to the point that they will not give referrals to my existing specialist but only to the " doctors of their choice"  this is causing great trouble in getting the treatment I am in need of. I have been using the same specialest for 12 yrs. now all of sudden the PCP says no more! you will either do it my way or not at all. .....some guidence here would be great


It sounds like you are within an ACCOUNTABLE CARE ORGANIZATION.

Center for Medicare & Medicaid Services (CMS).gov - Accountable Care Organizations (ACOs)  

 

You may not even be informed of it.  Can you get out of it - that depends on who is paying the bills and why.

This CMS site has several videos on ACO's -

https://innovation.cms.gov/initiatives/aco/ 

 

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how do i find out if iam in a ACCOUNTABLE CARE ORGANIZATION.?

the funny part of this is the pcp wrote referrals all year to the very doctors she now refuses to write referrals for. 

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@AnthonyR624223 wrote:

how do i find out if iam in a ACCOUNTABLE CARE ORGANIZATION.?

the funny part of this is the pcp wrote referrals all year to the very doctors she now refuses to write referrals for. 


All kinds of explanations could be true here - who knows- you have to get all the specifics.

Maybe You just went into the "group", OR your PCP just began this type of payment arrangement, OR the other docs may have left or never entered the group.

 

Like I said, it all depends on who is paying and what type of plan you may have.

What type of insurance coverage do you have ?  All of it.

Like do you have traditional Medicare and also get help via Medicaid (state/federal)?  <<<< I am betting this one since you mentioned capitation.

https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medic... 

 

Perhaps a Medicare Advantage plan that is considered Special Needs?

https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/special-needs-plans-snp 

 

An ACO is a group of beneficiaries that are treated by providers who are in a Medicare Shared Savings Program.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/about 

They get paid different than other providers for the same services.

 

Guess, you could always ask your PCP if they participate in a Medicare Shared Savings Program (MSSP) and if you are within an ACO or a Special Needs plan under that MSSP.  The problem is getting out of it - I am guessing that you may need extra financial help and most likely Medicaid is involved - that means your state is involved.

 

It is very hard to explain things when so much of it depends on all the specific details - all I can give you is generalizations.

 

It could also be that the specialist which you previously saw and referenced, may no longer accept your specific health plan or combination of health plans. 

 

Is it that your PCP does not agree that you need a specialist or just that specialist? 

 

If under this care arrangement, your PCP should have a group of providers that can provide for your health needs - medically, necessary needs.  Any Referrals may not be the specialist that you want - but if the PCP agrees that you need a (whatever) type specialist, there should be one in the MSSP program or one that will accept the rate of pay that can provide care.

 

 

 

 

 

 

 

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I have humana advantage gold plus plan, which I have had for the last 3 years, I have selected my doctors and specialist based on what hospital they work with. I have been very careful about that process. last year I was forced to select a new pcp after humana notified me that my current pcp was no longer on their plan.  once again, I went through the process of picking a pcp based on hospital affillation, so I started with the new pcp on jan 4th 2019, my wife quit her on the first day since she seen fit to actually insult her upon entering the exam room.  I stuck it out with her becuse I had many irons in the fire at the time including the fact that I was already scheduled to get a pacemaker in the next 5 days, which the new pcp delayed, i did get it done in the next 10 days.  so throughout the year this same pcp issued referrals for all the current specialist I was seeing all carddio and ep docs. then all of sudden in october she said "no more" you will either do it my way or no way"  all this leads up to some conversations I have had with others that included comments about the doctors "IPA" and that she was "CAPITATED"  and now I am trying to understand how that effected me getting to see the specialist that I have been using for 10-12 years and are all in the same network as the pcp!! sorry for the long winded rant, I am just trying to get some answers about this so it won't happen to me again. thank you for any help and direction

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@AnthonyR624223 

 

Humana Advantage Gold Plus Plan is an HMO.

You do have to have a referral from your pick of PCP to an IN-NETWORK specialist. 

Seems you may have a couple of problems or at least one of them:

1.  Your selected PCP sees no medically necessary reason to refer you to a specialist.

2.  The specialist that you want to see is NO LONGER In-Network - they leave all the time, as you saw last year when your previous PCP left the plan.

 

I don't know where you are getting the IPA / capitation information - with this Humana Advantage Gold Plus Plan you have given the power of referrals to your chosen PCP.

 

Open enrollment ends tomorrow - so it maybe too late to choose another plan for 2020.

However, maybe you can change your PCP - but that may not fix the specialist (that you want to see) problem. 

 

Does your current PCP not think you need to see a specialist?  Ask Them.

Is the specialist you want to see, no longer in the HMO network?  Call them.

I don't understand who is tellin you about IPA's and capitation.

By picking this low cost plan (Humana Advantage Gold Plus), you are accepting the fact that they are managing your care - meaning, saving money by using only those providers that are in the HMO's network and other approved care management procedures..

If they are further managing your care by some other means - they need to tell you how this works.

 

This is from the Humana website https://www.humana.com/medicare/medicare-advantage-plans/humana-gold-plus-hmo 

With Humana’s HMO plans, you choose a doctor from our network to coordinate your care. This doctor is your primary care physician (PCP), and he or she will work with you to coordinate your care. Referrals from your PCP are generally required to see specialists or other providers.

 

You're covered for unlimited medical doctor visits with affordable copayments, so you can see the PCP you choose as often as you need. Plus, you're not locked in once you pick your doctor. You can change to a different in-network doctor whenever you like.

 

New for 2020! We’re offering a new HMO point of service (HMO-POS) plan. Like a traditional HMO plan, the HMO-POS plan offers the option, in certain circumstances, to use providers that are not in the plan’s network.

 

Humana Gold Plus HMO -

(a synopsis from Aging In Place.org)

https://www.aginginplace.org/medicare-plans-offered-by-humana/ 

With an Health Maintenance Organization (HMO) plan, you are required to name a primary care physician who participates in the plan’s network. This medical professional is responsible for your overall care and can refer you to specialists or other providers (who are also in the network) if your medical condition warrants it.

 

Some people prefer these types of plans because they usually have lower premiums and lower out-of-pocket expenses.

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@GailL1 said "

Open enrollment ends tomorrow - so it maybe too late to choose another plan for 2020.

However, maybe you can change your PCP - but that may not fix the specialist (that you want to see) problem. "

 

Changing PCP's merely means Dr Welby will cease to receive the capitation fees and they will now be paid to Dr Kildare.

 

Your PCP in an HMO is REQUIRED to refer you only to specialists that are in your plan network. This become a challenge when the PCP is merely a contractor for an HMO carrier vs an employee.

 

Beyond the referral, your HMO may overrule the PCP recommendation and refuse to allow you to see that particular doc. HMO plans impose quite a few limitations on choice. When you join an HMO you are signing away your rights to direct your care.

 

Caveat emptor


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I can only hope, that some of the readers here learn as much as they can abou IPA'S AND CAPITATED PCP'S,  it is what controls your health care and treatment.  you should ask your doctor if they are involved with an IPA OR ACCEPT CAPITATED PAYMENT. 

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@AnthonyR624223 capitated fee structure means your PCP is paid a flat amount each month while you are covered by the plan and is paid regardless of how many (or few) times you see him or her.

 

Capitated fee structures most often appear in HMO model plans. While it can be an MA plan can also include employer group insurance and individual HMO plans. Kaiser uses the model exclusively but other carriers do as well.

 

If you want freedom of choice for your care do not enroll in a mangled (managed) care plan.

 

FWIW your doctor probably doesn't know if your coverage is part of a capitated agreement or not. The office staff, more specifically those who handle billing, might know. Most large practices "farm out" the coding and billing to 3rd parties that specialize in health care billing.


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Thank you for the info, I am aware that my plan is a humana HMO, and that my primary care doc will have to write a referral for specialest I need to see. that being said, all my doctors that I have been using for the last 12 years are in my humana network, I keep check on that every year to make sure. I have a pacemaker just this year, and now some caroted artery issues. 

 

the other player in this is the IPA, this particular pcp has been writing referrals since jan 4 for all my current doctors, cardio, vascular, sleep, etc....then all of sudden on oct 28th, she said NO! you will do it my way or no way!!

 

some comments in the pcp office is that the IPA is squeezing her to send me in their direction, which is unacceptable! the fact that there are other players involved in my treatment and care just in not right. that an ipa can control my healtcare......sorry for the rant and thank you for your input. 

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@AnthonyR624223 if you like everything about your plan but the PCP, change PCP's


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@somarco wrote:

@AnthonyR624223 if you like everything about your plan but the PCP, change PCP's


I agree - but have another question for you - just when you get time and if you know.

 

So could there ever be a HMO plans like this one at Humana, where they are not actually hiring the providers, like Kaiser Permanente, but have an agreement with them for payment based on the patient not the services?

 

If so, could providers in this type of HMO network develop agreements with other (same HMO) providers under an IPA? 

 

From the AAFP:  https://www.aafp.org/about/policies/all/independent-physicianassoc.html 

Independent Physician Associations (IPAs)

An independent physician association (IPA) is a business entity organized and owned by a network of independent physician practices for the purpose of reducing overhead or pursuing business ventures such as contracts with employers, accountable care organizations (ACO) and/or managed care organizations (MCOs). There are substantial opportunities for innovation in delivery system modeling and benefit design in the creation of physician networks. Specifically, creation of practice networks involving patient-centered medical home (PCMH) practices may accelerate important and necessary changes in health care delivery.

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@GailL1 wrote:

@somarco wrote:

@AnthonyR624223 if you like everything about your plan but the PCP, change PCP's


I agree - but have another question for you - just when you get time and if you know.

 

So could there ever be a HMO plans like this one at Humana, where they are not actually hiring the providers, like Kaiser Permanente, but have an agreement with them for payment based on the patient not the services?

 

If so, could providers in this type of HMO network develop agreements with other (same HMO) providers under an IPA? 

 

From the AAFP:  https://www.aafp.org/about/policies/all/independent-physicianassoc.html 

Independent Physician Associations (IPAs)

An independent physician association (IPA) is a business entity organized and owned by a network of independent physician practices for the purpose of reducing overhead or pursuing business ventures such as contracts with employers, accountable care organizations (ACO) and/or managed care organizations (MCOs). There are substantial opportunities for innovation in delivery system modeling and benefit design in the creation of physician networks. Specifically, creation of practice networks involving patient-centered medical home (PCMH) practices may accelerate important and necessary changes in health care delivery.


I am not really sure what you are asking here, first what I do know is this: and it was quoted from the medicare government site.  once a person buy a medicare advantage plan ( which is anything above part A and B) every single MA plan is CAPITATED.  which means that all the services and equiptment required for medical care and treatment have been established via contract negotiation and the the provider in my case it has been determined between HUMANA and MEDICARE GOV, what the GOV WILL pay HUMANA for any medical care, management, equiptment etc........once that happens in order for the PROVIDER OR PCP to get into the healthcare game, especially if they are a lone PCP,  is to either join or form a IPA. now it is up to the IPA TO negotiate on behalf of the PCP for all their needs and fee's.  so, here is where the problem for the " PATIENT" begins, SINCE THE IPA IS IN CONTROL OF THE "LONE" PCP, THEY WILL DICTATE WHERE AND HOW THE PATIENT TREATED. because they are in control of the bottom line!! it is all about the DOLLARS!! NOTHING ELSE, NOTHING MORE.  I dont think it will be long for the HMO'S to disapear...I was trying to gain the knowledge into the entire chain of custody of the patient and how that dictate their treatment.  it all starts with the capitation, then the provider (humana) then the IPA, AND THEN THE PCP.... the moral of the story is: if you doctor only cares about their bottom line (THE DOLLARS) the patient is screwed no matter what plan they have or how much they pay. it is a sad day in america when our care and treatment is CONTROLLED BY THE IPA!!!

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@AnthonyR624223 you are getting too deep in the weeds. Plus, I would not put a lot of stock in what you see on the Medicare site regarding insurance plans, including MA. Much of what I have seen is confusing, wrong or both.

 

Short answer to all your questions.

 

MA plans are required to cover everything that is covered by original Medicare. But that does not mean your claims and OOP are equal between Medicare and MA.

 

When you enroll in an MA plan your benefits and claims are managed by the insurance carrier, not Medicare.

 

MA carriers are paid a monthly fee by CMS for every enrollee. The MA carrier uses that money to pay claims according to THEIR contracts. The fewer claims paid, the more money the carrier makes.

 

In many states over half the plans are HMO. Likewise, over half do not charge a monthly premium.

 

Claims are controlled in many ways including, small networks, limited access to health care, out of network penalties, copay's, pre-authorization, claim denials.

 

Consider MA plans to be like Private Benjamin's awakening. She thought she joined the Army with the yachts and the condo's. 

 

Same for MA plan holders.

 

You don't get to do it your way.

 

If you want your claim paid, play by the rules.


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