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
PER CASE
FEE FOR SERVICE
CAPITATION
ON RETAINERSHIP BASIS
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
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
• 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
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
• 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
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
The possibility of Providers giving Suboptimal
Care through under utilisation of Care Services
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
•
•
•
•
•
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.
END