MANAGEMENT OF CAPITATION UNDER THE NATIONAL HEALTH INSURANCE SCHEME

1
MANAGEMENT OF CAPITATION UNDER THE NATIONAL
HEALTH INSURANCE SCHEME

• 
  
• 
  BEING A
  PRESENTATION
• 
  BY
• Dr HOPE
  UWEJA
• Gen. Manager
  (Accr. Insp)

2
MODE OF PAYMENTS UNDER MANAGED CARE

• PER DIEM
• PER CASE
• FEE FOR SERVICE
• CAPITATION
• ON RETAINERSHIP BASIS

3
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

4
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

5
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

6
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

7
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

8
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

9
DISADVANTAGE OF CAPITATION PAYMENT SYSTEM IN
MANAGED CARE

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

10
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.

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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.

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END