Weavermom asked a good question about the difference between capitation payments and bundled payments:
Is this the same as capitation? Where doctors basically get paid more when they provide the least treatment? I believe that this has been tried, and I find it personally terrifying. The minute I get expensive, I’m expendable. The minute I get really sick, I am ‘stealing’ my doctor’s take-home pay. If I am mis-construing the point, please let me know….
Capitation payments are when a provider group gets a set fee per person it covers per month to maintain their patient pool’s health. If the provider group spends less than the total payment, they keep the difference as profit. If they spend more than the total payment, the provider group eats the loss. The goal of this payment structure is to encourage providers to perform efficient and effective care on patients while also encouraging preventative and low cost early interventions instead of high cost emergency/acute interventions. Capitation models have been around for a couple of generations now, and it effectively shifts some of the popualtion health management risks and responsibilities away from the insurance company and towards the primary care providers.
Bundled payments are also lump sum payments which are intended to promote efficient, effective care while shifting some of the treatment and outcome risk onto the providers. However, bundled payments are far more targetted than general capitation payments. In the example that Weavermom respnded to, the bundle payment was for less than a dozen types of cancer diagnosises. The providers are given a big lump of money per person with the specific diagnosis and that money can be spent however the doctors think is appropriate. The goal, in the example that I used this morning, would be to encourage doctors to use a shorter treatment at higher doses which is as safe and effective as a longer course of treatment at lower dosing while being significantly less expensive and disruptive of patients lives. Bundled payments are often calculated as the sum total of the best practice course of treatment plus a small percentage added in for contingencies and profit. The goal is to not pay for expensive and ineffective treatments.
Both of these payment schemes do provide an incentive for doctors to undertreat initially. That is a downside to the system when the current treatment levels are either at the ideal point or are already under the ideal point. However, from a system/policy perspective, most Americans are overtreated for mimial real gain in health (see the cancer example from this morning, back surgery versus physical therapy etc) but at great additional cost, so as long as there are strong quality metrics built into the program that monitor results for performance similar to or better than traditional payment schemes, I think this is a risk worth taking.
Finally, as a side note, bundled payments and capitation payments can be quasi-blended together when capitation payments are aggressively risk adjusted. For instance, if a diabetic individual is in a capitated group where the baseline capitation payment is $450 per person per month, the fact that the person is diabetic might lead to a risk adjustment of 100%, so the diabetic person would be a revenue stream of $900 per month as diabetics are significantly more expensive to keep in good health than non-diabetics, all else being equal. So there is a back door way of a chronic condition becoming a quasi-bundled payment within a capitation scheme.






