Capitation advantages, concerns
For patients, a major concern regarding capitation models is whether their contracts allow them to see the specialists of their choice. While the care provided under capitation is more aligned and consequently more effective, patient choice (as with any narrow network) is restricted.

This makes the quality of the patient/member experience even more essential to provider/payer customer retention. Providers/payers must compensate for the loss of patient/member choice through superior engagement and efficient care coordination. Improving both should help to ensure better outcomes and satisfy patients/members.
One clear advantage offered by global capitation programs is consistency of contracts. Nonetheless, providers with contracts across different lines of business – Medicare, Medicaid, commercial, employer-direct components – need the ability to manage the nuances of each program. An administrative strategy for a successful capitation program is to develop a more consistent view of the included services and guidelines. Using this approach can streamline management of multiple programs across payer contracts.

By creating incentives for collaboration and better care coordination between primary and specialty care providers, capitation contracts are strongly supportive of VBC goals. As the Centers for Medicare and Medicaid Services (CMS) writes, “When incentives for primary care clinicians are aligned to reward the provision of high-value care, the quality and cost effectiveness of patient care improve.”

Preparing your organization for capitation
Healthcare organizations that have no experience with global capitation must take several steps to ensure their ability to fully support capitation reimbursement models. Thus, it is imperative that:

• Primary care and specialty care are aligned
• Patients/members are provided a positive experience that includes successful delivery of care documented through quality measures associated with outcomes
• Healthcare organizations deploy a digital infrastructure that supports a network of multiple stakeholders, which may include hospitals, health systems, physician practices, payers, social service networks, and community-based organizations

Conclusion
Global capitation can benefit providers, payers, and patients. But these contracts require thoughtful planning, careful alignment between PCPs and specialists, a commitment to optimizing the patient/member experience, and a robust and scalable digital infrastructure. As healthcare organizations continue to migrate to more narrow networks and assume risk for a particular population under a fixed payment model, they have a greater stake in understanding referral patterns and consumption of services and are motivated to be judicious about how they deploy resources.

About the author: Lynn Carroll is the COO of HSBlox, an Atlanta-based technology company empowering healthcare organizations with the tools and support to deliver value-based care (VBC) successfully and sustainably.

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