History of Capitation
Events Surrounding Capitation
Shaping the 20th Century
1900 to 1905
National Healthcare
Reacting to Government Control
English Healthcare
Government Sponsorship 1920 – 1930
Differences in British and U.S. Health Care
Beginnings of Blue Cross
Capitation in the Western United States
Local Medical Society Expelled Shadid
The CCMC
New Deal Health Care
Contractor General Hospital
Kaiser Health Delivery
1950 to 1970
1965 Medicare 101
HMO Act of 1973
The 1980s
1990s to today
Dates Leading to Managed Care Capitation
1847 - American Medical Society
1883 - Bismarck Introduces Employer Funded Coverage
1911 - England Introduces Compulsory Health Care Coverage
1912 - Private Insurance Introduced
1918 - California Voters Defeat State Health Care Insurance
1927 - Baylor Hospital Offers Prepaid Hospital Coverage
1934 - Prudential and Metropolitan Offer Indemnity Coverage
1935 - 1939 Health Care Expansions
1938 - Government Antitrust Case and the AMA
1945 - McCarran-Ferguson Act
1965 - Medicare Signed into Law
1966 - Adoption of CPT code by AMA
1973 - Health Maintenance Organization Law Passed
1986 - Catholic Health Care West Consolidates 10 Hospitals
The 1990s to Today - Building Managed Care Infrastructures
Patient Care (top of page)
Meet Managed Care
Patient Identities Navigating Managed Care
Subscriber
Dependent
Dual Coverage
Linked
Member
Eligibility
Zebra
The Managed Care Highway Rules of the Road
Benefits
Copayments
Plan Providers
Exclusive Providers
Emergency Room Rules
Out of Area Rules
Maximum Visit Restrictions
Your Health Care Under Managed Care and Capitation
Obtaining a Referral
Starting Line
The PCP Role in Obtaining a Referral
The Specialist Role in Obtaining a Referral
The HMO or IPA Medical Review Process
Referrals for Diagnostic Services
Referrals for Ancillary Services
Going to the Doctor
Be Prepared
Be Patient
Be Financially Knowledgeable
Your Membership Card
Copayments
Benefit Hand Book
Plan Provider Roster
Obtaining Prior Authorization
Start - What Needs an Authorization?
The PCP in the Authorization Process
The Specialist in the Authorization Process
Identities of the Specialist
The Hospitalist Role in the Hospital
HMO IPA Guidelines for Authorization Review
The Discharge Planner
The Nurse Reviewer
Large Case Management
Hospital Facility Authorization
One-Hour Surgery
HMO Drug Formulary
A Formulary is a Guide for your Physician
Formulary Example
Wellpoint and the FDA
Home Health Care
What Happens When You Have the Best Insurance?
Managed Care Highway Driving Test
Test your Knowledge of Managed Care
Capping the Physician (top of page)
Before Managed Care, the Fee For Service Business Model
Fueling the Fee For Service Business Model
Variations on the Business Model
Differences in Specialties
Variety of Services
Physician CPT codes
Hourly Based Physicians vs. Procedure Based Physicians
Office Based Doctors vs. Hospital Based Doctors
The Managed Care Makeover of the Physician Business Model
Reduce the Number of Billed Services
Medical Policy
Surgery Protocol
Benefit Design
Reduce Amounts Being Billed
Antitrust Issues
California Relative Value Scale
Resource Based Relative Value Scale
Work Units
Practice Units
Malpractice Units
GPCI Units
The Formula
Calculate and RBRVS Payment
Conversion Factor
Addendum A & B
Withholds
Utilizing Oversight Review
Prospective Review of Care
Retrospective Review of Care
New Business Relationships
The Independent Practice Association
Cost Shifting Operations
The IPA, Origins and Today
Influences on the Doctor
Dividing Doctors
Frustrations
Losing Authority
New Relationships
The IPA and the Doctor
Relationships to the Patient
Relationships to Hospitals
Doing Business with Managed Care
Eligibility Verification
Billing Requirements
Proprietary Rights of Patients
Outcomes of the Makeover
The Marketplace (top of page)
Competition in Health Care before Managed Care
Health Insurance Trade Associations
Medical Competition
Health Care as a Commodity
Shared Monopolies
Marketplace Competition
Benefit Plan Design
Delivery System Deployment
HMO
POS
PPO
EPO
IDS
IPA
MSO
Location Issues
Funding Sources
Government Funded
Government Employee Funded Plans
Federal & State Funded Entitlement Plans
Stock Market Funded
Taxation Influence
Not-For-Profit Systems
Hospitals
Foundations
Self-Funding
For Profit Systems
Privately Funded
Employer Employee Funded
1999 Health Care Market Share Chart
Serious Concerns for the Future of the Health Care Market
Doing the Math (top of page)
The Data and Math used in Managed Care
Capitating the U.S. Healthcare system?
Insured
Uninsured
Premium
Delivery System
Providers
The Employer
Data Set and Premium Calculation
Healthcare Data for Jones Manufacturing
Allocating Premium Cost
Ratios and the Premium Formula
Health Care Premium Calculation
Plan Benefits
The HMO
Cost Model
A Sample Model
Length of Stay
Per 1000 Utilization
Average Service Cost
Cap Model
Employer
Employee
Premium
HMO
IPA
Ancillaries
Hospital
IBNR
Lag Report
IBNR Calculation Example
Completion Ratio
Lag Ratio
IBNR Estimate
Start - End Risk
Direct Risk
Delegated Risk
Claim Cycles
Stop Loss
The Hospital
The Doctor
Reporting Capitation
Payment Reporting
Enrollment Reporting
Claim Lag Reporting
Financial Reporting
Utilization Reporting
Physician Utilization
Primary Care Doctor
Specialty Care Doctor
Risk Assumptions
Business Partnering Assumptions
HMO
Primary Care
Specialists
Capitation Cost Assumptions
Monthly Visits
Sharing Capitation
Capitation Budget Calculation
The Parts of the Budget
Contract Risk Assumptions
Customer Services Cost
Provider Services Cost
Financial Reporting Cost
Credentialing Cost
Quality Care Program Cost
Cost Containment
Government Reporting
Measurement Tools
Physician Fee For Service Tools
A & R Days Outstanding
Collection % of Billings
Overhead % of Practice Income
Relative Value Scale Unit Cost
Capitation Tools
Completion Ratio of Claims
Medical Loss Ratio
Per 1000 Utilization
Delegating CPT code Risk
Ancillaries
Attachments:
On the CD-ROM under spreadsheets folder
Ardays.xls - AR Days Outstanding calculation
IBNR.xls - Incurred But Not Reported calculation
RVScost.xls - Relative Value Cost Practice Analysis
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