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.

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