Overview
The Blended Capitation Model (BCM) compensates family physicians based on the number of patients they have and the type of services provided.
This model offers flexibility to family physicians, allowing them to customize their service delivery in innovative ways. Physicians participating in the BCM can dedicate more time to each patient and provide a wide range of care that focuses on health promotion, wellness, and collaboration with other health care providers.
The primary goal of this model is to enhance Albertans' access to primary health care by establishing stronger and lasting relationships with their family physicians. Simultaneously, the BCM supports the long-term stability of the health care system, increased predictability for oversight of health care expenditures, and a more resilient and sustainable health care system.
Eligibility for the Blended Capitation model
To be eligible to apply for a BCM Clinical ARP, primary care clinics must:
- be office-based
- offer comprehensive primary care services
- possess strong administrative capabilities
- be able to adapt to expected practice changes
Additionally, clinics must be:
- inherently interested in exploring new clinical processes to improve patient care
- able to navigate and overcome challenges through innovative solutions
- committed to quality improvement
Primary care clinics who have a philosophy of care aligned with the Patient’s Medical Home (PMH) are likely to benefit the most from this model.
No requirement to maintain a certain number of affiliated patients
Clinics that join the BCM are not obligated to maintain a specific patient roster size. Clinics have the discretion to affiliate as many patients as they choose. The BCM compensation is directly correlated with the number of patients that are affiliated to the clinic’s roster.
Physicians should consider patient access when developing their service delivery model, ensuring that patients can access timely care at their clinic.
The physician-patient affiliation process
Both the physician and patient are required to sign a form, indicating their agreement to establish a physician-patient relationship and acknowledging the associated expectations and benefits. Completed forms are collected by clinics and the clinic electronically submits the patient’s information through the Central Patient Attachment Registry (CPAR) online system.
Initially, physicians may bill fee-for-service for up to two interactions with each patient before formally committing to the relationship. However, once the initial 2 interactions are exhausted, the patient will have to be affiliated to the clinic’s roster for the physician to be compensated for further services they provide.
Basket of services and capitation rates
The BCM "basket of services" refers to the range of services that a non-specialized general practitioner typically provides in an office-based setting.
A patient’s capitation rate is determined by calculating their average use of services from the basket based on their age, sex, and risk status.
How physicians are paid
Once a patient is formally affiliated to a clinic’s roster, the clinic receives a patient-based capitation payment every two weeks. Capitation payments are calculated based on 85% of the patient’s total capitation rate and serve as compensation for the in-basket health services provided by physicians.
Physicians are able to receive the remaining 15% of the patient's total capitation rate through fee-for-service submissions. However, physicians do not receive more than 100% of the patient's capitation rate for providing in-basket health services.
All services provided outside the basket of services are reimbursed at 100% of the fee-for-service rate.
BCM clinics continue to remain eligible for all other payments, such as those from physician support programs like the Business Cost Program, Rural Remote Northern Program, etc..
Compensation for out-of-basket services
Out-of-basket services are those medical services found in the Schedule of Medical Benefits (SOMB) that are not listed in the BCM basket of services.
Processing payments for out-of-basket services is not dependent upon the patient’s affiliation status on the clinic’s roster. All out-of-basket services for patients who are both affiliated and unaffiliated are assessed and paid at 100% of the fee-for-service rate using existing SOMB rules.
Submit fee-for-service claims for in-basket health services
It is important that physicians continue to bill fee-for-service for all of the services they provide, even if the clinic has received payment for the full capitation rate for a patient who is affiliated to the clinic’s roster.
Capitation rates are calculated based on the average utilization of the basket of services. As a result, a substantial decrease in billing for services delivered could jeopardize the level of compensation clinics receive.
Additionally, a patient's risk status or case complexity is determined, in part, by diagnostic codes associated with fee-for-service claims. If reporting decreases, the complexity of patients may be underestimated, making them appear healthier than they actually are. Consequently, this underestimation may lead to under-representation in capitation payment for services that are provided.
Business Cost Program and Rural Remote Northern Program payments are also contingent on consistent billing.
Compensation compared to fee-for-service
Compensation levels for clinics who join the BCM depend on a multitude of factors. For instance, clinics that enhance efficiencies by using other health care providers or prioritizing disease prevention may have the opportunity to affiliate more patients to the clinic’s roster, resulting in increased compensation.
However, if a clinic expands its patient roster size to the extent that it compromises patient access, financial penalties may be incurred, leading to a decrease in compensation.
Financial modelling is offered to clinics that are eligible for and interested in exploring the BCM. The modelling provides an estimation of a clinic’s future compensation levels compared to historical fee-for-service earnings. This will help the clinic to understand their potential earnings within the BCM.
At any point during exploration of the BCM, clinics have the autonomy to withdraw their interest. Similarly, clinics who join the BCM can choose to voluntarily leave the model at any time, with appropriate notice, if the compensation arrangement no longer suits their practice.
Patients who receive care at another clinic
An affiliated patient can seek care wherever they choose. However, when an affiliated patient receives an in-basket service at a different clinic, the patient’s home clinic experiences a financial deduction equal to the value of the service provided. This is to ensure duplication of payment does not occur. The deduction incurred by the home clinic amounts to 100% of the fee-for-service cost of the service provided, but will not exceed more than 85% of the patient’s total capitation rate.
If an affiliated patient receives an out-of-basket service at another clinic, the home clinic does not face any financial deduction.
In the event that an affiliated patient decides to affiliate with a different clinic or leaves the province or country, the initial affiliation with the home clinic is automatically terminated.
Information technology requirements
Clinics are granted access to:
- Central Patient Attachment Registry (CPAR) – to manage their patient roster
- APP Online – to access their financial reports
Additionally, clinics are obligated to utilize an electronic medical record.
To facilitate the implementation of the BCM, clinics receive resources and support in utilizing both CPAR and APP Online. This support is provided prior to the implementation stage, ensuring clinics are well-prepared and equipped to effectively utilize these systems.
ARP model or fee-for-service
The primary tenet of the BCM is to advance the Patient’s Medical Home at the clinic level. To do so and ensure continuity of care and optimal access for patients, it is preferred that all physicians working within a clinic transition to the BCM. However, alternative options may be considered on a case-by-case basis.
Participation is voluntary and clinics can leave the model at any time if the compensation arrangement no longer works for them.
Switch to a Blended Capitation model
If you are interested in the Blended Capitation model, contact us.
Contact
Connect with us if you have questions or are interested in a model:
Email: [email protected] – Accelerating Change Transformation Team (ACTT)
Email: [email protected] – Alberta Health