Make sure that the scope of services required under the contract is well defined and within the capabilities of the provider. Make sure that the rate of claims used to calculate the capitation rate has been historically predictable and stable. Make sure that the provider has the wherewithal and resources to actually have an impact on the flow of patients and the services that they receive. This is one of the keys to a successful arrangement, and it is to the advantage of both parties that this be so. Primary care capitation requires a primary care assignment where members choose a PCP or where one is assigned to them.
Capitation implies that a specific set of services is paid on a fixed monthly fee per member.
Many times primary care capitation is also accompanied by various incentive risk pools, where physicians can share in savings that accrue for reduced utilization of specialty services and hospital care. Global medical group capitation is an extension of primary care capitation, but usually covers all physician services. Thus, a patient chooses a medical group and the services covered include physicians specialty care as well. This approach works well for medical groups, medical specialty clinics or physician care clinics. A key component of how successful these programs are within each respective provider group is predicated on the various means of distribution of the cap revenue to the individual members of the medical organization.