Blended Capitation Clinical ARP model

The Blended Capitation Model is a new method for paying family doctors based on how many patients they have and the number of services provided.

The goal is to provide Albertans with increased access to primary health care by supporting stronger and long lasting relationships with family doctors. This new model will give doctors the flexibility to provide services in different ways so they can spend more time with you and deliver a full range of care that encourages health promotion, wellness and teamwork with other health providers.

At the same time, the Blended Capitation Model will support the health system over the long term because government will have a better idea of the health services that physicians are providing, resulting in a more stable health system and better ability to predict health care spending.

Through a combination of patient-based capitation payments and volume-based fee for service payments, the Blended Capitation Model aims to promote collaborative team-based comprehensive care that encourages health promotion, wellness, continuity of care, and system sustainability. It supports the guiding principles of Alberta’s Primary Health Care Strategy, the patient’s medical home, and the section of general practice and section of rural medicine’s Primary Care Compensation Strategy.

Information for Albertans

1. Changes in the care received under this new payment model

You will continue to receive excellent care from your family doctor with the added benefit of increased access to primary health care. The goal is for you to have more of your health concerns addressed in each appointment, receive a greater range of services, and develop a close relationship with your doctor and other health care providers. The model is designed for you to have greater access to other health providers, such as nurses, dieticians and physical therapists, throughout your health care journey. There will also be a greater emphasis on patient education, health promotion and wellness.

2. Where and when you can seek care under this new payment model

You will still be able to access care anywhere at any time. However, your family doctor’s pay will be impacted when you access care from a family doctor at another clinic, medicentre or walk-in clinic. This is why it’s important to sign up with your family doctor by completing an “affiliation form”. The affiliation form outlines details of the patient-doctor relationship, and asks patients to seek as much care at the clinic where they have signed up as possible. This will allow your family doctor to have a full understanding of your needs and your care and will create a trusting and well-informed relationship between you and your family doctor.

3. Affiliate with only one clinic

You can only be signed up at one clinic at a time. If you sign up with one clinic and then later sign up with a second clinic, you will automatically be removed from the first clinic’s affiliation list.

4. Benefits and responsibilities of signing the affiliation form

As part of the Blended Compensation Model, both you and your doctor will sign the affiliation form agreeing to a patient-doctor relationship and the expectations and benefits related to the relationship. By signing the affiliation form, you are agreeing to seek care, whenever possible, at the clinic you sign up with and to update the clinic of any changes in your health. In turn, you have the benefit of accessing care in one place that not only coordinates your care and journey in the health system, but also creates a better relationship with your doctor, clinic and other health providers.

Information for primary care physicians

1. Eligibility for the Blended Capitation Model

Office-based comprehensive primary care clinics that have high administrative capacity and are able to adapt to the anticipated practice changes are eligible to apply for the Blended Capitation Model. In addition, prospective clinics must operate out of a single location, have a minimum of three physicians, and all of the physicians within the clinic must be interested in joining the model. The physicians may provide services in this clinic full-time or part-time, but will not be able to provide the same program services (or “in-basket services”) to the same program patients (or “rostered patients”) outside of this clinic.

2. No requirement to maintain a certain affiliated patient panel size

Clinics that join the new model are not subject to any roster size requirements. Clinics have the discretion to sign up, or “affiliate”, as many patients as they see fit to their roster. The model compensates clinics based on their rostered patients. However, rostered patients who are not able to access services at the clinic and must seek care elsewhere will cause the clinic to be financially penalized for the amount of the in-basket services provided. This means that physicians should consider patient access when creating their service delivery model.

3. The physician-patient affiliation process

Both the physician and patient will sign a form agreeing to a physician-patient relationship and its associated expectations and benefits. Completed forms will be collected by clinics who will then submit the corresponding patient information electronically to Alberta Health through the Central Patient Attachment Registry (CPAR) online system. Physicians can bill up to two interactions with each patient before formally committing to the relationship. However, once the initial two interactions are exhausted, the physician will not receive compensation for any subsequent services provided unless they affiliate the patient.

4. Basket of services and capitation rates

A basket of services has been developed to reflect the typical activities of a non-specialized general practitioner in an office-based setting. The capitation rate is calculated based on a patient’s average use of the basket of services based on their age, sex and risk status.

5. How physicians are paid in this new model

Once a patient is formally affiliated with a participating clinic, a payment structure will begin where a patient-based capitation payment is made bi-weekly. These payments are intended to compensate physicians for any in-basket health services provided and are calculated based on 85% of the patient’s total capitation rate. Physicians are eligible to receive the remaining 15% of the patient’s total capitation rate through fee-for-service submissions. Physicians will not receive more than 100% of the patient’s capitation rate for providing in-basket health services. All out-of-basket services will be paid at 100% of the fee-for-service rate. All other payments, such as the Business Cost Program and Rural Remote Northern Program, will not change.

6. Compensation for out-of-basket services

For rostered patients, a clinic will be paid 100% fee-for-service for any out-of-basket health services provided. For non-affiliated patients, clinics can bill up to two interactions (inclusive of in-basket and out-of-basket services) with each patient. However, once the initial two interactions are exhausted, the physician will not receive compensation for any subsequent services provided unless they affiliate the patient.

7. Continue submitting fee-for-service claims for in-basket health services

Physicians must continue to bill for all services provided, even when the physician has received the full capitation rate for a rostered patient.  Capitation rates are calculated based on the average use of the basket of services, therefore a significant decrease in reporting could compromise the level of compensation physicians receive. Additionally, a patient’s risk status is determined based on diagnostic codes associated with fee-for-service claims. If reporting decreases, risk status will be underestimated, patients will appear to be healthier than they are, and payment will be under-represented.

8. Physicians’ compensation compared to fee-for-service

In general, compensation levels will depend on a number of factors. For example, if a clinic creates efficiencies by utilizing other providers or prioritizing disease prevention, they may be able to affiliate more patients and receive a higher level of compensation. However, if a clinic increases its panel size to the extent that patient access is compromised, compensation may decrease due to financial penalties.

Financial modeling will be completed for clinics that are eligible, and selected, for inclusion in the model. This modeling will give clinics an idea of their future compensation levels. Additionally, clinics can leave the model at any time if the compensation arrangement no longer works for them.

9. Impact of patients who receive care at another clinic

If an affiliated patient receives an in-basket service at another clinic, the home clinic receives a financial deduction (or “negation”) for the value of the service provided. The home clinic will be negated at 100% of the service cost, but will not be negated more than 85% of the capitation rate for that patient. The home clinic will not be negated if an affiliated patient receives an out-of-basket service at another clinic. If an affiliated patient subsequently signs up with a different clinic or leaves the province or country, the initial affiliation will be automatically terminated.

10. Information Technology requirements for new compensation model

Physicians will be given access to the program CPAR in order to maintain their roster, and access to a second program “APP Online” to access their financial reports. They will also be required to use an electronic medical record. Clinics will receive support for using both CPAR and APP Online prior to implementation of the Blended Capitation Model.

11. Either the new compensation model or fee-for-service

All physicians within a clinic will need to move onto this compensation model. This will allow for continuity of care and sufficient access within the clinic.

12. Switch to a Blended Capitation Model

In 2017, the Sylvan Family Health Center was selected as the demonstration project for the Blended Capitation Model in Alberta. Alberta Health is currently recruiting new clinics for the Blended Capitation Model.

Participation in the model is voluntary and clinics can leave the model at any time if the compensation arrangement no longer works for them.

Contact

For more information, email Rebecca Gibeault at rebecca.gibeault@gov.ab.ca or Allan Florizone at allan.florizone@albertadoctors.org