By NextBestFitCapitation for primary care and integrated systems
Pay a fixed amount per enrolled person per year to a primary care practice or integrated system.
Optional, as the detailed plan sets out: primary care practices can take a blended per-patient payment, and integrated systems can take a risk-adjusted budget for patients who choose them.
To review: Opt-in only; the fee schedule stays the default. Watch for upcoding and avoiding sick patients.
Review ledgerHow this path connects
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Pay primary care practices per enrolled patient
- Risk-adjust payments
- Set quality and access requirements
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
- U.S. prices are far higher than in other countries
Paying a fixed amount per enrolled person instead of per service removes the incentive to bill more services, rewarding prevention and allowing care by calls and messaging.
- Prevention and public health are underfunded
Fixed payments per enrolled person reward prevention rather than additional services.
- Reduces income or business for affected groups
Fixed payments per enrolled person leave small practices bearing financial risk.
- Paying a fixed amount per patient rewards doing less
Fixed payments per enrolled person create incentives to avoid sick patients or under-treat them.
3 paths soften this
Risk adjustment plus outcome monitoringPaying a fixed amount per patient rewards doing lessChosenBlended payment: part capitation, part fee-for-servicePaying a fixed amount per patient rewards doing lessChosenSalaried clinicians in public or non-profit groupsPaying a fixed amount per patient rewards doing lessRejected - Targets and quality metrics invite gaming
Fixed payments per enrollee create an incentive to avoid sick patients rather than provide their costly care.
Who's affected
- People with employer coverage
- U.S. prices are far higher than in other countries: Private plans pay the highest prices, passed on through premiums.
- Taxpayers and public budgets
- U.S. prices are far higher than in other countries: Public programs pay more than peer countries too.
- Doctors, nurses, and other clinicians
- U.S. prices are far higher than in other countries: Paying a fixed amount per enrolled person instead of per service removes the incentive to bill more services, rewarding prevention and allowing care by calls and messaging.
- People who will need care in the future
- Prevention and public health are underfunded: Limited prevention funding leaves chronic disease driving treatment needs.
- People with ongoing or specialist care needs
- Prevention and public health are underfunded: Limited prevention funding leaves chronic disease driving treatment needs.
- Hospitals, clinics, and care organizations
- Paying a fixed amount per patient rewards doing less: They keep the difference when care costs less than fixed payments.
- Targets and quality metrics invite gaming: They can benefit by changing referral dates, avoiding sick patients, or upcoding.
- Health insurers, brokers, and their shareholders
- Paying a fixed amount per patient rewards doing less: They keep the difference when care costs less than fixed payments.
- Hospitals and specialist groups with high private prices
- U.S. prices are far higher than in other countries: Providers with pricing power earn more per service.
- Drug and device makers
- U.S. prices are far higher than in other countries: U.S. prices are well above those in peer countries.
- Hospitals, clinics, and care organizations
- Prevention and public health are underfunded: More chronic disease creates more treatment business.
- People with ongoing or specialist care needs
- Paying a fixed amount per patient rewards doing less: Fixed payments encourage avoiding sick patients or providing less care.
- Targets and quality metrics invite gaming: Gaming wait-time and quality measures undermines their intended protection.
- Risk-adjusted payments; quality bonuses
Where it has been tried
- UK GPs, Kaiser Permanente: Capitated primary care.
- England, United Kingdom: For 2023–2024, England's GP global-sum payment rose from £99.70 to £102.28 per weighted patient.Sources: NHS England (2023)