Farmer Steven A, Shalowitz Joel, George Meaghan, McStay Frank, Patel Kavita, Perrin James, Moghtaderi Ali, McClellan Mark
Duke-Margolis Center for Health Policy, Washington, District of Columbia; George Washington University, Washington, District of Columbia; Northwestern University Feinberg School of Medicine and Kellogg School of Management, Chicago, Illinois; The Brookings Institution, Washington, District of Columbia; and
Northwestern University Feinberg School of Medicine and Kellogg School of Management, Chicago, Illinois;
Pediatrics. 2016 Aug;138(2). doi: 10.1542/peds.2015-4367.
Payers are implementing alternative payment models that attempt to align payment with high-value care. This study calculates the breakeven capitated payment rate for a midsize pediatric practice and explores how several different staffing scenarios affect the rate.
We supplemented a literature review and data from >200 practices with interviews of practice administrators, physicians, and payers to construct an income statement for a hypothetical, independent, midsize pediatric practice in fee-for-service. The practice was transitioned to full capitation to calculate the breakeven capitated rate, holding all practice parameters constant. Panel size, overhead, physician salary, and staffing ratios were varied to assess their impact on the breakeven per-member per-month (PMPM) rate. Finally, payment rates from an existing health plan were applied to the practice.
The calculated breakeven PMPM was $24.10. When an economic simulation allowed core practice parameters to vary across a broad range, 80% of practices broke even with a PMPM of $35.00. The breakeven PMPM increased by 12% ($3.00) when the staffing ratio increased by 25% and increased by 23% ($5.50) when the staffing ratio increased by 38%. The practice was viable, even with primary care medical home staffing ratios, when rates from a real-world payer were applied.
Practices are more likely to succeed in capitated models if pediatricians understand how these models alter practice finances. Staffing changes that are common in patient-centered medical home models increased the breakeven capitated rate. The degree to which team-based care will increase panel size and offset increased cost is unknown.
支付方正在实施替代支付模式，试图使支付与高价值医疗相匹配。本研究计算了一家中等规模儿科诊所的盈亏平衡人头费率，并探讨了几种不同的人员配置方案如何影响该费率。
我们通过对诊所管理人员、医生和支付方的访谈，补充了文献综述和来自200多家诊所的数据，以构建一份按服务收费的假设性、独立、中等规模儿科诊所的损益表。该诊所转变为完全人头付费制以计算盈亏平衡人头费率，保持所有诊所参数不变。调整小组规模、管理费用、医生薪资和人员配置比例，以评估它们对每月每人盈亏平衡费率的影响。最后，将现有健康计划的支付费率应用于该诊所。
计算得出的盈亏平衡每月每人费率为24.10美元。当进行经济模拟允许核心诊所参数在广泛范围内变化时，80%的诊所盈亏平衡时的每月每人费率为35.00美元。当人员配置比例增加25%时，盈亏平衡每月每人费率增加12%（3.00美元）；当人员配置比例增加38%时，增加23%（5.50美元）。当应用来自实际支付方的费率时，即使采用初级保健医疗之家人员配置比例，该诊所也是可行的。
如果儿科医生了解这些模式如何改变诊所财务状况，诊所更有可能在人头付费模式中取得成功。以患者为中心的医疗之家模式中常见的人员配置变化增加了盈亏平衡人头费率。基于团队的护理将在多大程度上增加小组规模并抵消成本增加尚不清楚。
