Medical Groups in California: Managing Care under Capitation

Health Affairs

Volumn 15, Issue 1, 1996, Pages

  Trauner, Joan B ^a,b   Chesnutt, Julie S ^c  

^a PM Squared

^b Human Resources Advisory Group ^*

^c NONE

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CAPITATION FEE; COST CONTROL; ECONOMICS; FINANCIAL MANAGEMENT; FORECASTING; HEALTH INSURANCE; HEALTH MAINTENANCE ORGANIZATION; HOSPITALIZATION; HUMAN; RISK; STATISTICS; UNITED STATES; UTILIZATION REVIEW;

CALIFORNIA; CAPITATION FEE; CONTRACT SERVICES; COST CONTROL; FORECASTING; HEALTH BENEFIT PLANS, EMPLOYEE; HEALTH MAINTENANCE ORGANIZATIONS; HOSPITALIZATION; HUMANS; RISK;

EID: 1542534798     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.15.1.159     Document Type: Article

References (9)

1. The UMGA (Seal Beach, California) is composed exclusively of medical groups and selected IPAs providing health services to prepaid plan enrollees. UMGA membership includes more than eighty-five medical groups and seven IPAs nationwide, of which a majority (fifty-one) are headquartered in California. To qualify for membership, groups must have at least one capitated contract covering at least 2,500 enrollees, have a common medical record, and pass a site visit. As of January 1995, total UMGA membership represented over 4-5 million prepaid enrollees and 10,000 physicians. The average UMGA member group has eighty-one physicians, 49,000 prepaid enrollees, eight health care sites, and ten HMO contracts. The MGMA (Englewood, Colorado) represents more than 6,500 medical group practices nationwide. MGMA's membership includes both medical groups (of at least three physicians) and management organizations that provide administrative and related support services to one or more medical groups. GHAA (Washington, D.C.), known as the American Association of Health Plans (AAHP) since its merger with the American Managed Care Review Association in November 1995, is the national trade association representing managed health care plans. The AAHP has approximately 1,000 member plans nationally, including HMOs, PPOs, and other types of managed care plans, covering approximately 100 million Americans.
2. J. Trauner, R. Miller, and J. Chesnutt, "Managed Care in Southern California: Multiple Variations on a Capitation Theme" (Unpublished manuscript, September 1994); and A.C. Enthoven and S.J. Singer, "Managed Competition and California's Health Care Economy," Health Avoirs (Spring 1996): 39-57
3. J. Trauner, R. Miller, and J. Chesnutt, "Managed Care in Southern California: Multiple Variations on a Capitation Theme" (Unpublished manuscript, September 1994); and A.C. Enthoven and S.J. Singer, "Managed Competition and California's Health Care Economy," Health Avoirs (Spring 1996): 39-57
4. For all figures presented in this DataWatch, the "average" line in the graphs represents the member-month weighted average for the five-group sample.
5. The UMGA survey does not include any information on institutional risk pool distributions.
6. The MGMA samples were compiled from the 1,166 responding MGMA member groups as published in "MGMA Cost Survey: 1994 Report Based on 1993 Data." The comparison California and non-California samples comprised all responding MGMA groups that (1) were multispecialty, (2) reported between $50,000 and $925,000 in net prepaid revenues per FTE physician (to assure significant prepaid revenue), and (3) had fewer than 1,000 FTE physicians (to eliminate very large physician entities affiliated exclusively with one prepaid plan).
7. Net medical revenues means total income received for patient care activities less adjustments for patient refunds, returned checks, and so on.
8. Also see J.C. Robinson and L.P. Casalino, "Vertical Integration and Organizational Networks in Health Care," Health Affairs (Spring 1996): 7-22.
9. Based on data from the 393 plans responding to GHAA's Eighth Annual Industry Survey, as published in HMO Industry Profile: 1994 Edition. Utilization information is for 1992; financial information is for 1993. California statistics are for HMOs with more than 50,000 enrollees, excluding statistics reported by the Kaiser Foundation Health Plans in northern and southern California. National statistics include all survey respondents, including California plans.