Table 7 Expert panel’s comments and decisions on capitation attributes and levels
Initial attribute name | Initial levels | Comments by experts | New attribute name | New levels |
|---|---|---|---|---|
1. Adequacy of the payment rate to cover the cost of services | Adequate to cover the costs. Inadequate (Patients must co-pay) Inadequate (Patients don’t co-pay) | The attribute was highly correlated with the ‘capitation amount’ attribute. Therefore, the attribute was dropped | Attribute dropped due to inter-attribute correlation | |
2. Capitation amount | 1200 per individual per year 1500 per individual per year 2000 per individual per year 2400 per individual per year 3000 per individual per year 3600–4800 per individual per year 4000 per individual per year 5000 per individual per year 6000 per individual per year 10,000 per individual per year 80,000 per individual per year | The attribute name was retained as it was salient and would enable calculation of marginal willingness to accept estimates The levels were reduced to four. The currency was in Kenya shillings. The base level was set to “1200” which reflected the current capitation rate per individual per year. Then, to get the other levels 1200 was added to the levels i.e. 1200 + 1200 = 2400. 2400 + 1200 = 3600. 3600 + 1200 = 4800. The levels were plausible and capable of being traded | Capitation amount | 1200 per individual per year 2400 per individual per year 3600 per individual per year 4800 per individual per year |
3. Services covered | All services including complex diagnostics e.g. imaging, optical and dental services. Consultation + laboratory tests + drugs. Consultation + drugs Consultation + laboratory tests. Laboratory tests + drugs Consultation + other diagnostics Consultation only | The attribute name was retained as it was salient The levels were reduced to three packages namely comprehensive, enhanced and basic. The comprehensive package had all services including complex diagnostic services, optical, and dental services | Services covered | Comprehensive (All services including complex diagnostics e.g. imaging, optical and dental services) Enhanced (consultation + laboratory services + drugs) Basic (Consultation + drugs) |
4. Autonomy to use capitation funds. | Flexible Rigid | The attribute was viewed as salient to public health care providers. The panel decided that the terms “flexible” and “rigid” needed to be simplified to be understandable to health care providers. From the qualitative study, this attribute was specific to public providers as they had to first deposit the PPM funds into a pooled account run by the county governments. Then, they would wait for the county governments to reimburse the funds back to them after some time. This was a legal requirement in some counties. Therefore, levels were simplified from “flexible” to “do not have to pay the county first” and “rigid” to “pay the county first as usual.” | Autonomy to use capitation funds. | Do not have to pay the county first. Pay the county first as usual. |
5. Payment schedule | 2 weeks 4 Weeks (Monthly) 3 months (Quarterly) 6 months (Bi-annually) 12 months (Annually) | The attribute name was viewed as salient and self-explanatory. It was therefore maintained. The level “annual payments (12 months)” was viewed as far apart. Therefore, the level was dropped. | Payment schedule | 2 weeks 4 Weeks (Monthly) 3 months (Quarterly) 6 months (Bi-annually) |
6. Predictability of payments in terms of timing | Timely (Providers know when they will be paid). Delays (Providers don’t know when they will be paid). | Predictable was viewed as a complex word. Therefore, the attribute name was changed to “payment patterns”. The levels were simplified to include the words “timely” and “delayed” This attribute was viewed to be similar to “payment schedule”. However, it differed from the first one as payment schedule might be set, but not followed. | Payment patterns | Timely Delayed |
7. List of clients registered to a health facility | List available List not available | Health care providers in Kenya did not have access to the list of enrolees registered to their health facilities. This was viewed by the panel to be a transparency issue rather than a capitation attribute. Therefore, the attribute was dropped as it was not relevant to the decision context | Attribute dropped as it was not relevant to decision context. | |
8. Predictability of payments in terms of amount | Predictable – (Providers know the amount to expect) Unpredictable (Providers don’t know the amount to expect). | Health care providers could not predict the total capitation amount they expected to receive from the purchaser (NHIF) as they did not know the number of clients registered to their health facilities. Therefore, this attribute was deemed to be correlated to the “list of clients registered to a health facility” attribute. Furthermore, it was viewed as a transparency from the purchaser issue rather than a characteristic of capitation. Therefore, the attribute was dropped. | Attribute dropped due to inter-attribute correlation and irrelevance to decision context. | |
9. Complexity of accountability mechanisms | Simple accountability requirements Complex/burdensome accountability requirements | The attribute name was maintained as it was salient. Unlike, FFS payments, the main accountability issue with capitation was notifying the NHIF every time an enrolee sought care at a health facility. The levels were simplified by removing the word accountability | Complexity of accountability mechanisms | Simple requirements Complex requirements |
10. Performance requirements | Payments linked to performance Payments not linked to performance | The attribute name was maintained as it was salient. It was decided that the attribute and levels should delink individual performance from health facility performance. Since the attribute focussed on health facility performance rather than individual performance, the word “facility” was added to the attribute-levels | Performance requirements | Payments linked to facility performance Payments not linked to facility performance |