Fact Check: Does OHS’s Primary Care Roadmap include capitation? Yes, 31 times

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In the Insurance Committee’s March 1st public hearing on HB-5042, advocates stated that the Office of Health Strategy’s Primary Care Roadmap plan, authorized in the bill, includes capitation as the payment model. Primary care capitation has failed in Medicare despite significant investment and multiple trials. Advocates are concerned that, if implemented, the Roadmap would divert $3.9 billion/year from other critical care and that access to primary care will suffer under capitation. OHS has represented to legislators that the Roadmap does not include capitation as a payment model.

However, a search of OHS’s Roadmap document, accessed from OHS’s website today, found six references to capitation and twenty five references to prospective payment. The Roadmap notes (p. 12) that “Prospective primary care payment is sometimes referred to as “capitation” because the prospective payment is made on a per patient basis.”

Searching OHS’s online Roadmap document finds six references to capitation and capitated payments.

Page 11 has two references

“Insurers provide prospective notification of those patients for whom they are receiving capitated payment.”


“Insurers reattribute patients monthly, communicate these updates to practices in a timely manner, and use these updates when calculating capitation payments.”

Page 12 has four references  

“In addition, some practices will benefit from education and coaching about how to deliver patient care in a financially sustainable way in the context of a capitated payment methodology.”


“Insurers supply providers with timely, high-quality data to allow more effective management of their patient panel and their revenue under a capitated arrangement.”

“Insurers also provide appropriate technical assistance and educational support to facilitate the transition to capitated payments.”


Footnote 11 – “Prospective primary care payment is sometimes referred to as “capitation” because the prospective payment is made on a per patient basis.”

There are also twenty five references to the equivalent term “prospective payment” in the Roadmap document, (per footnote 11).

Page 9 – one reference

Page 10 – three references

Page 11 – three references

Page 12 – six references

Page 13 – seven references

Page 14 – two references

Page 15 – one reference

Page 17 – one reference

Page B-3 – one reference

It should be noted that, in response to primary care provider complaints, capitation/prospective payment was made a voluntary option for primary care practices in the Roadmap. However, it is not voluntary for patients and there is no provision in the Roadmap for patients to opt-out or to be notified that their provider is paid a capitated fixed fee for their care whether or not they receive services. From the Roadmap — “Interested primary care practices are prospectively paid a fixed monthly PMPM fee for most primary care services in lieu of FFS payments, regardless of the services provided to the practice’s defined patient panel during a given month.” (p. 12)