CAPITATION SURVEY QUESTIONNAIRE

2009

SECTION I. GENERAL INFORMATIONPlease indicate the type of organization you’re with:

Group practice—Primary care IPA

Group practice—Multispecialty Hospital

Group practice—Specialty HMO/health plan

____________________________________ Health system/IDS

Other _________________________________

Please tell us which state you work in: ______________________________

Would you classify managed care/capitation penetration in your area as:

High (over 25%) Moderate (10%–25%) Low (under 10%)

Would you classify your area as primarily:

Urban Suburban Rural

SECTION II. ENROLLMENT, PMPM, AND UTILIZATIONIn the grid on the following page, please provide PMPM rates for each type of capitation contract by specialty. Please include enrollment and utilization data by contract type where indicated. Fill out the grid as completely as possible, separating professional and technical components of your PMPM rates where applicable, or provide printouts of your PMPM rates. Please attach a list of cov-ered services by contract type.

We need your help. To provide the most meaningful data possible in our annual survey of capitation rates and trends, sponsored by Capitation Rates & Data, we need your participation. Please take a moment to complete this confidential survey form and return it to Les Masterson, HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Or fax to Les’ atten-tion at 781/639-2982. Please provide us with data as of July 1, 2008. The results will be tabulated, and sub-scribers to Capitation Rates & Data will receive the 2009 Capitation Survey as part of their subscriptions. The first 20 people who respond to this survey will receive a $5 Starbucks gift card. Note: This is a confidential survey. We will not disclose individual infor-mation. Please return the completed questionnaire to us by August 15.

GIFT CARD Provide your name and contact information at the end of this survey, and the first 20 respondents will recieve a $5 Starbucks gift card!

(please specify)

(please specify)

Ex

am

ple

35,0

00

9.4

5X

310

121

5.5

2.9

men

tal hea

lth, phar

mac

yG

loba

l –

all

serv

ices

All

phys

icia

n se

rvic

esA

ll ho

spit

al s

ervi

ces

Phys

icia

n sv

cs –

out

pati

ent

onl

yH

osp

ital

svc

s –

inpa

tien

t o

nly

All

prim

ary

care

svc

sA

ll sp

ecia

list

serv

ices

Sp

ecia

lty

co

ntr

acts

Alle

rgy

Ane

sthe

sio

logy

Add

icti

on/

Beh

avio

ral/

Men

tal

Hea

lth

Car

dio

logy

Car

dio

vasc

ular

Sur

gery

Chi

ropr

acti

cD

enti

stry

Der

mat

olo

gyD

ME

Emer

genc

y M

edic

ine

Endo

crin

olo

gyFa

mily

Pra

ctic

eG

astr

oen

tero

logy

Gen

eral

Sur

gery

Ger

iatr

ics

Hem

ato

logy

/Onc

olo

gyH

om

e H

ealt

hH

osp

ital

ist

Infe

ctio

us D

isea

seIn

tern

al M

edic

ine

Labo

rato

ryN

ephr

olo

gyN

euro

logy

Neu

rosu

rger

yN

ucle

ar M

edic

ine

OB

-GY

NO

phth

alm

olo

gyO

ral

Surg

ery

Ort

hodp

edic

sO

tola

ryng

logy

Path

olo

gyPe

diat

rics

Phar

mac

yPh

ysic

al M

edic

ine/

Reh

abPl

asti

c Su

rger

yPo

diat

ryPs

ychi

atry

Pulm

ono

logy

Rad

iati

on

Onc

olo

gyR

adio

logy

(pr

ofe

ssio

nal

onl

y)R

adio

logy

(te

chni

cal

onl

y)R

adio

logy

– a

llR

heum

ato

logy

Uro

logy

Vis

ion

Car

e/O

pto

met

ryO

ther

(pl

ease

def

ine

belo

w)

Co

vered

Serv

ices/

Sp

ecia

ltie

sServ

ices

Ex

clu

ded

fr

om

Co

ntr

act

PM

PM

Ra

te

Note: For maximum accuracy, please eNsure proFessioNal aNd techNical compoNeNts are listed separately wheN applicable.

ch

eck

on

eU

tili

za

tio

n d

ata

Cover

ed

Lives

Pro

fess

ional

Tec

hnic

al

(wher

e ap

plica

ble

)

% o

f Pre

miu

m,

if a

pplica

ble

Com

mer

cial M

edic

are

Med

icai

dIn

pat

ient

adm

its/

1000

Inpat

ient

day

s/1000

Outp

atie

nt

vis

its/

1000 ER

vis

its/

1000

avg

LOS

20

08

CAPITATIO

NSU

RVEY

QUEST

IONNAIRE

2009 CAPITATION SURVEY QUESTIONNAIRE

SECTION III. STOP-LOSS INSURANCEPlease fill out as shown in the example for at least one of the policy types shown.

Check here if you do not carry stop-loss insurance, and skip to the next section.

Contract type Policy purchased through (check one)

Policy typeAttachment

pointPremium

PMPM

(Medicare, commercial, or

Medicaid)

Contracting HMO

Private insurer

Self-insured

EXAMPLE $25,000 $2 X

Per case

PMPY

Other (specify type)

Strategy

Has been implemented

Planned for implementation

Has been effective

Has not been effective

Too soon to tell

Clinical paths/guidelines

HospitalistsSubcapitation Changing physician incentives Risk-sharing partnerships

Physician profiling

Disease management

Direct contracting

Electronic medical records

Pay for performance

Other (please specify)

____________________________

SECTION IV. TRENDS AND ISSUES IN RISK CONTRACTINGPlease indicate which of the following strategies you have implemented to improve performance under capitation/managed care and indicate whether that strategy has been effective.

How many capitated contracts do you have? ________

What strategy has been most effective and why? __________________________________________

What percentage of total revenue is derived from the following sources?

Capitation ______% FFS______% CDHP_______% Other_______%

What percentage has your capitation revenue increased (decreased) in the past year? ________%

Overall, have your capitation agreements been:

profitable breakeven losing money

2009 CAPITATION SURVEY QUESTIONNAIRE

How have your capitation agreements performed compared to your discounted FFS business?

more profitable less profitable

If you have renegotiated a contract in the past 12 months, has the capitation rate: increased decreased stayed the same

On a percentage basis, how much has your cap rate increased or decreased?

Commercial ______% Medicare ______% Medicaid ______%

In the past year, have you seen capitation activity in your market:

rebounding declining staying about the same

Are member copays factored into your cap rate?

Yes No

What is the average copay collected from members in capitated arrangements? $______

What is the penetration of consumer-driven health plans (HSAs, HRAs, defined contribution plans) in your market?

0–5% 5%–10% 10%–20% 20%–30%

Is CDHP contracting in your market:

increasing decreasing staying about the same

Regarding healthcare transparency, my organization:

has published pricing data on our Web site has published quality data on our Web site

plans to publish pricing data on our Web site plans to publish quality data on our Web site

GIFT CARD The first 20 respondents will receive a $5 Starbucks gift card. Please provide your name, company name, address, phone number, and e-mail address below.

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________