training pack remuneration - pilot practices final v0.2

November 2015

Training pack for practices

Prototype remuneration - capitation and activity

This training pack should be used by practices who operated under pilot arrangements prior to starting their prototype agreement

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Contents

• Remuneration – general principals

• Capitation

• Activity

• Process for the calculation of capitation and activity elements for blend A and blend B

• Remuneration year-end adjustments

Prototype remuneration – general principals

This section will cover:

• The key principles underpinning the remuneration mechanism for prototypes

Prototype remuneration general principals (1)

A prototype’s contract value (for general dentistry) will be split between:

1. Capitation: The number of actual patients a practice will be expected to have on their list at year-end

2. Activity: The minimum level of activity that a practice will be expected to deliver

If a practice delivers less than the minimum level of activity, they may compensate for this by caring for more patients

Practices will also be subject to a remuneration adjustment in respect of quality (Dental Quality and Outcomes Framework - DQOF) at year-end.


• The calculation of the actual remuneration for the year is based on a combination of capitation and activity delivered. This process is undertaken at year-end

• Up to 10% of the contract value is at risk where expected capitation and activity levels are not met

• Up to 2% of the contract value will be recognised where expected capitation and activity levels are exceeded

• A further financial adjustment is applicable for DQOF at year-end (up to 10%)


There will be two blends of remuneration tested in the prototypes:

• Blend A: Where the capitation element covers band 1, and the activity element covers bands 2 and 3

• Blend B – Where the capitation element covers band 1 and band 2, and the activity element covers band 3

Practices will be expected to deliver all necessary care to each patient on their list within their overall contract value

• A practice’s expected patient list excludes patients last seen by a foundation trainee (FT) at the practice

• A practice’s minimum activity requirement excludes activity delivered by an FT


Capitation


• How the expected patient list is calculated

• What are the triggers for people joining / leaving a patient list

• The mechanism of how patient numbers are counted

How expected capitated patient list figures are calculated (1)

• The expected patient list will be based on pre-pilot levels with adjustments to reflect:

– referrals– urgent treatment– charge exempt courses of treatment– relevant changes in delivered and commissioned

levels of UDAs

• This figure is referred to as the expected capitated patient list

How expected patient list figures are calculated (2)

• Where the patient list at the end of March 2015 is below the baseline expected patient list, the practice will be given until March 2017 to recover the shortfall

• It is expected that practices will have recovered half of this shortfall by March 2016

What triggers capitation?

• A patient should join the practice patient list when they attend for an oral health assessment (OHA)

• They will remain on this list for a period of three years unless they attend for NHS treatment elsewhere, except where the patient attended another practice for urgent, referral and charge exempt treatment. In these cases the patient remains on your practice list

• The three year capitation clock will re-set:1. At the IC course of treatment (CoT)2. At the oral health review (OHR)

Capitation - practice patient list

OHA

New to practice

Patient list

IC / OHR

Existing patient

Patient added to patient list

Patient 3 year clock reset

Patient treated

elsewhere (excluding

referrals out, urgent

treatment and exempt items)

Patient removed from patient list

Patient lapses after

3 years

Patient lists are defined as all NHS patients treated at a practice within the last 3 years who have not had NHS treatment at another primary care dental practice (except for urgent / referral or charge exempt)

1. Urgent treatmentA new patient treated at practice A does not get added to their patient listPractice A’s patient treated elsewhere remains on their patient list

2. Referral patientsA new patient referred to practice A for specific treatment does not get added to their patient listPractice A’s patient treated elsewhere remains on their patient list

3. Charge exempt items A new patient treated at practice A does not get added to their patient listPractice A’s patients treated elsewhere remains on their patient list

Capitation - exclusions

How patient numbers are counted

• During the year appointment transmissions from OHA / OHR appointments will be used to add and retain patients on a practice’s patient list as well as FP17 information, which will be used at year-end

• Therefore timely appointment transmissions will ensure that the patient list is as accurate as possible throughout the year

How patient numbers are counted (2)

TRIGGERS CAPITATION

FP17 opens FP17 closes FP17 opens FP17 closes

TRIGGERS CAPITATION

TRIGGERS CAPITATION

CoT CoT

Oral Health Assessment /

Review

Treatment&

Stabilisation (if necessary)

ICs at relevant

interval if required

Appointment data (DPMS) Transmitted within 7 days by practice

Capitation scenarios

YES

NO

NO

NO

Fred attends for an OHA on 1 August 2015. Is Fred added to the practice’s patient list?John is a patient of Smiley Dental and has toothache whilst on holiday in Devon. He attends a dental practice for an urgent course of treatment. Does John get removed from Smiley Dental’s list?Wendy gets referred from her own practice to Jones Dental Ltd for treatment. Will she get added to Jones Dental’s patient list?

Doris is a patient at Thompson Dental practice but attends your practice for a denture repair. Does she get added to your practice list?

Activity


• How the minimum expected activity level is calculated

• What and how activity is counted

How expected activity levels are calculated (1)

• Expected activity levels will be based on pre-pilot levels with adjustments to reflect:

– referrals– urgent treatment– charge exempt courses of treatment– any changes in commissioned levels of UDAs


• Expected activity levels will depend on the prototype blend the practice is allocated to:

– Blend A: Band 2 and band 3 activity

– Blend B: Band 3 activity

• Where a practice has been given an interim expected patient list size for 2015/16 a corresponding pro-rata activity level will be calculated

Blend A - Establishing expected activity levels

BAND 1

1 UDA

BAND 2

3 UDAs

BAND 3

12 UDAs

2 UDAs 11 UDAsACTIVITY

CAPITATION

OHA / OHR & prevention = capitation (Band 1)All treatment = activity (Bands 2 and 3)

Blend B - Establishing expected activity levels

BAND 1

1 UDA

BAND 2

3 UDAs

BAND 3

12 UDAs

9 UDAsACTIVITY

CAPITATION

OHA / OHR, prevention and routine treatment = capitation (Band 1 and 2)Complex treatment = activity (Band 3)


• For the prototypes an allowance will also be made to recognise the increased time spent on prevention when following the pathway and a fall in treatment volumes observed in the pilots

• Expected activity levels will be adjusted by:– Up to 20% for Band 2 – Up to 30% for Band 3

• Once all of these adjustments have been made this is the minimum expected activity level for the practice

What activity is counted (1)

• Activity delivered will be submitted and counted via the FP17 at the end of the course of treatment

Blend A• Band 2 = 2 UDAs• Band 3 = 11 UDAs

Blend B • Band 3 = 9 UDAs

Counting of activity for urgent treatment, referral patients and charge exempt courses of treatment will depend on whether this activity is provided to a patient who is on the capitated patient list or not:

• Where the patient is on the practice list: No activity is counted

• Where the patient is not on the practice list: Activity is counted

What activity is counted (2)

Activity scenarios

1.2

YES

0

John is a patient of Smiley Dental and has toothache whilst on holiday in your area. He attends your dental practice for urgent dental treatment. How many UDAs do you receive?

Wendy gets referred to your practice from her own practice for treatment. Will you receive any UDAs for her treatment?

Doris is your patient and turns up at your practice for a denture repair. How many UDAs do you receive?

Process for the calculation of capitation and activity elements for blend A

Blend A

Capitation element This covers the OHA / OHR and prevention, i.e. all band 1 care

Activity element This covers all treatments provided, i.e. all band 2 and band 3 care

Process for calculating the capitation and activity elements for blend A practices

STEP 1• Calculate the number of UDAs to be

allocated to the activity element (band 2 and band 3)

STEP 2• Apply the adjustment for prevention and

treatment volumes to give minimum expected activity level

STEP 3• Calculate the value of the minimum

expected activity level by multiplying the expected UDAs by the UDA value

• The remainder of the contract value is then allocated to the capitation element

Example – blend AA practice has a total contract value of £700,000 made up of:

The UDA value is £25.00 and the baseline expected patient list (based on pre-pilot position) is 10,000

In the baseline year the practice delivered:

• 6,240 Band 1 courses of treatment (6,240 UDAs)• 3,520 Band 2 courses of treatment (3,520*3 = 10,560 UDAs)• 600 Band 3 courses of treatment (600*12=7,200 UDAs)

General dentistry £600,000 24,000 UDAsOrthodontics £75,000 1,250 UOAs

Sedation £25,000 250 CoTs

TOTAL £700,000

Example of how capitation and activity elements for a prototype contract will be established – blend A

Activity levelsVolume of

CoT

UDAs for activity element

Activity level (unadjusted)

Band 2 3,520 * 2 7,040 Band 3 600 * 11 6,600 Minimum activity level (unadjusted) 13,640

Split of contract valueValue of activity level 13,640 * £25.00 £341,000.00Value of capitation level £600,000.00 - £341,000.00 £259,000.00TOTAL £600,000.00

Step 1: Calculate the number of UDAs to be allocated to the activity element (band 2 and band 3)

Example of how capitation and activity elements for a prototype contract will be established – blend A

• The activity element is £256,300.00 for which the practice would be expected to deliver a minimum of 10,252 UDAs

• The capitation element is £343,700.00 for which the practice would be expected to have 10,000 capitated patients


Prevention & treatment volume adjustment

Minimum expected

activity levelBand 2 7,040 - 20% 5,632 Band 3 6,600 - 30% 4,620 Minimum expected activity level 10,252

Value of activity level 10,252 * £25.00 £256,300.00Value of capitation level £600,000.00 - £256,300.00 £343,700.00TOTAL £600,000.00

Step 3 - Calculate the value of the minimum expected activity level and capitation element

Step 2 - Apply the adjustment for prevention and treatment volumes to give minimum expected activity level

Practice 1 Baseline courses of treatment

UDAs Blend A activity (UDAs)

Fall in treatment volumes adjustment

Adjusted Blend A activity (UDAs)

Band 1 3100 3100 0 0Band 2 1100 3300 2200 80% 1760Band 3 300 3600 3300 70% 2310Total 10000 5500 4070











Blend A examples

Process for the calculation of capitation and activity elements for blend B

Blend B

Capitation element This covers the OHA / OHR and prevention and routine treatments provided i.e. all band 1 and band 2 care

Activity elementThis covers the more complex treatment provided i.e. all band 3 care

Process for calculating the capitation and activity elements for blend B practices

STEP 1 • Calculate the number of UDAs to be allocated to the activity element (band 3)

STEP 2• Apply the adjustment for prevention and

treatment volumes to give minimum expected activity level

STEP 3• Calculate the value of the minimum

expected activity level by multiplying the expected UDAs by the UDA value

• The remainder of the contract value is then allocated to the capitation element

Example – blend BA practice has a total contract value of £700,000 made up of:

The UDA value is £25.00 and the baseline expected patient list (based on pre-pilot position) is 10,000

In the baseline year the practice delivered:

• 6,240 Band 1 courses of treatment (6,240 UDAs)• 3,520 Band 2 courses of treatment (3,520*3 = 10,560 UDAs)• 600 Band 3 courses of treatment (600*12=7,200 UDAs)

General dentistry £600,000 24,000 UDAsOrthodontics £75,000 1,250 UOAs

Sedation £25,000 250 CoTs

TOTAL £700,000

Example of how capitation and activity elements for a prototype contract will be established – blend B

Activity levelsVolume of

CoT

UDAs for activity element


Band 3 600 * 9 5,400 Minimum activity level (unadjusted) 5,400

Split of contract valueValue of activity level 5,400 * £25.00 £135,000.00Value of capitation level £600,000.00 - £135,000.00 £465,000.00TOTAL £600,000.00

Step 1: Calculate the number of UDAs to be allocated to the activity element

Example of how capitation and activity elements for a prototype contract will be established – blend B

• The activity element is £94,500.00 for which the practice would be expected to deliver a minimum of 3,780 UDAs

• The capitation element is £505,500.00 for which the practice would be expected to have 10,000 capitated patients


Prevention & treatment volume adjustment

Minimum expected

activity levelBand 3 5,400 - 30% 3,780

Minimum expected activity level 3,780

Value of activity level 3,780 * £25.00 £94,500.00Value of capitation level £600,000.00 - £94,500.00 £505,500.00TOTAL £600,000.00

Step 2 - Apply the adjustment for prevention and treatment volumes to give minimum expected activity level

Step 3 - Calculate the value of the minimum expected activity level and capitation


UDAs Blend B activity (UDAs)


Adjusted Blend B activity (UDAs)

Band 1 3100 3100 0 0Band 2 1100 3300 0 0Band 3 300 3600 2700 70% 1890Total 10000 2700 1890











Blend B examples

Remuneration year-end adjustments

Remuneration year-end adjustments

• Practices will receive 1/12th of their contract value each month

• At year-end financial adjustments (if applicable) will be made for:– Capitation (patient numbers) and activity– Quality (DQOF)

Year-end process for capitation and activity

• At year end a practice will be reviewed to assess whether:

– Patient numbers are above or below the expected level (capitation)

– Activity is above or below the expected minimum level

• The value of these year-end delivery positions are calculated and combined to determine the actual remuneration level for the year.

Year-end process for capitation and activity (2)

Combined capitation and activity under-delivery• A practice will be allowed to carry forward the combined

value (£) of under-delivery (for capitation and activity)• The maximum carry forward will be 4% of the contract value• Where the value (£) of under-delivery is greater than 4% the

financial recovery will be applied up to 10% of the contract value

Combined capitation and activity over-delivery • A practice will be allowed to over-deliver by up to 2% of the

contract value (£)• This value may be paid by the commissioner or carried

forward

Year-end process for capitation and activity (3)

• The calculation of the year-end position will be calculated by NHS England and the programme

• This process will be undertaken after all year-end data has been received and processed by NHS BSA

• Practices will be notified of their year-end position and any associated financial adjustment or carry forward by NHS England

• Any financial adjustments will be applied and processed via Payments on Line (PoL) and reflected in a practice’s monthly pay schedule

Calculating activity performance at year-end

RULE 1

• If patient numbers are less than or equal to 100% of expected levels, then any adjustment relating to activity delivery will be capped at 100%

RULE 2• If patient numbers are more than 100% of the expected

level, then any adjustment relating to activity will be capped at the same percentage as the achieved level for the patient numbers.

How the year-end process will work

STEP 1 •Calculate the year-end delivery percentage for the capitation and activity elements separately

STEP 2 •Apply rules for adjustments (if required) to activity and capitation delivery

STEP 3 •Calculate the combined value of the year-end achievement for capitation and activity

STEP 4 •Apply the carry forward for the previous year

STEP 5 •Calculate the final position and carry forward (if applicable) for the next year

Year-end mechanism year 1

Practice informationBlend type BContract value £600,000.00Capitation element £505,500.00Activity element £94,500.00Expected patient list 10,000Expected UDAs 3,780Carry forward from previous year £0.00

Year end deliveryPatient numbers 9,900UDAs 3,818

Year-end mechanism year 1Step 1 - Year end delivery percentage for capitation and activityCapitation 9,900 / 10,000 99.00%Activity 3,818 / 3,780 101.01%

Step 2 - Apply rules for adjustments for activity elementCapitation 99.00%Activity 100.00%

Capitation 99.00% of £505,500.00 £500,445.00Activity 100.00% of £94,500.00 £94,500.00Total £594,945.00% total £594,945.00 / £600,000.00 99.16%

Step 4 - Apply carry forward from previous yearCarry forward from previous year £0.00

Step 5 - Calculate the final position and carry forward (if applicable) for next yearFinancial adjustment £0.00Carry forward value (99.16% - 100.00%) * £600,000.00 -£5,040.00Carry forward percentage -£5,040.00 / £600,000.00 -0.84%

Step 3 - Calculate the combined value of the year-end achievement for capitation and activity

Year-end mechanism year 2

Practice informationBlend type BContract value £600,000.00Capitation element £505,500.00Activity element £94,500.00Expected patient list 10,000Expected UDAs 3,780Carry forward from previous year -£5,040.00

Year end deliveryPatient numbers 10,200UDAs 3,893

Year-end mechanism year 2Step 1 - Year end delivery percentage for capitation and activityCapitation 10,200 / 10,000 102.00%Activity 3,893 / 3,780 102.99%

Step 2 - Apply rules for adjustments for activity elementCapitation 102.00%Activity 102.00%

Capitation 102.00% of £505,500.00 £515,610.00Activity 102.00% of £94,500.00 £96,390.00Total £612,000.00% total £612,000.00 / £600,000.00 102.00%

Step 4 - Apply carry forward from previous yearCarry forward from previous year -£5,040.00

Step 5 - Calculate the final position and carry forward (if applicable) for next yearFinancial adjustment £0.00Carry forward value (102.00% - 100.00%) * £600,000.00 + -£5,040.00 £6,960.00Carry forward percentage £6,960.00 / £600,000.00 1.16%

Step 3 - Calculate the combined value of the year-end achievement for capitation and activity

training pack remuneration - pilot practices final v0.2

Healthcare