capitation
captn_amtDefinition
ISO-11179 Definition
A healthcare payment model in which a provider or health plan receives a fixed monthly payment per enrolled member to cover all covered healthcare services regardless of the actual volume of services delivered, transferring utilization risk from the payer to the provider. Capitation aligns provider financial incentives with preventive care and care coordination because providers profit by keeping patients healthy and avoiding unnecessary services rather than by increasing service volume. Medicare Advantage capitation payments from CMS to health plans are calculated by multiplying the county-level benchmark rate by the member RAF score, adjusted for quality bonus payments based on CMS Star Ratings.
Provider capitation arrangements may be global covering all services or partial covering specific service categories such as primary care or specialty care. Healthcare data teams track capitation payment amounts by member, calculate per-member-per-month capitation yield by plan and service category, reconcile capitation receipts against expected amounts based on attributed member RAF scores, and model capitation adequacy relative to actual claims costs to assess financial performance under full-risk contracts.
Standard Abbreviation
captn_amt
Category
Production DDL — FACT_QUALITY_MEASURE
CREATE OR REPLACE TABLE FACT_QUALITY_MEASURE (
qlty_key INTEGER NOT NULL -- surrogate key,
mbr_key INTEGER NOT NULL -- FK to DIM_MEMBER,
plan_key INTEGER NOT NULL -- FK to DIM_PLAN,
meas_yr SMALLINT -- measurement year,
hedis_meas_cd VARCHAR(20) -- HEDIS measure code,
denom_ind CHAR(1) -- denominator eligible,
numer_ind CHAR(1) -- numerator met,
excl_ind CHAR(1) -- exclusion indicator,
gap_open_ind CHAR(1) -- care gap open,
star_rtg_nbr DECIMAL(3,1) -- star rating,
qlty_scr DECIMAL(5,2) -- quality score,
perf_thrsh_pct DECIMAL(5,2) -- performance threshold,
raf_scr DECIMAL(10,3) -- risk adjustment factor,
outreach_cnt SMALLINT -- outreach attempts,
load_dt TIMESTAMP_NTZ NOT NULL -- load timestamp
);
Standard Snowflake DDL for the canonical quality table. Convert to BigQuery or Databricks →
Why This Term Matters
Quality measure data determines how payers and providers are rated and reimbursed under CMS Stars, HEDIS, and value-based care contracts. Data engineers who understand quality terminology build measure calculation pipelines that correctly attribute patients, apply denominator exclusions, and flag documentation gaps before submission deadlines. Incorrect quality data directly affects star ratings, pay-for-performance bonuses, and Medicare Advantage plan bids.
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