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Care Plus Funding Formula calculation and rules

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					Care Plus Funding Formula calculation and rules
There are a number of terms used in the funding model below:
  Care Plus Eligible – is the maximum number of enrollees that could
    receive Care Plus funding.
  HUHC – is the number of High User Health Card enrollees.
  Care Plus Residual – is equal to Care Plus Eligible less HUHC holders
  Care Plus Enrolled – is the actual number of patients that have enrolled
    in Care Plus.
  Care Plus Uptake – is the number of Care Plus enrollees as a
    percentage of Care Plus Residual

Care Plus Eligible
The Care Plus funding formula was initially set up so that a maximum of 5% of
the population could receive the funding.

A matrix of percentages was set up:

Sum of Annual Rates    Non Maori/Pacific       Maori/Pacific
Age Bands Gender      1 thru 4      5      1 thru 4        5
00-04     F               1.5%      2.2%       2.3%        2.6%
          M               1.7%      1.9%       2.0%        3.1%
05-14     F               1.1%      1.2%       1.3%        1.4%
          M               0.7%      0.8%       0.9%        1.6%
15-24     F               1.4%      2.5%       3.3%        3.4%
          M               0.5%      1.5%       1.6%        1.7%
25-44     F               2.4%      2.6%       3.8%        4.3%
          M               1.3%      1.6%       3.1%        3.6%
45-64     F               4.8%      8.5%      13.8%      13.9%
          M               6.0%      9.3%      15.9%      16.7%
Over 65   F              18.4%     22.4%      29.2%      33.8%
          M              21.2%     24.7%      37.2%      41.0%

For each PHO the number of enrollees in each of the 48 combinations of
variables above is multiplied by the cells of the matrix above to calculate the
Care Plus Eligible. For instance, for PHO A the number of enrollees is:

Sum of Annual Rates        Non Maori/Pacific              Maori/Pacific
Age Bands Gender        1 thru 4          5          1 thru 4           5
00-04     F                     608            111           216            282
          M                     603            133           227            311
05-14     F                   1,341            192           458            629
          M                   1,337            224           452            579
15-24     F                   1,243            270           414            460
          M                   1,265            253           418            415
25-44     F                   2,964            594           630            718
          M                   2,825            608           535            609
45-64     F                   2,912            469           388            411
          M                   2,802            521           377            360
Over 65   F                   1,729            303           124            119
          M                   1,530            328           104            122
Multiplying both the tables together gives:

Sum of Annual Rates          Non Maori/Pacific             Maori/Pacific
Age Bands Gender          1 thru 4          5         1 thru 4           5
00-04     F                         9             2             5             7
          M                        10             3             5            10
05-14     F                        15             2             6             9
          M                         9             2             4             9
15-24     F                        17             7            14            16
          M                         6             4             7             7
25-44     F                        71            15            24            31
          M                        37            10            17            22
45-64     F                       140            40            54            57
          M                       168            48            60            60
Over 65   F                       318            68            36            40
          M                       324            81            39            50

Summing these gives a total of 1,994 Care Plus Eligible (or 5.8% of PHO A’s
34,523 enrollees).

Care Plus Residual
Care Plus Residual is calculated by subtracting the number of HUHC holders
in the PHO from the Care Plus Eligible figure above.

E.g. for PHO A the number of HUHC holders is 646.
Therefore, Care Plus Residual = 1,994 – 646 = 1,348.

The annual Care Plus rate (exclusive of GST) from 1 July 2008 to 30 June
2009 is $236.7092

The maximum amount that PHO A can receive for Care Plus for the year is
therefore 1,348 x $230.2665 = $319,084.1

Care Plus Enrolled
Care Plus Enrolled is the actual number of enrollees in a PHO that have
enrolled with Care Plus. For our example PHO A this is 560.




1
  Prior to 1 July 2007, this calculation was broken down by Practice Formula Type (i.e.
Access and Interim). Since 1 July 2007, as we no longer distinguish between Access and
Interim in Care Plus calculations this breakdown is no longer factored in.
Care Plus Payment
The amount actually paid to the PHO is based on the following formula:

 Care Plus Uptake % (X)             Percentage of maximum amount paid
 0 <= X < 50%                       50%
 50% <= X < 65%                     65%
 65% <= X < 80%                     80%
 80% <= X                           80% or 100% (see “Other Rules” below)

For PHO A the Care Plus uptake is 560 / 1,348 = 42%.

Based on the table above the PHO has achieved the 0% <= X < 50% uptake
band so will receive 50% of its maximum potential funding of $319,084
calculated above, or $159,542.

Payment Frequency
Note all the amounts mentioned above are annual amounts. These annual
amounts are divided by four and calculated each quarter when the PHO
enrollee volumes are sent through to HealthPAC. HealthPAC then divide
these quarterly amounts by three and pay the PHOs each month.

So for instance PHO A would normally receive $39,885.50 per quarter (i.e.
$159,542 / 4), this would be split into three monthly payments of $13,295.

Other Rules
Uptake levels over time - Based on the methodology above if a PHO has
qualified to receive Care Plus payments but do not actually sign up any Care
Plus enrollees they will still be able to get 50% of the maximum funding. As a
result a new rule was put in place so that if the PHO had not achieved a
certain Care Plus uptake within 9 months and within 12 months then their
funding was reduced. This rule is shown in the table below:

 Care Plus uptake %     No. of monthly             No. of monthly
 (X)                    payments each quarter      payments each quarter
                        after 9 Months             after 12 Months
 0 <= X < 20%           0                          0
 20% <= X < 30%         1                          1
 30% <= X < 40%         2                          2
 40% <= X < 50%         3                          2
 50% <= X               3                          3

So, if PHO A had been signed up to Care Plus for more than 12 months,
given that it had 42% enrolled it would receive only two of its monthly
payments of $13,295.
Uptake level of over 80% - As mentioned in the Care Plus payment table,
once a PHOs Care Plus uptake is over 80% it can receive either 80% or
100% of its maximum funding. For the PHO to receive 100% of the funding it
not only has to have over 80% Care Plus uptake but it also has to have
achieved over 70% uptake in all three of the High Needs groups.

In the example below you can see that the PHO has an overall Care Plus
Uptake of 84.8%.    This PHO would be eligible to receive 100% of its
maximum funding because it has exceeded 70% uptake in the three High
Needs groups (denoted in bold red).

 Category             Non Maori Non Maori Maori /          Maori /     TOTAL
                      / Pacific   / Pacific    Pacific     Pacific
                      Dep <5      Dep 5        Dep <5      Dep 5
 Care Plus Eligible          7625        1259        1018          412  10314
 HUHC                         532           98          73          24    727
 Care Plus Residual          7093        1161          945         388   9587
 Care Plus Enrolled          6235         857          718         317   8127
 Care Plus Uptake          87.9%       73.8%        76.0%       81.7% 84.8%

If any of the three bold red numbers did not exceed 70% then the PHO would
continue to only receive 80% funding until it had achieved at least 70% uptake
in all three.

				
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