Officials interviewed from both the NHIA and NHIF agreed that National Health Insurance is critical to the overall health of their population and enrolling poor populations into the schemes was a priority for both agencies to reach UHC. Further, accrediting private providers in particular was seen as an important aspect of achieving UHC as well. In fact, officials in both countries said local SHI representatives were encouraged to recruit private clinics in areas that were under-served by public health facilities.
Sometimes our staff may just go appoint a person because you are a private facility within this locality, can you please apply [for NHIS accreditation]?…Maybe there is only one clinic, there is only one pharmacy shop or pharmacy in the locality ourselves can appoint them to say that we think if you can apply it will help our members. (NHIA Official, Ghana)
In Kenya, this practice was specifically linked to reaching poor populations:
We do have a report, and from that we were able to see that majority of [wealth] quintile one [the lowest wealth quintile] that we targeted, they normally access government facilities and their issues was just the distance. Especially outside of urban areas. (NHIF Official, Kenya)
However, while SHI officials expressed a strong desire both to accredit more private providers and to reach more patients with SHI coverage, all were aware of the many challenges both providers and patients faced in gaining meaningful access to the benefits of National Health Insurance. These challenges were corroborated by our interviews with providers and patients, and included difficulties navigating complex accreditation processes, inadequate or delayed reimbursements, and difficulties operating under capitation schemes among providers. Patients faced logistical challenges at registration sites and complained of being charged out of pocket even when paying with their SHI card; difficulties that are particularly burdensome for low-income populations.
However, both providers and patients did receive some meaningful benefits from the SHIs as well. Providers often found that their client load increased as a result of becoming accredited and some felt they were better able to serve poor clientele. Patients felt that SHI coverage gave them greater access to a variety of providers, including the quality private providers they preferred. These perspectives are detailed below and interwoven with data from the SHI officials themselves to lend an institutional perspective to the benefits and challenges experienced on the ground.
Accreditation/enrollment
Providers: Why become Accredited & Experiences with the accreditation process
Particularly by the last round of data collection (2017), providers commonly cited market pressure as a strong motivator to seek out SHI accreditation. It was common for both Kenyan and Ghanaian providers to report that they sought out SHI accreditation due to client demand, considering accreditation critical to business viability and also to serving low-income populations. While this trend was relatively consistent across rounds of data collection in Ghana, in Kenya client demand became a strong motivator only recently, following the extension of outpatient coverage to beneficiaries other than civil servants in 2015. By attracting more clients through their SHI accreditation, providers in both Kenya and Ghana most often reported that they hoped to increase their clinic revenues.
In addition to providers’ perceptions that becoming SHI-accredited would generally increase client flow, a number of providers specifically mentioned that they wanted to better serve low-income clients while also maintaining a viable business. In Round 1 of data collection some providers in Kenya expressed concern about finances, which were constrained by the low-income patient population they served. Indeed, providers in both countries cited clients’ frequent inability to pay as a reason why they decided to apply for SHI accreditation in the first place. When faced with low-income patients who couldn’t pay, providers in both countries reported negotiating prices with these patients or treating them for free; both options that can be financially challenging for small private clinics that already operate on constrained budgets. Thus, providers in both countries suggested that SHI accreditation was in fact essential to maintaining their business viability, particularly for clinics serving a low-income population. As one provider in a low-income neighborhood in Ghana said:
If you not accepting, look…look, look at the people who are around, they are all poor… Without NHIS you can’t operate in a clinic they better shut down your clinic, yeah. (Doctor at a BlueStar clinic, Greater Accra, Ghana)
This provider maintained that, because her clinic was operating in a low-income neighborhood where people had little money to pay for healthcare, financing from the NHIS allowed her to keep her clinic open. One NHIA official echoed this provider’s statement, saying:
It’s demand driven…So, you apply when you think you need NHIA to support in terms of getting people coming to your facility…So, depending on where the [facility] is located, and let me say that in this country…you realize that most private facilities have difficulty getting members. People coming pay out of pocket because their fees are a bit on the higher side. And so most of them are rushing [to become accredited] because they noticed that without NHIA they can’t survive. Especially depending on where the facility is located if the poverty level is very high they don’t have NHIA, you are not a member of NHIA, you are not accredited or credentialed it’s likely that your facility may collapse. (NHIA Official, Ghana)
Further, among providers who hadn’t previously served low-income populations, some felt that SHI accreditation enabled them to do this. As one provider in Kenya said:
Coz people used to see us initially like this place is expensive it is for the rich. But due to NHIF now we encounter all groups. All classes. So, if somebody goes there he or she says but I was treated at [clinic name] And they are like, with which card, NHIF. So the… the… that thing of a hospital for the rich…It’s now over. (Auxiliary Nurse at a non-franchised clinic, Nyanza, Kenya)
In this case, the provider felt that her clinic’s reputation had changed as a result of accepting NHIF. While this clinic had formerly served a wealthier population, she claimed that their clientele had changed after becoming NHIF accredited, and they were able to serve lower-income clients paying with an NHIF card.
Across all three rounds of data collection, most providers in Ghana had already been accredited with the NHIS for a significant period of time. These providers generally cited few challenges with the accreditation and renewal processes, noting that NHIS officials would even visit a clinic well in advance when their accreditation contract was due to expire to give them sufficient time to renew. Some newly accredited providers cited long wait times of up to 2 years to receive their accreditation, but generally clinics were able to renew their contracts within 3-to-6 months.
In contrast to the providers in Ghana, most Kenyan providers did not have NHIF accreditation in the early rounds of data collection and became more interested in pursuing accreditation more recently. However, Kenyan providers often lacked information on the accreditation process. This lack of information discouraged those providers who found the process daunting. Among those who had attempted to go through the accreditation process, Kenyan providers regularly cited difficulties with hold-ups in the accreditation process and having to “push” to keep the process moving forward.
Patients: Why Enroll & Experiences with enrolling in/renewing SHI membership
Like the providers interviewed, patients were generally positive when discussing the potential benefits of Social Health Insurance and their comments indicated that the SHIs were fulfilling their primary purpose of providing financial protection for enrollees. Clients in both Ghana and Kenya were aware that SHI coverage is useful for reducing costs and making healthcare more affordable, and commonly cited this as a benefit and a reason for enrolling. In particular, patients commonly suggested that this increase in affordability translates to an increase in healthcare accessibility; this suggestion was sometimes linked specifically to the benefit of affordable maternity services. Indeed, clients said that they were more likely to visit the clinic when they weren’t feeling well or had an antenatal appointment because they knew NHIS would cover their costs:
Because with the card, if I go anywhere and I’m registered – when I’m sick, I just take it along with me. With that you don’t fail to go to the hospital because of lack of money, right? (Patient at a Bluestar clinic, Ashanti, Ghana)
Because if you have it and sickness strikes, even if you do not have money you will not worry because the card will pay. You’ll just be sorted. (Patient at a non-franchised clinic, Coast, Kenya)
Further, a number of patients in both countries saw a link between the SHIs and access to healthcare for people with low income. Patients in Kenya often noted that NHIF is helpful in cases where someone has “no money” or a “lack” of money and one patient noted that NHIF was especially useful for the “under privileged people.”
While fewer Kenyan patients were enrolled in NHIF than their counterparts in Ghana, those who were enrolled cited few challenges in the enrollment process other than cost.
Interviewer: Okay. And what is so challenging about applying for NHIF? What is difficult?
Respondent: Money. [Laughs] It is only money. (Patient at a Tunza clinic, Central, Kenya)
However, this may be a result of the automatic enrollment many Kenyans receive through their work. In addition, a number of women interviewed in Kenya reported that their husband was the primary NHIF cardholder for their household, indicating they may not have gone through the enrollment process themselves.
Once enrolled, some clients again cited cost as a barrier to maintaining their NHIF membership. Patients reported allowing their enrollment to lapse because they could not make the monthly payments. In these cases, the NHIF requires patients to pay a penalty for a lapse of less than 1 year, while those who have neglected to pay for more than a year must renew their membership and wait 60 days for re-activation. These requirements made it even more challenging for clients to maintain or renew enrollment during times of financial hardship. A few Kenyan patients also said they didn’t see enough financial benefit in continuing to pay for insurance when they still incur charges in the clinic, though it was not clear if they were referring to legitimate charges or to informal charges levied by providers on top of their NHIF payment.
In contrast to the cost barriers experienced by patients in Kenya, Ghana interviewees often cited logistical challenges as a barrier to renewing their NHIS membership. The most commonly cited cause for allowing enrollment to lapse was long wait times at NHIS registration centers. Clients often reported leaving their home at 3:00 or 4:00 am to join the line for registration and then waiting a full day to go through the process. Some spent all day waiting only to be told to return the next day when the machines used for registration were experiencing connectivity issues.
[The NHIS officers] asked us to wait. So, we waited for a while, and the computer was going off and coming back. So, they told us they were wasting our time, so we should go, but when the computer begins to work well they will work on everything. (Patient at a non-franchised clinic, Greater Accra, Ghana)
One NHIA official confirmed that connectivity has been a problem, particularly for mobile registration sites.
You know, it’s a developing country and that in most of the remote areas you will not find connectivity. And that also affected somehow when we were doing the enumeration [to identify and enroll poor populations into NHIS]…In some instances they would do the same …They will need to travel or walk to a distance where they can get connectivity to get the system a bit [inaudible] before they can go back and continue. (NHIS Official, Ghana)
In addition to the connectivity challenges, a couple of clients reported having been asked for bribes to move the process along more quickly and they were clearly critical of this practice. Conversely, several women noted that they were pushed to the front of the line and enrolled for free when they were pregnant; a result of the NHIS Free Maternity Services.
Benefits of the SHIs
Providers: Perceived benefits of accreditation
As providers anticipated, there was general consensus that SHI accreditation did increase client volume. In addition, some providers reported attracting more patients who would not have been able to pay for services otherwise:
Because when we started in the initial stages and I think the first year, we were solely cash and carry and the attendance was not much but as we had NHIS accreditation, the attendance went up…We were expecting an increase in NHIS patients, those who cannot afford to pay cash and carry, yes. That is why they have the NHIS cards, and those are the people we were targeting, the people in the communities around and the villages around. That majority of them are having NHIS cards and those were the people we were targeting. (Owner of a BlueStar clinic, Volta, Ghana)
However, it was unclear in both countries whether this increase ultimately translated into more profit, making the private facilities more financially viable and sustainable. Although we did not collect data that would allow us to corroborate these reports, preliminary results from a study among Amua providers in Kenya suggest that NHIF accreditation often does boost profits, although there is some differentiation according to NHIF contract type [57]. Similar data is not available for Ghana, though Ghanaian providers likely have more difficulty realizing profits under the NHIS due to payment delays and low reimbursement rates.
Patients: Perceived benefits of enrollment
While patients in both countries felt that having NHI coverage made healthcare more accessible, several patients in Ghana particularly appreciated having access to a wider variety of both providers and services through the NHIS. Patients in both countries overwhelmingly cited the caring, respectful treatment they received at private clinics and shorter wait times as the reasons why they would visit a private clinic over a public facility. In comparison to private providers, many clients thought that staff at public health facilities were at best over-worked and disinterested in serving patients, and at worst disrespectful.
Those for the government, mostly if we go you get that you are there and the Doctor is busy concerned with other things, he is not even in a hurry with you. And like here when you just arrive here [the private clinic], you are attended to, mostly those doctors who are here are so many it’s not only one Doctor. Which problem do you have…
Like everyone wants to help you, they have the heart to assist you. So, we see that here is better than public
. (Patient at a Tunza clinic, Nyanza, Kenya)
Indeed, one patient in Ghana said she valued the NHIS because it makes private healthcare more affordable, covering all of her services regardless of whether she is attending a public or a private facility. As one NHIF official in Kenya said, enrollees are “spoiled for choice” when more facilities become accredited and the competition this creates among providers can result in improved quality of care at clinics who are vying for clients.
Although patients in both Ghana and Kenya expressed an overall preference for private providers, clients in both countries perceived that they could access a wider range of services at a public hospital than they could at a private clinic, and often thought that staff at public facilities were better qualified than private practitioners. As a result, clients sometimes reported seeking out public facilities when they believed they were in need of more services or specialized equipment.
Because there are some of the private hospitals, maybe the illness you are suffering from – let’s take for example, the big, big sickness around – when you go to the hospital that the company has recommend to you, they might not be having those particular machines there to use. But when you have nationwide, uh, National Health Insurance and go the government hospitals, they will serve you. (Patient at a BlueStar clinic, Ashanti, Ghana)
Clients and community focus group participants in both countries also noted that public facilities are cheaper than private clinics. When weighed against the benefits of a private facility, though, cost was less of a concern than reliability and quality of treatment.
However, while patients in Ghana appreciated having more provider choice under NHIS and Kenyan patients expressed a preference for private providers, having NHIF coverage had much less effect on provider choice in Kenya than in Ghana. Kenyan patients were far less likely to consider whether or not they could pay with NHIF when selecting a clinic. Thus, patients enrolled in NHIF may not be realizing the benefit of greater provider choice to the same extent as their counterparts in Ghana.
Challenges with the SHIs
Providers: Challenges under accreditation
Particularly in Ghana, providers often found that the anticipated financial benefits of accepting SHI coverage did not match their experience once accredited. While some Kenyan providers complained of delayed payments from NHIF, this problem was far more pronounced in Ghana. Providers interviewed there frequently cited payment delays as their greatest challenge with NHIS; a finding that held true across all three rounds of data collection. These delays ranged from 3-to-4 month delays in 2013 to providers in 2017 commonly reporting waiting 9-to-12 months for payment. In the face of these delays, providers often faced challenges stocking drugs and paying staff.
While the NHIA officials interviewed did not speak directly to these delays, they did confirm that the NHIA was facing financial difficulties. One official acknowledged an institutional problem with “sustainability,” stating that the organization’s funding had not increased in the 13 years since it was founded, although membership had grown over tenfold during this time.
In addition to payment delays, providers in both countries also complained that reimbursement rates were inadequate. In Ghana, providers complained that NHIS reimbursement rates were too low and needed updating to bring them in line with current market prices. Further, smaller providers faced challenges with the drugs and services reimbursed by NHIS. As noted above, these reimbursements are restricted according to provider type. Providers complained that such restrictions put smaller clinics at a disadvantage because they are only authorized to receive reimbursement for a smaller selection of drugs and services than they often provide. One NHIA official noted that inadequate funding was a common complaint, but that fraud was also a major concern from the NHIA side. This official felt that providers sometimes tried to submit claims multiple times in order to get more money, or that they did not understand why certain claims were rejected and felt they were being cheated by the NHIA as a result.
So while as you were crying that our money is not enough, obviously in the insurance industry we still have people who want to abuse the system…So, NHIA over the years we’ve used what we call telecall audit system where we audit claims that are submitted to us…[In some cases], you were paid 10 million [Ghana Cedis] but we notice that 2 million of them were back claims. So, we deduct it from the claim that you submit. (NHIA Official, Ghana)
Challenges with capitation schemes
In Kenya, outpatient NHIF coverage functions on a capitation system; a system that pools financial risk across an entire patient population and pays providers a regular lump sum based on the number of patients registered to their particular clinic, regardless of whether or not all patients require services during the defined period. In Ghana, the NHIS started a capitation pilot in the Ashanti region in 2012 and has plans to continue scaling up to other regions following review of the initial pilot, although these plans are currently on hold. We found that capitation posed some unique challenges for providers. Providers in both countries had difficulty understanding the guiding principles behind capitation, which led to misunderstanding of the system’s mechanics. Namely, rather than understanding capitation as a risk pool that covers an entire group of patients, providers instead saw the regular lump sum payments as a cap on the amount they were able to spend on an individual patient during the payment period.
Interviewer: How much do they allocate under capitation for one patient maybe…?
Respondent: 500 [KSH], inclusive of lab.
Interviewer: One treatment or…?
Respondent: Yeah, one treatment. Not more than five hundred for outpatient.
(Nurse/Midwife at a Tunza clinic, Eastern, Kenya)
However, while providers had difficulty understanding the financial aspects of capitation, they all understood that SHI payments are tied to the number of clients registered with their particular facility. As a result, a lack of understanding around facility registration among patients proved challenging at the clinic level. Several providers complained that patients came to their clinic expecting free treatment even though they were registered elsewhere. Further, some providers reported that they were losing clients to other facilities as a result of competition under capitation.
The capitation is decreasing our savings…the other facility has taken all our customers. (Midwife at a BlueStar clinic, Ashanti, Ghana)
In some cases, providers suggested that patients were registering with competing clinics that offered more services or had more highly qualified staff. There also was suspicion that larger clinics with more resources were recruiting clients and even paying their registration fees.
The capitation is collapsing our work. It’s collapsing our work. And so we cannot get money to go and register for the clients to choose my facility. That’s what most doctors are doing. They go and pay for the cost of registration for the clients for their facility. Mhmm. And for us, the midwives, we do not have the money to be able to do that thing [pay for clients to enroll in NHIS]. (Owner at a BlueStar clinic, Ashanti, Ghana)
Conversely, NHI officials thought that capitation was good for providers, particularly those in the private sector. Recognizing that private providers have to cover all of their own costs and sometimes struggle to do this, officials from both NHIs noted that the regular payments with, in the case of Kenya, rates higher than those set for public facilities, should be a good thing for these providers.
Private providers in terms of the capitation program supporting fully…to them it’s cash up front and they don’t get any support from the government in terms of payment of salaries for the staff. So that is the difference between them and the public providers; public provider’s staff get paid through government fund. So, it’s in the interest of the private providers to really get involved and support the capitation program, since on a monthly basis it becomes cash up front for them. (NHIA Official, Ghana)
Effects of provider challenges with the NHIs
As a result of the financial challenges that providers faced participating in the SHI schemes, costs often were passed on to patients to cover out of pocket or services were limited, regardless of whether or not the services they were using were fully covered by insurance. In order to manage financial shortfalls caused by significant payment delays in Ghana, providers reported charging clients on top of NHIS reimbursement rates, operating on credit (particularly with pharmacies in order to stock drugs), or paying some clinic costs out of their own pocket. One provider had her own internal system that functioned like health insurance risk pooling, whereby she charged clients with minor ailments in order to cover the costs of more expensive treatments for others:
The clinic must take money from one patient and use it to buy drugs to cater for another patient whose sickness is severe and at the verge of death. Ahaaa. It may even happen that at the time, the patient at the verge of death may have no money, and must you leave that person to die? No. you will not leave that person. You must find something to do so that that person can also come back to life. (Midwife at a BlueStar clinic, Ashanti, Ghana)
Some providers also mentioned that clients expect all of their services to be free under NHIS, but due to reimbursement restrictions for smaller providers, they cannot offer NHIS patients the same services they would receive at a larger facility. Patients therefore demand services for free that smaller providers cannot offer and some providers said they had lost clients as a result. Some providers also felt that these differential reimbursements forced them to treat patients differently according to their NHIS status, offering more comprehensive services to clients not covered by insurance.
Under capitation in Kenya, provider misunderstanding of the system often resulted in patients being charged when they required services or drugs that exceeded the monthly amount providers believed they were allotted. In instances where patients were not asked to pay, Kenyan providers regularly mentioned limiting the services they provided to clients paying with NHIF instead, so as not to risk losing money for their clinic.
However, while the accreditation process in both countries provides quality checks on providers by ensuring they have proper licensure, equipment, and resource capacity, none of the providers interviewed mentioned interacting with SHI officials after the accreditation phase unless they were applying for a renewal. Beyond processing claims, which is conducted in regional, county, or district centers, on-site monitoring from both the NHIF and NHIA appears to be minimal. Without regular oversight, providers may have more opportunities to levy charges at will.
Patient challenges with SHI coverage
The greatest challenge patients in both Ghana and Kenya faced under the SHIs was a lack of knowledge. This lack of knowledge resulted in patients being unsure if they were charged correctly at the clinic and affected their perceptions of the care they received. Indeed, knowledge of SHI coverage among clients interviewed in both Kenya and Ghana tended to be experiential; when asked which services were covered by the scheme they often cited services they had received themselves, but had little knowledge of specific services or programs beyond their own experience. Patients generally understood that NHI doesn’t cover all services or drugs, but often weren’t able to cite specific services that are or are not covered. Further, some clients were aware of their lack of knowledge regarding NHIS services and expressed a desire to learn more about NHIS coverage from their providers:
We will also beg of them to tell us exactly what the health insurance covers. Because sometimes when you go to the hospital you will be told that the health insurance does not cover “Drip” and some of the drugs too are not covered by it…it does not cover admission beds too. So, we don’t know what exactly the health insurance covers… (Patient at a non-franchised clinic, Greater Accra, Ghana)
One NHIF official acknowledged the dearth of information passed on to enrollees, saying, We do a lot, but I think our communication is not as good as it should be. We don’t say as much as we should.
Corroborating provider reports of charging NHI-enrolled clients for drugs or services that should have been covered, patients regularly reported making some kind of out-of-pocket payment when they visited a clinic. This was particularly true in Ghana, where providers faced significant reimbursement delays. However, while patients often reported having paid for some services or drugs out of pocket when visiting the private clinic, they weren’t sure if they had been charged correctly. Among clients in Kenya, who knew less about NHIF coverage and did not expect completely free services under NHIF, satisfaction was higher with the amount they had paid in the clinic than their counterparts in Ghana. However, Kenyan patients also were more likely to report that they had paid nothing for their clinic visit, including drugs. While most patients in Ghana reported that the fees they paid felt reasonable, these patients were more likely to expect free services. This may be a result of having received more comprehensive coverage when the NHIS first started operating, and providers were paid adequately and on time.
Further, across rounds of data collection, patients in Ghana specifically expressed concern that NHIS doesn’t cover enough services or drugs, resulting in patients having to make additional cash payments at the clinic or visit a pharmacy to pay for medications out of pocket. A few patients reported that they didn’t even bring their NHIS card with them to the clinic because they felt it didn’t provide adequate coverage:
Respondent: Mm, me, to me, right now I don’t have health insurance. I have the card alright but it’s at home. When I visit the hospital, I go with money.
Interviewer: Okay, okay, okay, why?
Respondent: Because when I even possess the health insurance it covers nothing. Mm. (Patient at a Bluestar clinic, Ashanti, Ghana)
In this context, patients sometimes felt cheated by a system that they believed no longer functioned properly.
As a result, after initially enrolling in the SHIs, a number of patients in both countries reported allowing their enrollment to lapse when it came time to renew. In Ghana, for example, some patients decided not to re-enroll in the NHIS because they still paid at the clinic and therefore didn’t see any benefit in NHIS membership:
So, after the treatment, the drugs prescribe – sometimes the doctor writes prescription and if you have [National] Health Insurance they will tell you they don’t have but when you are buying with cash they will be able to get some for you…So, I normally see it as, I registered for when the Health Insurance was introduced about 12 years ago, but as it expired I’ve not re-apply for it again. (Patient at a Bluestar clinic, Ashanti, Ghana)
Among those who maintained enrollment, while a number of Ghanaian clients reported that they use NHIS to pay for services every time they go to the clinic, clients in Kenya did not report using NHIF every time they accessed health services. Ironically, and in contrast to complaints that NHIF fees were too expensive, some patients had only used NHIF one or two times even though they had been enrolled, and presumably paying the monthly fees, for years. Since NHIF fees are automatically deducted from workers’ salaries, it is possible that these interviewees did not have control over whether or not they paid for NHIF coverage, which would help to explain their continued payments. However, several patients apparently did not know how to use NHIF once they had it. These patients thought they had to bring their NHIF card with them to the clinic in order to receive services, although this is not the case, and so did not try to pay with NHIF when they didn’t have the card with them.
Interviewer: Have you ever used NHIF since you got it?
Respondent: I have never.
Interviewer: Why?
Respondent:…I always assume that they want the card. When I went [to the NHIF office] last year I was told that the machine was broken…The machine was broken. The one that generate the card. (Patient at a Tunza clinic, Eastern, Kenya)
Under Kenya’s capitation system, patients who paid for NHIF without using it may also have been registered with a particular clinic, but elected to receive services elsewhere; a hypothesis supported by our finding that NHIF-enrolled patients in Kenya were far less likely to seek out an accredited facility than their counterparts in Ghana.
Finally, SHI-enrolled patients in both countries disagreed on whether they were treated better or worse than cash-paying clients. In some cases, clients felt they were treated better or faster than patients paying with cash, which one Kenyan client suggested was because providers know that patients covered by NHIF are definitely able to pay. Conversely, some patients in both countries suggested that clients paying with cash received better services and higher-quality drugs than those paying with NHI.
Unlike providers, a number of whom were frustrated with the capitation pilot program in Ghana, or confused by the concept in Kenya, patients did not have strong reactions to the concept of capitation and were generally informed about the concept and the need to register with a particular clinic. However, patients had mixed reactions to the capitation model in terms of provider choice; some felt it gave patients the opportunity to choose the clinic where they wanted to seek treatment, while others suggested that capitation limits the ability to shop around.