Table 1.

Constraint, Agent-Principal, and Price Adjustment (CAP) Framework for Global Budget Payment: Selected Cases.

Health system	Constraint		Agent and principal		Price adjustment
	Capitation or facility-based	Hard or soft cap	Agent: providers	Principal: payers	Yes or no
CalPERS with Blue Shield4	Facility	Soft	Individual	Unitary	No
Maryland All-Payer Modela,5	Facility	Hard	Individual	Unitary	No
Alternative Quality Contract with BCBS in Massachusetts: 1-3,22	Facility	Hard	Individual	Unitary	No
Taiwan6,21,23-25	Capitation	Hard	Group	Unitary	Yes
Germany (ambulatory)20	Capitation	Hard	Group	Multiple	Yes, then replaced with volume capb
Canadian provinces of Alberta, Nova Scotia (ambulatory)26	Capitation	Hard	Group	Unitary	Yes
Canadian provinces of Quebec, British Columbia (ambulatory)27	Capitation	Soft	Group	Unitary	No
Canada (inpatient)27	Facility	Hard	Individual	Unitary	No
France (inpatient, public)c,14,27	Facility	Hard	Individual	Unitary	No

Note. CalPERS = California Public Employees’ Retirement System; BCBS = Blue Cross Blue Shield.

^aThe All-Payer Model in Maryland involves a common rate schedule for all payers.

^bIn German ambulatory sector, the point value dropped significantly after the implementation of the global budget payment system with price adjustment, resulting in a sharp decline in de facto prices and physician income. To stabilize the point value, a limit of maximal number of points per practice, that is, individual volume cap, was introduced at year 5 (year 1997).⁵

^cFrance has a multipayer health system with sickness funds, similar to the German system, but operates differently. Rather than paying out to providers using “multiple pipes,” each sickness fund in a given hospital’s catchment area pays their shares to the “pivot fund” or the dominant fund in the area.