️If I Ran the Nevada Health Authority… We’d Fix Nevada’s Suffocating Capitation Practices

By: Matt Brandenburg, OTD, OTR/L

You know that moment on Survivor when someone thinks they’re running the island? They’re all confident, smug, already planning who’s next to go until Jeff Probst reads the votes, and boom, they’re blindsided back to Ponderosa. That’s how insurance capitation works in Nevada’s therapy system. Decisions about who can treat whom and where kids with developmental delays or grandparents recovering from total hip replacements can actually go for care aren’t made by clinicians or families. They’re made by insurers holding the only torch that counts. They dictate which rehabilitation clinic you can see, and patients lose the chance to choose who helps them heal.

On paper, capitation seems like a potential fix for rising healthcare costs: insurers pay one clinic a flat rate per patient per month, no matter how much therapy that person actually needs. It’s supposed to cut costs and reward efficiency. But in practice, it’s more like Love Is Blind: insurers whisper sweet nothings about “value-based care,” but once the honeymoon’s over and real life starts (AKA when Grandma needs three sessions a week or an autistic child needs multidisciplinary care), everyone gets ghosted. The romance ends, and families are left holding the bill, or stuck on a two-year waitlist.

What’s Capitation, Anyway?

Capitation, in the insurance world, means a clinic gets paid a set amount per patient (usually a “per member, per month” (PMPM) rate) regardless of how much therapy that person actually needs. The idea is that by giving clinics a flat budget, insurers can control costs and promote efficiency. In theory, it’s a model meant to reward smarter care, not more care.

But Nevada is still early to the capitation game and the way it’s being implemented here looks very different from states that have attempted it responsibly.

In several Nevada regions, insurers have transformed capitation into an exclusive arrangement, handing all the patients in a region to a single therapy company. If your child or grandparent’s plan is tied to that contract, they can only receive OT, PT, or speech therapy from that one clinic. It doesn’t matter if it’s full, too far away, or not a good clinical fit. Everyone else (ie., families, independent providers, and new therapists trying to enter the workforce) gets locked out.

Other states that use capitation don’t do it like this.

For example, Colorado uses capitation in Medicaid behavioral health, but Network Adequacy Requirements establish broad provider networks within each managed care region, meet state-mandated network adequacy standards, and avoid relying on exclusive single-provider arrangements that restrict patient choice. Additionally, Colorado’s Department of Health Care Policy & Financing audits their Regional Accountable Entities for access measures like wait times, provider availability, and continuity of care, metrics Nevada insurers are not required to publicly report.

In other words: capitation itself isn’t the problem. Nevada’s exclusive, single-provider version of it is.

Where other states emphasize patient choice, regulated networks, and accountability, Nevada’s current approach concentrates power, restricts access, and leaves families navigating a maze built around contracts and not care.

How It’s Playing Out in Las Vegas

Here’s where it gets real, Real Housewives of Clark County real.

A child might already see a speech therapist at a neighborhood clinic where the team knows her and her family is finally seeing progress. But because her insurer’s capitation contract only covers one specific provider across the city, she can’t receive occupational therapy there. Instead, her mom gets told to drive across town twice a week, juggling work schedules, and sitting through 4 p.m. traffic on the 215.

Meanwhile, independent clinics with open schedules, specialized pediatric programs, and qualified and eager therapists are benched like Bachelor contestants who never got a rose. Multiply that story by thousands of Nevada families, and you get a system that rewards exclusivity over access and efficiency over empathy.

Who do current capitation practices hurt? (Spoiler: Everyone)

• Families: They’re forced into months-long wait-lists, splintered care plans, and exhausting commutes. For working parents, that’s not just inconvenient, it’s unsustainable.
• Nevada’s own health workforce data show that nearly 70% of the state’s population live in primary care health-professional shortage areas and 86.9% live in mental-health shortage areas. When families are funneled into a single clinic under a capitation contract that is already overbooked, this shortage is magnified.
• Clinicians: Independent and mid-sized therapy practices (often the community-based, family-centered ones) are shut out of capitated networks, meaning they lose funding, cannot grow, and cannot hire new grads.
• With only one clinic per region holding all the capitated contracts, smaller providers sit idle even when demand is high. That leaves fewer places where new therapists can train, discourages innovation (because in-network providers are rewarded for cost control, not creative care), and weakens Nevada’s ability to build a sustainable allied-health workforce.

Payment models that fix rates per-member‐per‐month pressure providers to cut visits or cherry-pick lower-complexity cases, discouraging therapists from taking on more complex, meaningful work that drives real outcomes.

• Patients: Continuity of care collapses. Kids lose momentum. Older adults drop therapy because they can’t drive that far. Progress stalls and public health declines.
• Studies of capitation payment models show they’re linked to reduced utilization of services and fewer visits overall. When a clinic’s budget is fixed, administrative priorities shift toward rationing care and quality of care becomes the first casualty.
• The System: Nevada already faces a shortage of healthcare professionals, and capitation bottlenecks make it worse. The supposed “cost-saving” model often backfires into longer recovery times and higher downstream costs.
• Even as the Silver State makes gains in licensing occupational therapists and other allied health professionals, persistent access gaps continue to delay care for thousands of residents. When therapy is delayed, the system pays later in the form of higher hospitalizations, slower recoveries, lost productivity, and greater overall cost.

If I Ran the Nevada Health Authority…

Capitation wouldn’t get to be the villain. Here’s how I’d rewrite the season:

🔥 End the Monopoly-esque Contracts – No single clinic should own an entire patient population. Nevada should spread capitated contracts across multiple providers and require insurers to open their panels based on geographic access and clinical demand. When all the patients in a region are funneled into one company, continuity of care crashes and competition for providing quality care evaporates.

🔥 Put Families First – Require insurers to offer family choice within therapy networks. A parent shouldn’t have to drive across town because an exclusive contract dictates where their child can go. Patients deserve options that are nearby, specialized, and appropriate for their needs, not whatever’s left after the handshake deals.

🔥 Transparency Rules – Force insurers to publish their capitation rates, patient outcomes, and referral data the same way hospitals report quality metrics. Nevada deserves to see who’s thriving because of good care versus who’s thriving because they’re the only ones allowed to give it. If an insurer claims capitation saves money and improves outcomes, show us the receipts.

🔥 Reward Quality, Not Quotas – Tie any capitation bonus to patient function, satisfaction, and continuity of care, not to how many visits were denied. Nevada’s shift from “volume to value” can’t just live in marketing copy; it should live in the metrics. Insurers that demonstrate real improvement in functional outcomes and equitable access should earn the incentives.

🔥 Create a Therapy Access Task Force – Establish an NVHA-led coalition of OT providers, PTs, SLPs, and families to evaluate provider networks, access barriers, and outcomes statewide. The task force should have authority to review contract practices, recommend reforms, and ensure that capitation aligns with public health goals and not corporate convenience.

🔥 Invest in the Workforce Pipeline – Simplify credentialing and network onboarding for qualified new clinicians, and incentivize community-based clinics to hire and train them. Nevada can’t fix access if early-career therapists have nowhere to work. Building a thriving allied-health workforce starts with fair contracts, open doors and mentorship that keeps talent in the state.

🔥 Ban Non-Compete Clauses – Prohibit non-compete agreements in healthcare provider contracts (or at minimum, cap their mileage and duration so clinicians aren’t locked out of serving their own communities). Therapists shouldn’t need a lawyer just to change jobs. Non-competes strangle innovation, limit collaboration, and drive skilled clinicians out of Nevada entirely. A free workforce, not a captive one, is how we expand care.

Final Rose Ceremony

If Nevada wants a healthcare system that actually puts patients first, capitation needs a serious overhaul. The current model doesn’t prioritize access, continuity, or quality; it prioritizes contracts. Patients deserve real choice, clinicians deserve real fairness, and the NVHA deserves a payment system that reflects the state’s values, not its loopholes.

Because when capitation becomes suffocation, no one wins (except the ones who already have the yacht).

Nevada’s healthcare story doesn’t have to be another rerun of monopolies and missed opportunities. We can write a new season! One where transparency, access, and accountability are the leads, not the cliffhangers. One where independent clinics thrive, new grads stay, and families actually get the care they’ve been promised.

If I ran the Nevada Health Authority, that’s the plot twist I’d bet on: giving the torch back to the healers, the families, and the people who make recovery possible. It’s time they finally get the rose. 🌹