Payment to Promote Sustainability of Care Management Models for High-Need, High-Cost Patients

May 2016

This resource reviews emerging payer and provider partnerships that incentivize value-based payment models. Key points and recommendations include:

  • The highest-need, highest-cost population is ever-changing. Payment systems should focus on identifying the population that will benefit most from care management services. Models must periodically re-evaluate this population.
  • Provider incentives must be based on Triple Aim outcomes — better care for individuals, better health for populations, and lower costs. If per-member-per-month incentive payments are used, there should be metrics that are evaluated to ensure that the Triple Aim is met.
  • Providers face financial “barriers to entry” to make initial programmatic and infrastructure investments. Preventing inappropriate and/or avoidable use of care requires upfront investments such as information technology, social supports, and expansion of primary care services.
  • Programs are most effective when they partner with patients, empowering them to take an active role in their own care management.
  • A form of sustainable payment is a per-member-per-month care management fee based on Triple Aim outcomes for high-risk patients, plus shared savings.
  • Providers with existing care management programs for high-need, high-cost patients prefer full-risk capitation payments.
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