Care Management Contracting for Complex Populations: Best Practices and Tools

Health care providers across the country are increasingly adopting care management programs to better serve high-need, high-cost (HNHC) patients, a small percentage of individuals with complex medical, social, and behavioral needs who utilize the largest proportion of national health care resources. A significant barrier to widespread adoption of these HNHC programs is garnering adequate payment for services. By establishing a deeper understanding of how to optimize payment and contracting approaches, providers can develop better methods for sustainability.

The Health Care Transformation Task Force (HCTTF) and the Pacific Business Group on Health (PBGH), with support from The Commonwealth Fund and The SCAN Foundation, have created resources to help provider and payer organizations effectively contract for high-need, high-cost programs. They include:

  • A whitepaper that shares information and recommendations from organizations with a range of different care models and contracting approaches; and
  • A practical set of guidelines for providers and payers as they create contracts that incorporate reimbursement for high-need, high-cost individuals.

The project primarily targets provider executive decision-makers and operational leads across areas such as financing, contracting, and clinical care management (with relevance to payers as well).

The report provides key insights and vignettes on topics such as identification/segmentation of target populations, care management program design, data access, and financial sustainability/return on investment. It builds upon months of research and interviews with organizations that operate successful care management programs for high-need, high-cost individuals.

The practical contracting guidance was developed in conjunction with industry experts who have significant experience designing contracts that incorporate reimbursement for HNHC-specific programs. Specific contracting areas addressed include:

  • Type & Level of Risk
  • Data Sharing
  • Patient Population
  • Consumer Engagement
  • Service Requirements
  • Quality Metrics/Performance Evaluation
  • Provider Network Requirements
  • Financial Structures
  • Return on Investment
  • Confidentiality Requirements

Read the accompanying press release

Download the full report here

Download the contracting guidance here