Payment Model Guidance for Caring for Children with Complex Medical Conditions

This guidance is for aligning payment incentives to support a focus on families, the use of care coordinators, enhanced relationships across providers, and support of the primary care physician.
Download
care_payment_model_report

The development of alternative payment models for the children with complex medical conditions (CMC) population is challenging. Movement from the traditional fee-for-service model to alternative payment models requires detailed planning that involves the entire health care network (both internally and externally). When developing new sustainable payment models, children’s hospitals should:

  • Leverage components of emerging Centers for Medicare & Medicaid Services (CMS) payment models for complex adult patients.
  • Examine new models with a focus on care coordination and community, payer and provider partnerships.
  • Understand the demographics of your specific population and consider the difficulty in crafting specific models for smaller populations; industry experience shows leveraging larger populations or adult populations mitigates both the cost and risk.
  • Develop the infrastructure to build solid analytics, primary care provider support and payer relationships.
  • Begin to better understand your health system’s unreimbursed costs.
  • Obtain actuarial expertise to analyze, implement and monitor any alternate payment model.
  • Obtain payer expertise or a champion to build and maintain strong payer relationships.

Related Content

The Budget Reconciliation Bill's Financial Impact on Children’s Hospitals

The budget reconciliation legislation will have a devastating effect on the financial viability of America’s children’s hospitals.

Sep. 04, 2025

A Basketball Brotherhood Fortifies Teen During Cancer Journey

After a life-changing diagnosis, a teen discovered hope through a bond with a collegiate basketball team — proving that support, connection, and community can transform even the toughest journeys.

Sep. 02, 2025

Speaking Volumes: Team IMPACT Amplifies Advocacy

Learn why a football player says teaming up with a 13-year-old was the best part of his college experience.

Aug. 06, 2025