Payment Model Guidance for Caring for Children with Complex Medical Conditions

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.
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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.
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