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.