Groups Team up to Offer Contracting Tool

From Health Plan Weekly

Trying to address the perplexing challenge of how to manage significant care costs for high-need members of employer-sponsored plans, the Pacific Business Group on Health (PBGH) and the Health Care Transformation Task Force (HCTTF), supported by The Commonwealth Fund and The SCAN Foundation, recently introduced a contracting tool.

The overarching idea is to offer strategies for effectively managing care programs and improving health outcomes for medically complex populations that work across lines of business — Medicare, Medicaid and commercial — and address populations at varying levels of risk.

The PBGH/task force tool recommends: identifying and segmenting the target population; designing the care-management program to jibe with the contract structure and the organization's ability to capture utilization savings; ensuring access to data; and setting up the program to provide a return on investment (ROI) over multiple years and meet specified contractual targets.

Margie Powers, director of PBGH's medically complex program, stresses the importance of being able to respond to diverse needs. "The medically complex population is not one-size-fits-all," she says. "It could be Medicare, Medicaid or commercial….There are different characteristics, and medically complex patients can become more or less complex over time. So providers and payers must be flexible to support them" with resources and staff.

Caitlin Sweany-Mendez, HCTTF's project lead, says that accessing data "is crucial, and it's surprising [that] lots of payers didn’t have formal data use as part of agreements."

She adds that payers are more sophisticated at doing ROI analysis than providers are because their care management programs tend to be larger. "We think it's important for providers and payers to have a comfort level, see actual outcomes attached to this as well," she says.

According to Sweany-Mendez, achieving ROI over the longer haul with these contracts could be a challenge. And longer contracting length, especially for a new program, is important for ROI.

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