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Developing a Sustainable Care Delivery Payment Model for Children With Medical Complexity.

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Developing a sustainable payment model for children with medical complexity (CMC) improved care coordination and stakeholder value. This innovative approach addressed financial challenges in pediatric complex care programs.

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Area of Science:

  • Pediatric Healthcare
  • Health Economics
  • Care Coordination

Background:

  • Children with medical complexity (CMC) represent a significant healthcare cost burden.
  • Existing fee-for-service models hinder financial sustainability for complex care programs.
  • Complex care aims to improve outcomes and family function for CMC.

Purpose of the Study:

  • To describe the development of a sustainable complex care payment model for CMC.
  • To evaluate the value generated by this novel payment model for stakeholders.
  • To outline key elements for successful payer-clinician collaboration in complex care.

Main Methods:

  • Collaboration between two Wisconsin complex care programs and their state Medicaid payer.
  • Utilized a Centers for Medicare and Medicaid Services Health Care Innovation Award.
  • Employed time-study methodology to measure the cost of care for services provided.

Main Results:

  • Established a sustainable payment model for complex care services.
  • Demonstrated value for CMC, families, and healthcare systems.
  • Facilitated a stronger payer-clinician relationship built on mutual understanding.

Conclusions:

  • Sustainable payment models are crucial for the viability of pediatric complex care programs.
  • Payer-clinician partnerships and robust cost-measurement are key to innovative healthcare financing.
  • This model offers a scalable solution for improving CMC care delivery and financial performance.