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Developing a Sustainable Care Delivery Payment Model for Children With Medical Complexity
Timothy E Corden1,2, Tera Bartelt2, Sarah Johaningsmeir1
1Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.
Insights
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.
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.
Abstract:
Children with medical complexity (CMC) are a small but growing population representing <1% of all children while accounting for >30% of childhood health care expenditure. Complex care is a relatively new discipline that has emerged with goals of improving CMC care, optimizing CMC family function, and reducing health care costs. The provision of care coordination services is a major function of most complex care programs. Unfortunately, most complex care programs struggle to achieve financial sustainability in a predominately fee-for-service environment. The article describes how 2 programs in Wisconsin worked with their state Medicaid payer through a Centers for Medicare and Medicaid Services Health Care Innovation Award to develop a sustainable complex care payment model, and the value the payment model is currently bringing to stakeholders. Key elements of the process included: Developing a relationship between payer and clinicians that allowed for an understanding of each's viewpoint, use of an accepted clinical service model, and an effort to measure cost of care for the service provided supported by time-study methodology.
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