How Community Health Centers Can Clarify and Quantify Performance for More Successful Payer Contracting

Payer contracting has become one of the most complex yet crucial aspects of ensuring financial sustainability for community health centers (CHCs). These centers, which focus on providing care to underserved populations, often face the challenge of aligning their mission-driven work with the intricate financial realities of healthcare reimbursement models. One of the biggest hurdles? Accurately capturing and negotiating the cost of care when it goes beyond just clinical data.

Health-Related Social Needs (HRSNs)—factors like access to nutritious food and transportation—profoundly impact patient outcomes and, consequently, healthcare costs. Yet, traditional contracting often overlooks these social determinants, focusing instead on clinical data. The result is a misrepresentation of the full spectrum of care provided by CHCs, which can lead to under-compensation from payers.

This is where our new approach to Combined Risk (clinical + social) comes into play. By developing a more holistic view of patient care that integrates clinical data with social determinants, CHCs can more accurately calculate the actual cost of care for their patient populations. This improves patient outcomes and strengthens the case for better reimbursement in payer negotiations.

What does this look like in practice?

A well-designed payer contracting system tailored for CHCs and Federally Qualified Health Centers (FQHCs) focuses on several key areas:

• Pinpointing patient cost and revenue opportunities: Understanding where costs are being driven and potential revenue opportunities lie allows CHCs to make data-informed negotiation decisions.
• Identifying key patient-provider relationships: These relationships are critical to patient outcomes and can significantly influence reimbursement models, particularly in value-based care arrangements.
• Prioritizing population segments: Some patients are different, and different populations will have other health and social needs. A targeted approach ensures that the highest-need populations receive the care they require while optimizing resources.
• Providing proof of performance: At the end of the day, payers want to see results. A robust system offers tangible, data-backed evidence that the care provided delivers a return on investment through improved patient outcomes, reduced hospitalizations, or more efficient use of resources.

With this system in place, CHCs can better serve their communities and have the tools they need to negotiate their fair share in payer contracts. By understanding the combined risk of clinical and social factors, they can advocate for reimbursement models that reflect the actual value of their care.

If you're leading a CHC and navigating the payer contracting landscape, there’s no need to go at it alone. Let’s start a conversation about how innovative payer contracting strategies can help CHCs like yours secure better patient and provider outcomes. After all, fair and sustainable contracts are not just about numbers—they're about ensuring that your center can continue its vital mission.

If you’d like to learn more about joining us on this journey towards enhanced value-based care and contracting, comment below or visit www.Nascate.com.?

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