Navigating value-based payments for enhanced care management (ECM)

CalAIM's enhanced care management (ECM) program provides a great opportunity for providers to deliver whole-person care while discovering additional revenue to reinvest in your community. A number of managed Medicaid plans (MCPs) are now offering some form of value-based payment. These value-based payments provide incentives to deliver high-quality, cost-effective care that improves patient outcomes and satisfaction, promotes care coordination, reduces administrative burden, and fosters long-term relationships with patients.

At a high level, the ECM payments offered today are typically a mix of the following:

1. PMPM payments: This payment is often based on the number of engaged members per month.
2. Outreach payments: This payment is typically based on outreach attempts. Typically FFS (fee for service) payment, can be based on each attempt (up to a max limit) or only on a successful attempt.
3. Value-based payments: This payment is based on the ECM provider's performance on predefined quality measures.

For long-term sustainability using value-based payments, providers need access to customized dashboards that allow them to track key performance metrics that are most relevant to their practice or organization, enabling them to monitor progress and make data-driven decisions. These metrics include:

Financial Metrics

Value-based payments are more complex than FFS. It is critical for providers to track their revenue to ensure that they are receiving appropriate reimbursement for the care they provide.

In addition, ECM providers can benefit from tracking the total cost of care (TCOC) by integrating claims data. TCOC measures the overall cost of providing care to a patient over a specific period. Tracking TCOC will help ECM providers negotiate better agreements with payers if they can demonstrate their impact in reducing the TCOC for the attributed population.

Clinical Metrics

Providers participating in enhanced care management (ECM) can benefit from getting insights into clinical metrics that measure the effectiveness of clinical care delivered to patients.

Clinical metrics such as blood pressure control, glycemic control, and medication adherence can help ensure that patients are receiving appropriate care for their chronic conditions.

Quality Metrics

Providers participating in enhanced care management (ECM) must regularly check their performance against the quality metrics used by MCPs.

Typical measures include care planning, blood pressure documentation and control, depression screening and response, and transitional care management (post-discharge assessment, etc.)

Process Metrics

Process metrics can be very useful to track how well is your 'machine' working. These metrics include tracking outreaches in a given period vs. past period, the number of care plans, as well as assessing the results by the lead care manager.

The process measures can also help you uncover opportunities to optimize your care pathways.

Connect with us?to learn how we can help you gain long-term financial benefits by diversifying your revenue through value-based care.?Our whole-person care platform can help you streamline your clinic’s participation in value-based care by discovering the insights you need to lower costs, improve efficiencies, and deliver quality, coordinated care.