Establish the Fee Strategy

Paying for Care

Stage One defines what the system must be capable of delivering. Stage Two establishes how progress and outcomes will be evaluated. Stage Three determines what those people, tools, and resources will cost, and how the cost should be shared.

The central financial decision is what the payment is intended to purchase.

In this model, members and participating organizations pay for primary care capacity: the clinical relationships, therapeutic resources, coordination, access, and time required to help people move through a complete arc of care.

This allows the system to:

• establish and maintain a primary care relationship;
• intervene before needs become more complex;
• select and sequence the appropriate clinical tools;
• coordinate care across practitioners and settings;
• adjust the strategy as the patient progresses;
• and remain present through the transition toward greater independence.

When the primary care system is paid primarily through isolated transactions, each visit, procedure, and service must stand on its own. Funding the care required across the arc gives the clinical model room to pursue the result rather than simply produce another billable event.

The Work

The clinical operating requirements established in Stage One will be connected to the outcome structure established in Stage Two. Together, they will show what the model must fund.

The initiative will determine:

• the people and clinical disciplines the system must support;
• the expected time and resources required across representative arcs;
• which services should be consistently available;
• which resources can be shared or accessed as needed;
• which costs belong within primary care;
• which risks should remain with major-medical insurance;
• and what reserves and safeguards are required for stability.

The coalition can then evaluate how those costs should be distributed among individuals, households, employers, cooperatives, community institutions, and other participating organizations.

Possible structures may include:

• individual and household membership;
• employer or organizational contributions;
• pooled primary care funding;
• defined member cost-sharing;
• mutual or cooperative arrangements;
• and coordination with major-medical insurance.

The final structure does not need to be predetermined. It must be built around the care and resources identified in the earlier stages.

Why This Matters

Paying for primary care capacity creates several advantages.

• Continuity becomes fundable. The system can maintain the relationships required to follow patients across time.
• Earlier action becomes practical. Care can begin before a need becomes severe enough to justify a more expensive intervention.
• Clinical tools can be used appropriately. Services can be selected according to the patient's stage and objective rather than the billing opportunity.
• Coordination becomes part of care. The work of holding the arc no longer disappears between separately billed encounters.
• Costs become more visible. Members and participating organizations can see what primary care capacity costs and what it is expected to accomplish.
• Better health has financial value. Completing the arc can reduce repeated visits, preventable escalation, and avoidable use of more expensive services.

What Remains Open

Stage Three does not assume that one fee structure will serve every population or community.

The coalition will help determine the appropriate contribution model, benefit boundaries, cost-sharing, reserves, insurance relationship, and protections required for the first build.

Those choices remain flexible. The governing standard does not:

The Required Result

A financing architecture that defines:

• what primary care capacity the model will fund;
• what resources members can access;
• how contributions and costs will be shared;
• what responsibilities remain with the member;
• where primary care ends and major-medical coverage begins;
• what reserves and protections are required;
• and what conditions are necessary for financial viability.

The Readiness Standard

Stage Three is complete when the proposed fee structure can reliably fund the clinical model, preserve access to appropriate care, protect members and the cooperative from unreasonable risk, and operate within a clearly defined relationship with major-medical insurance.

The result must also be clear enough for prospective anchor organizations to understand what they would fund, what their members would receive, and what value the model is designed to produce.