As California’s CalAIM initiative and the broader healthcare landscape continue shifting toward value-based care (VBC), Enhanced Care Management (ECM) providers must prepare to be successful. ECM’s emphasis on social determinants of health, preventative care, and care coordination aligns with Managed Care Plans’ (MCPs) evolving priorities and incentives to drive improved health outcomes and lower the total cost of care. While standard ECM reimbursement relies on a per- member-per-month (PMPM) model, MCPs are beginning to layer in quality-based payments that reward high-value processes and improved member health outcomes. In turn, ECM providers must build the infrastructure and capabilities needed to participate in these performance-based incentive models and should keep the following in mind.

1. Familiarizing Yourself with Quality Metrics: Quality metrics such as National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set (NCQA HEDIS), Prescription Drug Event (PDE), Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, etc. have been tied to Medicare, Medicaid and commercial value-based financial incentives for years. Managed Care Plans in Southern and Northern California are beginning to incorporate these measures into Enhanced Care Management contracts. Some common quality metrics we see across MCP’s include:

• Person-Centered Care Planning: Documentation of care plans that support coordinated, individualized care.
• Controlling High Blood Pressure (CBP): Percentage of members aged 18–85 with hypertension whose blood pressure is <140/90 mmHg.
• Blood Pressure Control for Diabetes (BPD): Percentage of diabetic members aged 18–75 with blood pressure <140/90 mmHg.
• Glycemic Status for Diabetes (GSD): Percentage of diabetic members with HbA1c or GMI <8.0%.
• Depression Screening and Follow-Up: Completion of PHQ-9 screening and appropriate follow-up for members who screen positive.
• Well-Care Visits (WCV): Annual visit completed with a Primary Care Provider (PCP) or Obstetrician-Gynecologist (OB/GYN) for members aged 3–21.
• Transitions of Care (TOC): Timely post-discharge follow-up within specified timeframes (e.g., 7 or 30 days, depending on the measure).

2. Understanding metric definitions is critical to reaching targets and earning additional revenues. Reading a metric definition without comprehending the measure specifications might lead to inaccurate inclusions or exclusions and missing targets. Some examples are below:

Person-Centered Care Planning:

• Measure Description: The percentage of ECM enrolled Members who had a Care Plan initiated or updated during each month of the measurement period.
• Measure Denominator: Members continuously enrolled during the entire measurement period within the same Healthcare Organization.
• Measure Numerator: Members in the denominator who had at least one intervention created / customized or updated each month of the measurement period.
• Nuanced takeaway: Patients who switched in or out of your organization during the measurement period will not be in the denominator.

3. Navigating Tiered Incentive Payouts: Many plans will offer larger incentives for meeting bigger targets. For example, you might get an additional $10 PMPM if 30-59% of your members have controlled blood pressure, $20 PMPM if 60-79% are under control and $30 PMPM if 80%+ are under control. It is important to understand what is feasible with your organization’s resources. It might be easier to get members to the top tier compliance for one measure than getting members to reach the lowest tier for three measures. Strategize in advance on how to best apply resources to get maximum compliance and incentive earnings.

4. Strengthening Data Infrastructure: A strong data infrastructure is essential to monitor quality performance and validate eligibility. Implementing the following strategies will help:

• Clarify Your Data Sources: Confirm how the MCPs are getting data from your organization to evaluate if a member meets the target. MCPs can receive measure-level data through various data sources including provider claims, an electronic health record (EHR), MCP provider portals, or ECM care plan submission.
• Evaluate Tracking Capabilities: Ensure systems are aligned to monitor performance and/or flag gaps. Identify platforms or systems where you can look to see if a patient is meeting the target. These could include the MCP portal, a regional health exchange, an in-house EHR or population health system.
• Streamline Internal Workflows: Assess whether your organization is currently capturing the right data to substantiate meeting a target and can support supplemental data submission when required.
• Understand Timing and Access: Confirm the frequency and source of data to ensure timely, coordinated internal reviews.
• Implement Data Validation Protocols: Regularly audit for accuracy, especially for member attribution and documented services tied to payment.

5. Validating Performance for Payment Accuracy: Even with the right infrastructure in place, ECM providers must take an active role in ensuring that performance data translates into accurate and timely payments. Success in value-based care requires rigorous validation and reconciliation processes to confirm that all services are properly captured, coded, and submitted in accordance with MCP requirements. Regular reconciliation between internal systems and MCP-generated reports can identify discrepancies, such as missing encounters, misattributed members, or uncredited services, that can result in lost revenue. A disciplined, structured approach to reporting validation not only safeguards incentive payments but also reinforces provider credibility with MCPs, positioning the organization for deeper participation in future value-based care initiatives.

As MCPs continue to embed quality incentives into ECM payment models, providers who invest in understanding metrics, data strategy, and workflow alignment will be better positioned to thrive. By taking a proactive, performance-driven approach, ECM providers can not only improve member outcomes but also position themselves for long-term success in an increasingly value-driven healthcare environment.

COPE Health Solutions has extensive experience in Medicaid revenue optimization strategies, including value-based compensation, and we offer comprehensive platform, workflow and success enablement solutions for ECM and value based care. For more information on ECM or value-based incentives reach out to COPE Health Solutions at info@copehealthsolutions.com.