Written by Many MCPs have recently shifted reimbursement models to focus on the number of encounters per member each month. With limited explanation from the plans and lacking billing guidance, this shift is causing confusion among providers. Here, we’ll explore the reasons behind this change and where it may be heading.
This change stems from a need to ensure that ECM/CS members are receiving the consistent care and support they require. For vulnerable populations under CalAIM, frequent interactions are crucial for staying connected to necessary services. By setting encounter-based expectations, MCPs are trying to ensure that these members, often facing complex health and social challenges, receive regular attention and interventions that help address their immediate needs.
For members with high-acuity needs, including a significant portion who are homeless, consistent in-person interactions serve as a lifeline. Without these touchpoints, members risk losing connection with essential support systems. Regular encounters enable case managers to assess evolving needs, link members to the full spectrum of available services, and prevent issues from escalating into crises. This approach is particularly valuable in reducing emergency room visits, as frequent check-ins allow for timely interventions that address problems before they become urgent.
While encounter frequency provides a necessary framework for ensuring regular engagement, it is not a sustainable long-term solution. The true measure of success for CalAIM lies in outcomes that reflect meaningful, lasting change in members’ lives. This encounter-based approach will likely evolve into metrics focused on outcomes such as health stability, housing security, and reduced need for crisis care. Shifting toward outcome-based evaluations will enable CalAIM to prioritize quality of care and long-term impact, ensuring that each encounter contributes to sustainable improvements for California’s most vulnerable populations.
Sprite Health offers a highly comprehensive digital platform that enables the efficient management of all ECM/CS requirements in a single place. Our solution is purposefully designed to cater to the specific needs of the CalAIM ECM/CS initiative.
Connect with us to learn how you can enhance outreach efforts, streamline care planning and coordination, and fosters a data-driven and outcome-oriented approach that advances equity, and clinical outcomes.