The Blueprint

Asking the right questions: Discussion guide for payer talks

by Amanda Berra

Providers are increasingly approaching health plans and employers to initiate discussions of medical home contracting opportunities. We all know how critical it is to come to the negotiating table thoroughly prepared with good discussion questions. But when it comes to medical home contracting, what are those good questions?

An emerging priority

Medical home contracting is one of our biggest priorities here at the Medical Home Project. We’ve done several research projects on this and we’re not done yet. Along the way, we’ve seen how crucial it is for providers to be thoroughly prepared to talk with payers (health plans or employers) about medical home contracting.

Here are some example discussion questions we suggest that providers bring to the table with them when talking with a potential partner, especially a partner that is approaching the provider with an arrangement in mind. If the provider is doing the initiating, not all of these questions apply. However, suggest thinking them through amongst your own team, so that you can come to the potential partner with your own ideas.

Example payer-provider discussion questions

  • What is the current state of this payer’s medical home contracting/program piloting? Are these programs designed to support broad-based transition of primary care practices to the medical home, or focused on enhancing management of specific conditions or patient populations, such as diabetics or highest-cost patients?


  • How tested is this health plan’s approach? If the approach is still in testing phase, are there mechanisms for addressing contract model shortfalls are discovered?


  • If a pilot, what would happen at the end of the pilot period, under scenarios of low-, moderate-, or high-performance against stated goals?


  • Would this medical home contracting arrangement require special data collection? How could we minimize complexity there? Are the target performance metrics similar to existing contracts with other health plans/the practice’s existing targets for PCMH?


  • If the payer is offering operational support (IT, staff), can we blend those resources seamlessly into the practice “back end,” so that patients perceive resources as coming from the physician office care team, or would those interfaces need to be separately branded as coming from the payer?


  • If the health plan has a minimum provider size to participate, and we fall under that size, will the health plan help connect us with other providers to form a “virtual panel,” or do we need to do that ourselves?


  • Would participating in this contract require treating enrollees of this health plan differently from other patients?


  • Will the payer notify patients about our practice’s participation in the medical home model? Can patients be given incentives for active participation?


  • Even if “medical home” contracting options are not (yet) available, are there primary care quality reward programs that we could make more substantial now as a way to support the medical home?


More information

Please see the growing set of related research and tools in the Medical Home Project's contracting resource suite.

  • Emerging Trends in Medical Home Contracting” (webconference): National trends and case studies in private payer activity in support of the medical home.


  • Employers and the Medical Home” (webconference): The medical home from an employer perspective, including employer viewpoint on medical home ROI, current models, and guidance on steering self-insured employee populations to the medical home.


  • Volume impact: How will PCMHs affect downstream utilization and referrals (expert blog entry): Outlines potential volume effects for specialists and acute care of affiliating with a high-performing medical home network


  • Health Coach Impact Calculator (tool): Customized pro forma that forecasts the financial impact of adding health coach FTEs to PCP practices in a FFS market. Captures and communicates the financial upside to a given physician practice of adopting near-term PCMH functionality (patient risk segmentation and proactive outreach to patients with chronic conditions for necessary care)


  • The ROI of the Medical Home: Clarifying (and Capturing) Financial Upside across Practices, Health Systems, and Payers (webconference, forthcoming): Walks through the critical levers to financial sustainability of a PCMH program from the perspective of key stakeholders, presenting a critical discussion of reported “ROI” results across well-known pilots.

Questions or comments? Always feel free to contact me (berraa@advisory.com)

Amanda Berra