How to Run a 90-Day Direct Contracting Pilot Without Betting the Plan

Most self-funded employers do not blow up direct contracting because the idea is bad.

They blow it up by trying to go from zero to a full network move in one shot.

A 90-day pilot is the practical middle ground. It lets finance and benefits teams see:

• Whether you can actually steer members
• Whether the unit economics beat your current contracts
• Whether your TPA and provider can operate the model without chaos

…on a narrow slice of spend that will not sink the plan if it underperforms.

If you cannot make a 90-day pilot work on 5–10% of spend, you have no business talking about a network overhaul.

Here is how to structure a pilot that is big enough to matter and small enough to unwind.

1. Start with one expensive, boring problem

The worst way to start is with a vision statement like "transform our network."

Pick a problem you would be embarrassed not to work on:

• Joint replacements where your average allowed amount is $45,000 and your best contracted site is at $30,000
• Imaging that still runs through hospital outpatient departments at 3–5× freestanding rates
• A local market where one health system effectively sets the price

Pull a simple view off your claims data:

• Top 10 DRGs or CPT groupings by allowed amount
• Site-of-service breakdown for those claims
• 12–24 month trend

Your pilot should live in one of those clusters, not your entire book. If everything is in-scope, nothing is.

2. Draw a hard line around eligibility

Vague pilots die in operations.

Define the pilot population so clearly that an HRBP could explain it in one sentence. For example:

"For Q3, all knee and hip replacement episodes for members living within 50 miles of City X will be routed through System Y’s direct program unless a medical exception is approved."

Good eligibility rules look like:

• All employees and dependents in one metro
• Members in a single plan option
• A defined cohort (for example, scheduled for specific elective procedures)

If your eligibility rule does not comfortably fit in a single bullet, your navigation and communications teams will improvise—and your data will be useless.

3. Pick a partner who can actually move the numbers

You are not looking for a logo. You are looking for a counterpart who will live with the economics and the operations.

For a 90-day pilot, the provider or platform needs to:

1. Commit to real pricing. Think Medicare-indexed case rates you can benchmark, not "discount off charges."
2. Stand up workflows fast. Eligibility, scheduling, and pre-cert need to be configured in weeks, not quarters.
3. Report like a grown-up. Basic utilization and performance data inside the 90-day window—not six months later.

This is often easier with:

• A motivated regional system that already sees a lot of your volume
• A specialty network focused on one service line
• A COE program that has run this play before

If your prospective partner cannot do these three things, you are not running a pilot—you are doing a case study for their marketing team.

4. Write a real contract, even for 90 days

"Pilot" is not an excuse for vague paper.

Lock down a short, sharp term sheet:

• Scope: Service lines, facilities, and the exact pilot population
• Pricing: Case rates or fee schedules, expressed relative to your current effective allowed amounts
• Payment timing: Clean claim definition and payment terms (for example, 30 days vs the 90–120 day carrier reality)
• Data rights: What files you get (frequency, fields, format) during the pilot
• Exit ramp: How either side unwinds if the pilot fails or materially underperforms

You are not signing a five-year strategic alignment document.

You are putting a real container around a 90-day experiment so you can trust the results.

5. Make the direct path feel like an upgrade

A direct contract that members never use is just an expensive press release.

For the pilot window, you want the preferred path to feel like a no-brainer:

• Waived or sharply reduced cost sharing when members use the direct pathway
• A clear cash incentive for completing the episode through the program
• Travel and lodging where distance is a barrier
• Scheduling handled by a human being or concierge team, not a 1‑800 maze

Then communicate like you are launching a new benefit, not issuing a policy memo:

• One-page explainer targeted at the pilot population
• Scripts and FAQs for HR, TPAs, and navigation vendors
• A single phone number or URL that owns intake

If the member experience feels like a narrower network with no upside, your steerage will stall in weeks.

6. Decide your scoreboard before go-live

Most pilots die because no one agreed what "good" would look like.

Before you launch, write down the metrics you will review at 30, 60, and 90 days. At minimum:

• Steerage: Percent of eligible episodes completed in the direct pathway
• Unit cost: Average allowed per case vs. baseline for similar cases
• Member experience: A simple 1–10 score or "Would you choose this path again?" question
• Operational friction: Count of issues from HR, TPAs, and providers

You are not trying to rebuild your actuarial model in 90 days.

You are answering one question: Is this pathway clearly better than the status quo on cost, experience, or both for this slice of spend?

7. Keep the pilot big enough to see, small enough to unwind

A real pilot should be visible in the numbers and invisible to the P&L if it fails.

As guardrails:

• Aim for 5–15% of annual medical spend in-scope
• Avoid high-volatility lines (NICU, complex oncology) in the first wave
• Align contract term tightly to the pilot window, with clear renewal language

If your lawyers and CFO feel like they are signing away multi-year commitments for an unproven model, they will slow-roll you—and they will be right.

8. Put a decision meeting on the calendar now

The worst pilot outcome is not "underperformed."

The worst outcome is "no one ever really decided."

Before you launch, schedule a decision meeting near the end of the 90-day window with:

• Benefits and HR leadership
• Finance (CFO or delegate)
• Your TPA or platform partner
• The provider or network partner, if appropriate

Tell them what you will bring:

• Baseline vs pilot unit cost and steerage
• Member and provider experience highlights
• Operational lessons learned
• A recommendation: expand, extend as-is, materially change, or exit

Then hold yourself to that.

The bottom line

A 90-day direct contracting pilot is not a side project.

It is a disciplined capital test on a stubborn cost problem.

If you:

• Start with one expensive, boring problem
• Draw a hard line around who is in the pilot
• Make the direct path a genuine upgrade
• Measure the few metrics that actually matter

…you will know, in three months, whether this model deserves more of your balance sheet—or just another vendor webinar slot.