Over the past decade, digital health has promised to transform care delivery by improving access, engagement, and outcomes for millions of Americans. Yet, for all that promise, many purchasers are still asking the same question: Are we getting what we paid for?

Performance-based contracts (PBCs) represent an important step forward in holding digital health solutions accountable—moving beyond per member per month fees that reward enrollment to payments being tied to measurable outcomes instead. PBCs also enable high-performing vendors to distinguish themselves in a crowded market.

This shift towards outcomes-based accountability is also gaining momentum in federal policy. The Center for Medicare and Medicaid Innovation’s new ACCESS Model signals Medicare’s intent to move beyond paying for technology adoption alone. ACCESS reinforces a core premise of this report: that aligning payment with verified performance is essential to realizing the full potential of digital health.

The PHTI Playbook on Performance-Based Contracting draws on insights from more than 50 employers, health plans, digital health vendors, brokers, consultants, data analytics companies, and other industry experts. It offers a roadmap for designing, negotiating, and implementing effective PBCs. It also provides condition-specific contracting toolkits to accelerate negotiations in clinical areas where digital solutions are increasingly central to care: diabetes, hypertension, musculoskeletal conditions, and depression and anxiety.

Our findings show that while interest in PBCs is widespread, they remain hard to scale—especially for employers with limited resources to negotiate and adjudicate the contracts. Historically, many contracts have relied on “clawback” performance guarantees that can create friction between purchasers and vendors. Under these arrangements, underperformance often gets obscured when averaged across populations, and shortfalls become future discounts rather than actual refunds—undermining the accountability these contracts are meant to deliver.

Adopting effective PBCs requires building stronger capabilities on both sides of the table. Purchasers need reliable data access and analytic capacity to assess impact, while vendors must strengthen transparency and measurement rigor. Large health plans and national employers are beginning to institutionalize these frameworks, while smaller purchasers need additional resources and support to evaluate performance confidently.

This playbook is designed to help purchasers and vendors of all sizes implement effective PBCs. It offers a practical foundation for standardizing key terms, streamlining negotiations, and linking evidence to payment. The market conditions are now aligned to make this possible: purchasers have grown more sophisticated in their demands for validated outcomes, and leading vendors have responded with greater confidence in their ability to measure and deliver meaningful results.

PHTI’s goal is to ensure that every dollar spent on digital health delivers benefits to patients and purchasers alike. By aligning incentives around clinical outcomes and cost savings, PBCs can help make digital health a driver of value across the healthcare system.