Construction-Manager-at-Risk (CMAR) is the delivery model in which the owner holds two separate prime contracts — one with the architect/engineer (A/E) and one with a Construction Manager (CM) — and brings the builder on board during design as a paid preconstruction advisor before that builder converts to an at-risk general contractor under a Guaranteed Maximum Price (GMP). For complex acute-care and other high-acuity healthcare projects, CMAR is the most common delivery model because it preserves the owner's design control while buying early constructability input and price certainty.

CMAR is a three-party model with two owner contracts

In CMAR the owner sits at the center of two independent contractual relationships, exactly as in Design-Bid-Build (DBB):

• Owner ↔ A/E — a professional-services agreement for design and construction-phase services. The A/E remains the owner's design author and (typically) the agent administering the construction contract.
• Owner ↔ CM (the "CMAR" or "CM/GC") — initially a services agreement for preconstruction, later amended (or running concurrently) to a construction agreement carrying the GMP.

The defining word is at-risk. Unlike a pure agency CM (CMa), who advises the owner for a fee and never holds trade risk, the CMAR takes on the risk of delivering the work at or below the GMP. The CM holds and manages the subcontracts, self-performs little or nothing, and stands behind cost and schedule the way a general contractor does. This is why the role is frequently written as CM/GC — Construction Manager during design, General Contractor during construction.

What CMAR is not:

• It is not Design-Build (DB), where a single entity holds both design and construction under one contract; in CMAR the owner keeps a direct line to the designer and never cedes design authorship.
• It is not Integrated Project Delivery (IPD) in its pure multi-party form, though CMAR is the platform on which many "IPD-lite" or progressive-design-build hybrids are built.
• It is not agency CM, because the CMAR carries financial risk, not just advisory responsibility.

CMAR therefore occupies a deliberate middle ground: the design-side separation of DBB plus the early-collaboration and cost-certainty advantages usually associated with DB.

The CM joins during design as a preconstruction advisor

The single most important structural feature of CMAR — and the reason it suits complex hospitals — is that the builder is selected and engaged before design is complete, often as early as schematic design (SD) or even programming. During this preconstruction (precon) phase the CM is paid a fee for services and acts as a member of the owner's project team, not yet as the holder of construction risk.

Typical precon-phase responsibilities of the CMAR:

• Constructability review — testing the evolving design against how it will actually be built, flagging conflicts, redundant systems, and details that are expensive or slow to construct.
• Budgeting and cost modeling — producing progressively refined estimates at each design milestone (article, SD, design development, and construction documents) so the design stays anchored to the owner's budget rather than drifting and forcing a late redesign.
• Value analysis / value engineering (VA/VE) — proposing alternatives that preserve clinical function and code compliance while improving cost, schedule, or lifecycle performance. In healthcare this must be done without quietly eroding infection-control, resilience, or FGI-driven program requirements.
• Scheduling and phasing strategy — building the master schedule, identifying the critical path, and (critically for occupied campuses) developing phasing and interim-life-safety strategies before the design is frozen.
• Long-lead procurement planning — identifying equipment and systems (electrical gear, generators, air-handling units, medical imaging, modular components) whose lead times can dominate the schedule, and sequencing early-release packages or early purchase orders.
• Market and trade-partner analysis — advising on bid packaging, trade availability, and local subcontractor capacity, and planning the bidding strategy for an open, competitive subcontract buyout.