States move to bring value-based pay to com­mu­nity health cen­ters

Modern Healthcare - - NEWS - By Maria Castel­lucci

The push for states to en­gage in these value-based pay­ment mod­els has been partly in­flu­enced by Med­i­caid ex­pan­sion un­der the Af­ford­able Care Act.

Al­though they serve more than 24 mil­lion low-in­come in­di­vid­u­als an­nu­ally, fed­er­ally qual­i­fied health cen­ters have largely been ex­cluded from ex­per­i­ments aimed at re­duc­ing costs and im­prov­ing clin­i­cal out­comes. That’s start­ing to change, though, as a hand­ful of states ad­vance al­ter­na­tive pay­ment mod­els for the cen­ters.

There are 1,400 such cen­ters, known as FQHCs, across the coun­try. They are re­im­bursed un­der a prospec­tive pay­ment sys­tem that pays a fixed amount for each pa­tient visit. The sys­tem was en­acted in 2000 to help strug­gling cen­ters to stay afloat with medi­ocre Med­i­caid pay­ments. Yet the vol­ume-based re­im­burse­ment model is show­ing its lim­i­ta­tions, es­pe­cially by pre­vent­ing cen­ters from par­tic­i­pat­ing in out­comes-based care ap­proaches.

These short­com­ings have en­cour­aged a grow­ing num­ber of states to con­sider es­tab­lish­ing al­ter­na­tive pay­ment mod­els that en­able such cen­ters to ex­pand ser­vices paid for by Med­i­caid. Fed­eral law al­lows states to es­tab­lish al­ter­na­tive pay­ment mod­els for its qual­i­fied health cen­ters as long as the rev­enue is equal to the prospec­tive pay­ment model. Cal­i­for­nia, Colorado, Min­nesota, New York, Ore­gon and Washington have cre­ated re­im­burse­ment mod­els that pay cen­ters for value-based ser­vices such as at-home vis­its, trans­porta­tion ser­vices and tele­health.

But shift­ing to a new payer model comes with chal­lenges that in­clude fi­nan­cial risks and dif­fi­culty ac­cess­ing ap­pro­pri­ate re­sources, es­pe­cially nec­es­sary data. It can also be dif­fi­cult to adapt to a new way of do­ing busi­ness.

“If you are on a visit-based model for decades and you change to an­other model, that’s hard,” said Craig Hostetler, ex­ec­u­tive di­rec­tor of the Ore­gon Pri­mary Care As­so­ci­a­tion, which works with FQHCs and the state to roll out and over­see the pro­gram. Of the six states, Ore­gon is far­thest along in its push to value-based care for the cen­ters. It be­gan a pi­lot pro­gram with three cen­ters in 2013. Washington plans to be­gin its pi­lot ini­tia­tive on July 1. The other states are still in the plan­ning and im­ple­men­ta­tion phases.

The push for states to en­gage in these value-based pay­ment mod­els has been partly in­flu­enced by Med­i­caid ex­pan­sion un­der the Af­ford­able Care Act, said Sara Rosen­baum, a pro­fes­sor of health pol­icy at Ge­orge Washington Univer­sity in Washington, D.C. States that ex­panded Med­i­caid saw a large in­crease in the num­ber of ben­e­fi­cia­ries seek­ing care at fed­er­ally qual­i­fied health cen­ters. In 2015, 55% of qual­i­fied health cen­ter pa­tients in ex­pan­sion states were Med­i­caid ben­e­fi­cia­ries, com­pared with 34% of health cen­ter pa­tients in states that didn’t ex­pand the pro­gram.

For Ore­gon, the visit-based model was no longer sus­tain­able. Of the 400,000 peo­ple treated at the state’s 200 qual­i­fied health cen­ters, about 60% are in­sured by Med­i­caid. A fed­eral match pro­gram that al­lowed the cen­ters to en­gage in tran­si­tional-care ser­vices such as part­ner­ships with com­mu­nity or­ga­ni­za­tions ran out at the end of 2013. This forced the cen­ters to cope with a strictly fee-for-ser­vice model that strained doc­tors and drained funds.

“The big mo­ti­va­tion was to get these FQHCs fi­nan­cially vi­able,” said Ja­mal Furqan, pro­gram man­ager for FQHCs at the Ore­gon Health Author­ity.

The new model uses a cap­i­tated per mem­ber, per month pay­ment sys­tem. The cen­ters gen­er­ate a list of pa­tients who have had a visit in the last 18 months and de­ter­mine the fixed rate for each pa­tient’s care based on their us­age his­tory.

Data col­lec­tion has been a chal­lenge, how­ever, he said.

Be­cause of the an­a­lyt­ics-fo­cused ap­proach of the model, the cen­ters must use EHRs in or­der to par­tic­i­pate. They also must have sta­ble fi­nances. There are bud­getary safe­guards a cen­ter has to make about a year be­fore it switches to the APM model to ac­count for any losses.

“They need to not be risk-averse,” Furqan said.

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