By Mission And Definition, Community Health Centers Already Perform Value-Based Care

Community health centers have been, and will continue to be, vital to achieving health equity in the United States. Over the past few decades, they have served historically marginalized communities and provided comprehensive, culturally competent, integrated care to millions of people. Health centers keep health equity at the core of everything they do. By mission and definition, all federally qualified health centers (FQHCs) provide high-quality care regardless of a patient’s ability to pay, and FQHCs reinvest any profits back into patient care. FQHCs should be at the center of the Biden administration’s plans to advance value-based care (VBC) models.

The Health Care Payment Learning and Action Network defines accountable care as care that “aligns care teams to help realize the best achievable health outcomes for all through comprehensive, high-value, affordable, longitudinal, person-centered care.” The Centers for Medicare and Medicaid Services’ (CMS’s) Innovation Center’s Strategy Refresh aims to have most Medicaid beneficiaries and all Medicare fee-for-service beneficiaries in an accountable care relationship by 2030. VBC can be defined as a health care delivery model in which providers, including hospitals and physicians, are paid based on patient health outcomes, holding providers accountable. It is an opportunity to incentivize care for patients first, but how does that work for FQHCs that already provide high-quality care?

Advocates for Community Health (ACH) is a membership organization for FQHCs that focus on visionary and innovative policy and advocacy initiatives to effect positive change across the nation’s health care system. Here, as the CEO of ACH, I outline recommendations for VBC design and implementation and advocate for FQHCs to be included in primary care discussions.

Risk Readiness And Patient Population

FQHCs often serve uninsured or Medicaid patients. However, many VBC arrangements put forward by CMS focus on the Medicare population. VBC models must consider FQHC’s abilities to take on risk, the multiple payers involved, and the dual-eligible patient population. While some larger community health centers are interested in Total Cost of Care (TCOC) models, some need assistance, particularly with technical assistance for data infrastructure and analyzing claims and reports from various sources and payers. The Physician-Focused Payment Model Technical Advisory Committee’s working definition of TCOC is “Population-based Advanced Payment Model in which participating entities assume accountability for quality and TCOC and receive payments for all covered health care costs for a broadly defined population with varying health care needs during the course of a year.” Like the definition of VBC, the TCOC definition is always evolving and often used as an umbrella term to describe accountable care.

Therefore, gliding pathways to risk should be an option for FQHCs so that health centers can be part of VBC while also choosing the appropriate amount of upside or downside risk-sharing arrangement that feels appropriate for the organization. In the Proposed Calendar Year 2023 Medicare Physician Fee Schedule Proposed Rule, the Medicare Shared Savings Program proposed similar options to smooth the transition for organizations into two-side risk.

Additionally, while FQHCs are interested in VBC, centers require explicit guidance for how payment arrangements affect existing models of care, such as Program of All-Inclusive Care for the Elderly (PACE) programs, Certified Community Behavioral Health Clinic (CCBHC) models, patient-centered medical home model, and the general FQHC Prospective Payment System. Federally protected, FQHCs cannot be paid below their Prospective Payment System rates. Therefore, CMS must clearly define what is considered in each TCOC savings calculations.

Data, Attribution, And Upfront Investment

In surveying some of our members, some FQHCs prefer prospective attribution with a 12-month lookback period meaning that a patient is assigned to an organization before the start of a certain year, and patient alignment is based off of the claims 12 months before the start of the year, allowing an organization to understand their patient population before the year begins. Even with the best data, some centers may not have the information technology infrastructure or support to understand and characterize their patient population. Some CMS Innovation Center models have an implementation period in which organizations are not financially accountable but can receive claims data. However, receiving this information in a timely matter is key, particularly for establishing benchmarks. Additionally, beneficiary attribution is tied to providers and organizations. Therefore, ACH suggests explicit guidance and transparency of overlaps rules for providers and for beneficiaries. For example, some models check overlap at the tax identifier number (TIN) level, and others work at the national provider identifier (NPI)/TIN level. With so many models, entities tend to “fight” for enough beneficiaries, which affects statistical reliability and evaluation of the models. Exacerbating the problem, as the Henry J. Kaiser Family Foundation points out, more patients are enrolling in Medicare Advantage, which could affect participation in VBC since those patients are no longer eligible to be aligned to a VBC model. FQHCs already struggle with data inaccuracy barriers similar to those experienced by other health systems, including data lag, internal inconsistency, lack of a master patient index, the need to match claims and data from various sources and managed care organizations, and errors that can affect medical loss ratio reporting requirements.

Furthermore, interpreting and evaluating the data require having a strong analytics team, not just one staff member. Building dashboards to understand data necessary to implement VBC may require substantial upfront investments. Therefore, similar to the proposed changes in Calendar Year 2023 Physician Fee Schedule and changes to the Medicare Shared Savings Program, FQHCs would benefit from one-time fixed payments and quarterly payments for the first two years for a five-year agreement. Payment amounts should reflect the type of entities and the patient population. We suggest allowing the upfront payments for FQHCs that serve the most vulnerable populations, particularly those uninsured and on Medicaid. FQHCs, similar to others in the health care field, struggle with workforce and unpredictability of funding, particularly from the 340B Drug Pricing Program.

Person-Centeredness And Quality Measures

According to the Uniform Data System, FQHC patient populations are made up of more than 62 percent racial and/or ethnic minority patients, a total of more than 16.5 million individuals. FQHCs serve almost one in four patients whose primary language is not English. Therefore, VBC models should provide culturally competent care, which requires proper workforce training, community-based partnerships, and buy-in. Many states require Medicaid managed care organizations screen for social determinants of health. At the ACH, most, if not all members screen for social determinants, and many centers use the standardized PRAPARE assessment. We suggest limiting the number of quality measures used but making the measures meaningful. The ACH advocates piloting the CMS Office of Minority Health’s Health Equity Summary Score for FQHCs to see if it is a good fit for TCOC models. Currently, the Health Equity Summary Score has been tested in the Medicare Advantage population only. The Assistant Secretary for Planning and Evaluation recently evaluated health equity measures, and the Health Equity Summary Score received the highest ratings during their technical expert panel.

Need For Flexibility, Especially For Behavioral Health

Health and well-being go beyond physical health. Some of our members state that 75 percent of all their visits involve behavioral health care, and oftentimes social needs are the root cause of physical ailments. The ACH recommends including substance use and behavioral health services and waivers along with physical health benefits so that states permit services to be offered the same day as other encounters. These flexibilities facilitate primary care and behavioral health integration. Additionally, FQHCs should be allowed to address behavioral health interventions to the needs of their communities by supporting telehealth, group setting services, and mobile crisis units. Another example of flexibility of behavioral health is the Certified Community Behavioral Health Clinics (CCBHCs) model, which allows 24/7 mobile crisis teams. The CCBHC demonstration is allowed under the Protecting Access to Medicare Act of 2014 and was most recently expanded under Section 11001 of the Bipartisan Safe Communities Act.

The ACH recommends the following additional flexibilities that could improve the care for patients: care coordination assistance, transportation services, nutritional services, and general provider and care-setting flexibilities. This includes allowing care “outside the 4 walls” and allowing telehealth and telemonitoring to be furnished in any geographic area and in any originating site setting, including the beneficiary’s home. The ACH also advocates allowing certain services to be furnished via audio-only telecommunications systems, adjusting in-person visit requirements, and allowing patients to see different providers (such as licensed marriage counselors, bachelor-level social workers, and community health workers).

Equitable Access Via Health Equity Payments

FQHCs are a willing partner for implementing VBC but need to be included as stakeholders. FQHCs should be included for VBC design, implementation, and evaluation discussions across local, state, and federal agencies. For example, the ACH responded to recent Department of Health and Human Services Environmental Justice Strategy and Implementation Plan Request for Information, requesting to be part of any task forces that involve health, health equity, or health care infrastructure. FQHCs know how to serve their community best.

However, FQHCs and other organizations need time to build infrastructure that ultimately affects patient outcomes. Therefore, the ACH suggests that any alternative payment methodology capitation meets, if not exceeds, the current Prospective Payment Systems to address the unique individual needs of the patients and the community. The focus of VBC should be preventive care, which requires an emphasis on modifiable social determinants of health. Therefore, we propose a health equity payment for facilities implementing VBC plans. In the ACH’s CHC Invest campaign, we suggest a very modest $25 per patient per month based off of the Innovation Center’s Comprehensive Primary Care Plus (CPC+) Model. CPC+ paid an average of about $25 per Medicare beneficiary per month in 2019, which successfully reduced outpatient emergency department visits and hospitalizations. Twenty-five dollars is a conservative amount compared to CPC+’s successor, the Primary Care First Model, which bases a population-based payment amount to a practice’s overall patient risk group. The Maryland Total Cost of Care (MTCOC) Model also provides a care management payment. MTCOC has reduced spending, doubled rates of follow-up after emergency department or hospital discharge, strengthened case management, supported processes to screen patients for social needs, and progressed initial ways for practices to integrate behavioral health care. The CMS Accountable Health Communities Model which included startup funds to build health care infrastructure also showed promising results regarding screening and referral practices.

Summary Of VBC Recommendations

In summary, the ACH recommends the following VBC standards to facilitate the inclusion of FQHCs:

1. Promote culturally and linguistically competent care, particularly through training for providers and increasing the health literacy of patients.
2. Make patient and claims data accessible and understandable in a timely manner.
3. Consider benchmarks that adjust for dual-eligible beneficiaries and local factors that also consider the dynamic nature of an organization’s underlying patient population and need to factor for social investments.
4. Provide transparency for provider and beneficiary overlap rules for attribution and TCOC calculations.
5. Consider Medicaid patients, not just Medicare beneficiaries, for VBC and TCOC models. Therefore, consider multipayers, PACE programs, Medicaid plans, and managed care organizations.
6. Allow flexibility with incentives based on the patient population, such as allowing flexibility to provide transportation services and promote behavioral health integration interventions.
7. Allow money or grants to alleviate infrastructure startup costs, particularly for data analysis and technical assistance needs.
8. Expand eligible providers such as community health workers.
9. Limit quality measures but make them count. Add in social determinants of health measures.
10. Create an FQHC task force to hear the perspective from those that serve the nation’s most vulnerable populations, especially for FQHC’s ability to handle VBC.

FQHCs serve some of our most vulnerable communities. The ACH recommends that the administration consider our feedback when designing VBC and include our frontline workers who can speak to barriers and unintended consequences to patients. Most importantly, VBC should be patient focused. Communities already know what they need; we just need to listen and remain flexible.