An arduous transition. That is how the leader of one Colorado community health center described his organization’s effort to switch from fee-for-service to a value-based payment model for improving patient care and greater accountability. “It is definitely a different environment when you start risk-stratifying patients and developing a more collaborative care model,” said Art Fernandez, chief operating officer at Mountain Family Health Centers in Glenwood Springs.
Fernandez was speaking during an Aug. 30 webinar titled “Accelerating Value-Based Payment in Federally Qualified Health Centers: Options for Medicaid Health Plans,” hosted by the Center for Health Care Strategies (CHCS). Fernandez and Patrick Gordon, CEO of Rocky Mountain Health Plans, discussed the lessons they are learning in the transition from volume to value. They said it involves, among other things, building relationships and good data stewardship.
CHCS notes that across the country, states, health plans, and providers, including federally qualified health centers (FQHCs), continue to move away from fee-for-service payments and toward value-based payment arrangements “because they give FQHCs more flexibility in delivering patient-centered care and the ability to obtain financial incentives from improving quality and reducing costs across the larger healthcare system, and do not require state or federal action.”
Mountain Family Health Centers is an FQHC system serving more than 21,000 patients across the West Mountain region of Garfield, Eagle, Pitkin and Rio Blanco Counties. “What we feel needs to happen is the integration of all facets of care, including medical, dental, behavioral health,” and that also involves care coordinators, case managers, and outside entities, Fernandez said. Most community health centers are not geared to offer case management beyond the primary care provider encounter, he said. “We have developed a team-based care model over the last four to five years, and Rocky Mountain Health Plan’s per member, per month payment model has allowed us to transition our operations. They have been great partners, but it has been difficult,” he said. Mountain Family Health Centers has moved 75 to 80 percent of its work into value-based delivery models.
CHCS has observed that “health plans can help FQHCs bolster efforts to coordinate care, use data, and fully engage the communities they serve. FQHCs are becoming increasingly important to health plans’ primary care networks, allowing them to expand their reach and have a greater impact on member health.”
Gordon noted that Rocky Mountain Health Plans operates a Medicaid health plan covering 190,000 people, across a wide geographic area and including a mix of urban and rural members. The value-based payment work with practices involves a highly engaged, continuous improvement process. “We have tried to organize the work at the local level as much as possible, and align with FQHC and public health catchments. That has served us well,” he said. “We have found that you have to have transparency, data, trust, infrastructure and time invested. I spend two hours each week with appointed CEOs from FCQHCs and mental health centers. We hold each other accountable as we align the leadership culture.”
The effort divides practices into four tiers based on their level of sophistication. They work their way up from basic engagement to mastery, where practices and the health plan work closely as partners on behavioral health integration and social determinant of health use cases. “The good news for us is that more than a year into this structure, the attribution breaks nicely, with 40 percent of practices in the top two tiers,” Gordon said. Those practices serve more than 60 percent of the membership.” The plan and providers report quality measures to the state of Colorado and the better they do on quality measures, the more the greater the potential for financial rewards.
“The real key is granular, drill-able data,” Gordon said. “We apply risk adjustment and cost and utilization data at the provider level to the extent we can and allow them to click in and see what is going on and see rankings. We focus on goals and not being prescriptive about measures. We produce run charts every month for all providers, including FQHCs, both raw and risk-normalized for comparison. I can’t overstate importance of risk adjustment.”
Gordon mentioned that his organization has been working on this concept since 2013, when it saw the Medicaid expansion coming. “The state became supportive once we got a statute through to permit the model and garner support,” he said. “Now the state is following through with formal alternative payment models for areas that Rocky does not serve. We are pleased, but it took a lot of work.”