The healthcare system is actively shifting away from fee-for-service models and moving toward value-based care. This puts greater focus on prevention and wellness and gives providers and payers new opportunities to work together and change the way Medicaid pays for care.
This is a “really interesting time to be innovating,” Andrey Ostrovsky, MD, former chief medical officer of the U.S. Medicaid program, said in the Center for Community Health Solution’s recent webinar. “We have a really robust federal backdrop to enable states like Ohio to advance value-based payment and do it in a way that’s focused on quality measurement, quality improvement, and transparency.”
Prior to the implementation of the Next Generation (Next Gen) managed care plan in Ohio, there wasn’t a lot of clinical accountability in the state, Dr. Ostrovsky explained, but now the program is focused on securing high-quality, evidence-based health care for Ohioans, which will give FQHCs and other community health centers the opportunity to provide more preventative care and get reimbursed for it.
(You can read more about value-based care in Ohio in our deep-dive guide. Download here).
In lieu of services (ILOS), for instance, allows Medicaid managed care plans to pay for alternative services without the need for an approved waiver. Covered expenses can include nutritious meals, personal care services, housing navigation, or air purifiers, so long as they are medically appropriate and cost-effective, which enables providers to treat patients’ social needs.
“In order for us to provide whole person care, we have to be able to do things innovatively. You cannot innovate in a fee-for-service model,” Adam Aponte, MD, MSc, FAAP, Chief Medical Officer at East Harlem Council for Human Services. This model isn’t conducive to care managers, home visits, and securing nutritious foods.
FQHCs are required to see new patients within four weeks, but most patients walking through the door are dealing with chronic conditions, said Dr. Aponte. In a value-based model, providers can be more innovative with their care and shift to care management, secure care navigators, and helping patients address food insecurity, home instability, and other concerns that prevent them from achieving health and wellness. It’s all about the “quality of care as opposed to the quantity of care,” he said.
The challenge for FQHCs, though, is that these value-based models come with upside risk and downside risk, Dr. Aponte said, admitting he’d take on downside risk if he could, as he’s confident in the quality of the organization’s work, its ability to engage patients, and reduce emergency visits.
“[As a non-profit] we have to make money, but not at the cost of compromising care,” said Dr. Aponte. Thankfully, providing the highest quality care possible, Dr. Aponte has found that East Harlem Council for Human Services has been able to better engage in quality-based incentive programs and this has helped increase margins and better serve the community.
This update was originally sent to newsletter subscribers. Sign up to receive monthly updates below.