In the traditional fee-for-service environment, the incentives to collaborate with peers are few and far between. More services equal more money, so why work with peers to improve outcomes and reduce spending – especially if you’re not the one footing the bill?
Value-based care flips this script on its head. By providing financial incentives to curb spending and deliver higher quality care to patients, value-based care forces partners to redesign their relationships and coordinate the way they manage patients so that everyone can share in the savings.
It’s not easy to adopt this mindset, especially when healthcare providers are still recovering from the COVID-19 pandemic and wrestling with a background of economic uncertainty. Cooperative care doesn’t always come naturally to historical adversaries and many provider entities, including federally qualified health centers (FQHCs) and other community health centers (CHCs), may struggle to find the resources to successfully make the shift on their own.
Fortunately, regulators, lawmakers, and influential payers are largely on the same page about the urgency of moving to a value-based reimbursement system. They are increasingly providing a wide array of tools, guidance, and innovative payment models to encourage providers to participate in the new performance-driven ecosystem.
Choosing the right path – and the right partners – will be crucial for finding success in this vibrant and complex environment.
In a recent roundtable webinar presented by Yuvo Health, a panel of experts from community health centers and payers shared their secrets to success, from more actionable use of data analytics to working closely with community partners to address the social determinants of health (SDOH).
“It’s incredibly important for payers and FQHCs to have a strong relationship with good communication,” said Jonathan Palisoc, a health economist and PhD candidate at the University of Michigan. “The most successful arrangements we've seen include robust data sharing connections and really clear communication around factors like risk scoring and patient attribution.”
“As we start to share financial risk more intensively, relationships are going to be the ‘secret sauce’ for capitalizing on these opportunities. FQHCs will need to work with larger local health systems, community-based organizations, specialists, and payers very effectively so they can create a network of care around patients who historically fall through the cracks.”
Making sense of a reimbursement landscape in flux
Each state is furthering the value-based care transition in its own unique way. In Ohio, for example, there are close to 60 CHCs serving nearly 900,000 patients, half of whom are Medicaid beneficiaries.
Working with this population is challenging under any reimbursement structure, says Jean Polster, RN, the retired CEO of Neighborhood Family Practice, an FQHC in Cleveland, due to deeply rooted socioeconomic and systemic challenges.
Related: Learn more about Ohio’s value-based care landscape for FQHCs with our downloadable guide.
“My health center has seven locations serving 22,000 individuals,” Polster explained.“There are many people living in poverty. One out of five of those individuals speaks a primary language other than English. These patients need a strong population health focus and the resources to support that."
“Right now, we are very siloed and fragmented as a CHC community. We all have the same goals, but we’re playing ping pong with the responsibility for achieving them. We need shared data and shared resources so we can agree on how things are documented, measured, and paid for in the real world where patient care meets managed care.”
Payers need to develop a more nuanced understanding of these challenges and provide concrete resources to smooth the path to shared value, she stressed.
Natalie Lukaszewicz, VP of Network Development and Contracting at Buckeye Health Plan, agrees there’s more than payers can and should do to accelerate the transition to value-based care, especially as the industry is changing so quickly.
“We want CHCs to be successful in the arrangements we’re offering, so we need to provide them with the support they need,” she stated. “In Ohio, we are engaged with our FQHC association, who has a model arrangement with a large number of FQHCs, to establish a shared savings program with a quality gateway. Year over year, our FQHCs have continued to improve on the bonuses they’re receiving, so we believe that this collaborative approach is very successful for all parties involved.”
In New York, another state with a strong focus on the value-based care transition, FQHCs are receiving similarly helpful attention from their payer partners as they navigate a shifting world.
“FQHCs are so well positioned to impact health equity and bring positive results for a very challenging segment of the patient population,” said Pantelis Karnoupakis, VP of Value-Based Payment Initiatives at Fidelis Care. “Regulators are starting to acknowledge that, which is allowing FQHCs to grow their value-based care portfolios and participate fully in the more advanced VBP environment.
“I remember being on the phone with New York State late in the evening in 2019, because we had submitted a risk contract for an FQHC that was going to be rejected because FQHCs couldn’t assume financial risk in New York State,” he recalled. “It was very frustrating. We felt that we were being limited in our ability to innovate – and to access the higher percentages of shared savings that other organizations could work toward.”
“Fast forward to 2022, and things have changed. Now, we have more opportunities, and we have organizations like Yuvo that can partner with us to open up the door to those types of arrangements. I’m so glad to see regulators and payers recognizing the value that FQHCs can bring and altering their frameworks accordingly.”
Getting creative to lay the groundwork for success in an FQHC
Increasingly CHC-friendly regulations are a significant step in the right direction, but there’s still more work to be done if CHCs are to succeed with earning shared savings, added Ari Benjamin, MD, Chief Medical Officer at Joseph P. Addabbo Family Health Center, a five-center FQHC located in medically underserved areas of Queens and Brooklyn in New York City.
CHCs need to transform themselves from the inside out with an eye toward improving provider and patient experiences, he said. This is the first step toward achieving better outcomes and effectively lowering spending.
“I remember first getting into value-based care as a provider at another organization and being annoyed at all the extra work and changing workflows, so I understand how my physician colleagues feel when we start throwing these new requirements and benchmarks at them,” said Benjamin.
“It would be a lot easier to navigate with better data. Patient attribution, quality performance, care gaps – all of these require very good data integrity and connections with partners, but a lot of FQHCs don’t have the capabilities and the resources.”
“We also need buy-in from upper management,” he continued. “VBC requires a lot from the staff, and the ROI might not be immediately apparent. Getting the executive team involved with understanding why we need an extra nurse, a quality improvement coordinator, or a diabetes educator will make it easier to secure those staff members and achieve ROI sooner.”
But the onus isn’t entirely on the provider community, Lukaszewicz acknowledged. Health plans need to step up and think outside of the box about how to recruit practices into the value-based ecosystem – and keep them there.
“Community health centers, in particular, just don’t have the resources to make these changes without support from the plan. They know they need to upgrade their EMR or implement tools for risk stratification, but without some funding to make that happen, neither the FQHC nor the payer is going to succeed.”
More robust investment from payers could help CHCs get a handle on some of the most critical competencies in value-based care, including understanding patient attribution patterns and engaging in accurate and appropriate risk coding.
“Risk coding is absolutely crucial,” said Karnoupakis. “Because Medicaid in New York and many other states use capitated payments, appropriate and comprehensive risk coding is the only way to make sure you are getting the revenue you need to care for your patients.”
“Some of the creativity we need from payers could lie in different ways of handling risk, such as updating risk adjustment in near real time. That way, FQHCs can receive payments that are really reflective of their current situation, understand their performance more accurately, and make better decisions that will save money for the payer.”
Getting upstream of patient risks by integrating community organizations
To make the most of value-based care, partnerships can’t just be limited to plans and providers. They have to extend far into the community.
“We typically think of healthcare as a three-sided partnership: payer, provider, and patient. But we need to add a fourth pillar, which is the community-based organization (CBO),” said Karnoupakis.
“We need the data they have to offer about lifestyle behaviors that drive patient decisions on a daily basis. We need their support when referring people to non-clinical resources to change those patterns of behaviors. Without the community, we’re missing so many opportunities to make a difference.”
CBOs are experts at addressing the socioeconomic needs in their areas and have access to resources that FQHCs will need to complete the circle of care around their vulnerable patients.
Once again, creativity and close collaboration will be key to bringing CBOs more closely into alignment with the clinical care ecosystem.
“We’re getting better, as a health system, about integrating these non-clinical resources for our very sick chronic disease patients,” said Lukaszewicz. “But we also need to focus on our healthier populations so that they don’t join that upper tier of complex, high spenders.”
“In Ohio, we’re implementing something called “care guides.” These are individuals who provide some coordination and management for less acutely ill populations, such as making sure they’re seeing their primary care provider at least once a year and that they’re taking advantage of the socioeconomic support services available to them.”
“It’s another way to engage with members earlier in the cycle, eliminate some of the barriers that contribute to poor health, and assist them in getting preventive care so they can live healthier lives. That’s our ultimate goal, and the only way we’re going to get there is if we all work together.”
There’s no doubt that value-based care can be challenging for CHCs, but it gets a little easier when payers and community organizations are there to offer support, resources, and fresh ideas.
By working more closely together and sharing experiences, data, and insights, the entire care continuum can see greater success with controlling costs, improving outcomes, and offering better experiences to all.
To hear more about how payers and FQHCs are partnering to advance value-based care in new and innovative ways, listen to the entire webinar on demand here.