Across the country, health plans and federally qualified health centers (FQHCs) are exploring opportunities to move away from fee-for-service (FFS) payments and toward value-based payment (VBP) arrangements. These payment arrangements reward providers for improving quality and decreasing health care costs, while offering greater flexibility to deliver care in innovative ways.
In a recent national webinar, the Center for Health Care Strategies (CHCS) invited Patrick Gordon, CEO of Rocky Mountain Health Plans (RMHP) in Colorado, and Kurt Hubler, Chief Network Officer of Inland Empire Health Plan (IEHP) in California to provide leadership perspectives on the ingredients required for a successful VBP partnership between a health plan and FQHCs. Mr. Gordon shared insights on RMHP’s VBP model that gives FQHCs and other primary care practices more flexibility in delivering patient-centered care and the ability to reap financial incentives from quality improvements and cost reductions across the larger health care system. Mr. Hubler outlined lessons from IEHP’s shared savings initiative and discussed why entering into VBP arrangements with FQHCs is important for health plans.
The below discussion is drawn from CHCS’ August 29, 2019 webinar, Accelerating Value-Based Payment in Federally Qualified Health Centers: Options for Medicaid Health Plans, which was made possible by the California Health Care Foundation and Blue Shield of California Foundation.
Q: How did you select the FQHCs to participate in your VBP initiatives?
Patrick Gordon, RMHP: Initially, all practices were eligible to participate as long as they were willing to adopt a non-FFS model, engage in our practice transformation activities, and understand the incentives and what the quality targets would be. A few years into the program, we introduced a much more formal tiering structure so we were able to adjust the payment and resources according to engagement and demonstrated competencies.
Kurt Hubler, IEHP: We started the pilot in part because a large practice came to us wanting to start a program that looked at total cost of care. We expanded to other large medical groups that were aligned with a hospital system. Practices need to have at least 5,000 members to participate.
How do you, as health plans, help FQHCs bolster team-based care and care management?
Our practice transformation team serves as our “boots on the ground,” and they are engaged in practice transformation, quality improvement, and developing data-use competencies.
K. Hubler: Each of the participating groups has an embedded health homes team, which is a multidisciplinary group that includes providers, such as a nurse, a behavioral health therapist, a community health worker, and others. A care management team is embedded at each of these sites so our members can actually see these providers in person, rather than just telephonically. The practices we work with are connected to hospitals, and we work with the practices to help build those medical group-hospital relationships. We also connect the group with other outlying hospitals that are frequently accessed by their members.
P. Gordon: Our practice transformation team serves as our “boots on the ground,” and they are engaged in practice transformation, quality improvement, and developing data-use competencies. We also deploy community care teams, sometimes housed by the FQHC or partner. We don’t embed them, rather, we contract with them and hold the provider partner accountable for meeting our care management requirements.
Are the resources you provide to FQHCs the same as those that go to other practices?
P. Gordon: It varies. FQHCs are very well situated to support this VBP strategy, and when they’re successful we invest heavily in them. We have a very large care coordination contract with Mountain Family Health Center, but that’s not the same across all FQHCs. It varies based on duration in the program, performance, and capacity.
K. Hubler: We only embed our care coordination teams in large practices, but offer telephonic support to other practices.
What does it take operationally for health plans to implement these kinds of VBP programs?
K. Hubler: It was about an 18-month process that started with us engaging an outside consultant. We spent about a year designing the program, creating reports, and developing financial and quality incentives. We took another six months to do clinical assessments for each of the medical group practices.
P. Gordon: There was about two years lead time. One of the challenges was moving away from an FFS mentality. We had to pay attention to attribution versus assignment, to make sure risk adjustment was working and our payments were accurate, and make sure that we had the reports in place to see that the program was performing better than FFS. It took a culture change and a commitment operationally.
What are the biggest challenges to gathering the data and how have you overcome those challenges?
HIE is very important and we’ve used every lever to pull hospitals into Colorado’s community HIEs. That’s a game-changer when it comes to care coordination and managing transitions.
K. Hubler: We’re doing data integration work that involves connecting the medical group with the regional health information exchange (HIE). All 32 contracted hospitals in our service area are connected to the HIE. Practices receive discharge information and emergency room encounters on a timely basis. We integrate the HIE data into their electronic medical record (EMR) so that the practices don’t have to go outside of the EMR for information. We also provide the practices with various data trending reports and historical member detail information. But most importantly, the practices seek information about their patients who are in the middle of care so their needs can be addressed timely. Because of the HIE, we are able to share information in real time.
P. Gordon: HIE is very important and we’ve used every lever to pull hospitals into Colorado’s community HIEs. That’s a game-changer when it comes to care coordination and managing transitions. We were able to get the state to: (1) move off HEDIS measures for several critical measures to clinical quality measures; and (2) adopt and modify accountable care organization (ACO)-type targets for clinic data to ensure that the plan, provider, and state were all aligned for specific target measures.
What advice would you give to providers to make the case to their health plans around data sharing, particularly around claims and cost?
P. Gordon: The big hurdle is inside the plan. Our biggest issue is: how can we meet the initial state requirements to be budget neutral, which have now been ramped up to a two percent state savings requirement? The only way we can do it is by actively working on data sharing and engaging in VBP, and working together with the practices to make it happen.
How did you select the quality measures for your models?
P. Gordon: Less is more. We kept the measures to 4-6. The average practice can’t focus, or really care about, more than that.
K. Hubler: We already had a substantial pay for performance program (P4P) with practices, independent provider associations (IPAs), and hospitals, so we didn’t want to duplicate what they were already incentivized to do in P4P. We diversified the measures to other quality metrics such as readmissions, caesarean delivery, breastfeeding, seven-day follow-up, controlling hypertension, etc., which would also move the needle on cost.
How are you measuring if the overall program is successful?
Growing attribution, moving practices up the tiering structure, getting past quality benchmarks are key to ongoing success.
K. Hubler: We compare the prior calendar year period to the performance period for both financial improvement and quality improvement. We track the quality measures in this program and also take into consideration the practice’s performance in the standard P4P program.
P. Gordon: The bottom line is if we’re going to do alternative payment methodologies, then we need to be able to afford to pay for them. The enhancements that go to top tier providers are significant — above either our fee schedule or the state’s fee schedule — and that only works if the plan performs really well. That’s the starting point — and the ending point if we fail. Growing attribution, moving practices up the tiering structure, getting past quality benchmarks are key to ongoing success. We feel good when we see that more members are being served in the higher tier practices and that the higher tier practices are meeting or beating network benchmarks.
How do social determinants of health fit in these models?
K. Hubler: We created a web site to help practices find resources in our community that their patients can access. The web site provides community resources for housing, home meals, transportation, county social services, etc. The link to this website can be embedded in their EMR.
P. Gordon: We are promoting social risk factor screening and awareness, developing incentives and supports for screening, and curating a network of human and community service providers, which is new territory for us. We are interested in building a broader network of community partners and developing mutually beneficial relationships with them. We are building on efforts by the HIE to roll out a social information exchange to support alerts, task and record sharing, and consent management to allow health care providers, human services and community agencies to share information.
How will you expand on these initiatives?
We need to move from a payment model to modernized partnerships with other entities that can really drive systems change.
P. Gordon: Although we’ve been able to put this model into all of our lines of business for primary care, we need to move from a payment model to modernized partnerships with other entities that can really drive systems change. We’re making a difference now, but there’s a broader world of risk-sharing to tackle, such as full capitation, ACO, and bundled payment arrangements. And of course, the need for even greater integration of social factors and the predictors of health and health care spend, which we can do with primary care and behavioral health providers.