In a pretty sweeping request for information CMS has recently put out seeking ways to approach value-based care through advanced or alternative payment models, the agency is seeking input on Medicaid models among an array of topics.
This RFI is specific to putting the new administration’s stamp on the CMS Innovation Center, aka CMMI. Born from the Affordable Care Act, CMMI is the originator of models alive in MACRA, and those no longer alive such as mandatory bundled payments.
Within Medicaid, there are significant opportunities to expand existing state-based pilots and burgeoning Medicaid ACOs to a broader value-based care approach via CMS payment models, but of course there’s some work to do first.
Within the FQHC program, there are opportunities to advance care management and value to a sector that includes more than 1,000 sites and 20 million Americans.
FQHCs have the technology
Increasingly, FQHCs are adopting technologies that can enable sharable longitudinal patient records, risk assessments and analytics, patient engagement tools and the ability to submit quality measures. Philips Wellcentive currently supports more than 40 FQHCs nationally located in more than a dozen states with a population health management technology that integrates with and aggregates data from EHRs.
FQHCs operating within Health Resources & Services Administration (HRSA) grants are already evaluated on performance metrics, which can be utilized within expanded value-based care models.
FQHC risk, capitation pilots underway
Existing state-based Medicaid ACOs pilots are also showing early success in utilizing a shared savings approach. As of July, 2017, 10 states have active Medicaid ACOs and several are working with the non-profit Center for Healthcare Strategies (CHCS) and its Medicaid ACO Learning Collaborative. Specific to FQHCs, Oregon began a pilot in 2013 utilizing a capitation rate for all Medicaid patients. California is moving toward a 2018 proposal that would also provide capitation for each assigned Medicaid beneficiary, that would bring modest downside risk if visits exceed agreed-upon thresholds compared to historical rates. CMS can leverage the research and analysis CHCS has at hand to examine a broad approach to FQHCs and VBC models, for example.
Doing so would mean an analysis of current payment structures that can vary by state, so that these health centers can move from fee-for-service to value. Some states, as you know, directly pay FQHCs a set rate per patient visit. Other states utilize a Medicaid managed care reimbursement supplemented by the state to cover any difference between the managed care payment and the prospective payment system rate.
Prospective payments (FFS) need addressing
To advance value-based care models to FQHCs and other Medicaid arenas, CMS should examine the current prospective payment system, along with evaluating what’s working within early Medicaid ACOs.
The current prospective payment system can be viewed as having similar shortcomings to FFS in terms of paying for volume. FQHCs are incentivized for in-office visits for services such as BP checks, which could be done remotely with the right technology. FQHCs also cannot bill for preventive or value-driven aspects of care such as care management or patient education. And while some Medicaid managed care plans do offer quality performance payments, the relatively low amount of reimbursement makes visit volume more attractive.
By examining what’s working and gauging provider and FQHC institutional interest in value-based care, combined with an examination of the prospective payment system, CMS can move toward aligning Medicaid models to the Medicare models emerging within MACRA.
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