All Roads Lead to Equity: CMS Innovation Center Partners with Health Centers for Value-Based Care

By Jerin Philip and Ryan Smith, NACHC staff

Ben Money, SVP of Public Health Priorities, NACHC

Recently the CMS Innovation Center (CMMI) invited NACHC to speak on recruiting health centers in value-based care (VBC) models. After announcing a new initiative to advance health equity, CMMI kicked off the expert panel with NACHC’s SVP of Public Health Priorities, Ben Money, who described the unique responsibilities health centers share:

“Health centers and other safety-net providers are located in areas of greatest need, have a common mission to assure that no one lacks health care, regardless of their ability to pay, and thereby assume inherent downside risk,” said Money. “CMMI should craft APMs specific to safety-net providers that focus on health outcomes, not downside risk.”

Under[AS1]  strict financial constraints for decades, health centers now have a once-in-a-generation chance to be funded in ways that recognize the hidden value they deliver and compensate them for the hidden costs they incur.

Yet, VBC has traditionally been associated with complicated contracts, disjointed reporting burdens, and insufficient data for misaligned quality improvement demands. So the question is can VBC be re-imagined to work better for the safety net and its most marginalized hardest-to-reach patients at health centers?

Make Equity a Less Risky Business

All health care providers, from large hospitals to small family practices, urban and rural, wrestle with reducing financial risk. With system-wide shocks like the pandemic, protection against financial losses remains top of mind.

However, the severity of this challenge sets safety-net providers like health centers apart from all other health care organizations, both nonprofit and for-profit. Most health centers operate on slim financial margins, limited cash reserves, and struggle to remain viable, particularly during the COVID-fueled “great resignation” amid inflationary pressures. Hiring qualified providers and paying allied health professionals like community health workers had been hard enough before the pandemic. With historically static, volume-oriented payments that do not factor in the full cost of care and support for their complex patients, it’s harder now more than ever for health centers to fulfill their mission and mandate to serve all patients who come through the door—regardless of their ability to pay.

Health centers have known for years the inherent financial risk of welcoming patients who fall into special categories (e.g., people with unstable housing, disabilities, language barriers, low-wage jobs). Safety-net providers are critical to ensure Medicaid, Medicare, and uninsured patients receive the medical care and social services necessary for their well-being. For many patients, there is simply nowhere else to turn for comprehensive care.

Account for the Full Value of a Health Center’s Impact

Understanding this reality, NACHC strongly recommends that CMMI develop alternative payment models specific to safety-net providers and address and risk adjusts for social drivers of health while integrating behavioral health. Health centers should be paid for all the work they already do to keep people healthy and  out of hospital or institutional care. As other health care organizations have reaped the benefits from the older fee-for-service emphasis on episodic, downstream treatment of chronic illness, NACHC emphasizes the cost-saving innovations that safety-net providers have achieved under enormous challenges. NACHC encourages CMMI to design alternative payment models that “price in” the assumed risks of safety-net providers and spillover economic benefits they generate. With sufficient upfront federal and state infrastructure investments, innovative providers can reorganize and expand their care teams to deliver the wraparound services that drive quality health outcomes for the populations at greatest risk. After decades of doing “more with less,” the safety net stands ready to do even more with more.

Higher Standards for Greater Access

Participating in the federal health center program requires accountability standards, quality oversight, competitive applications/re-applications, and technical assistance that HRSA’s Bureau of Primary Health Care (BPHC) delivers. BPHC requires substantial levels of public accountability for patient outcomes and in caring for the uninsured and underinsured. The accountability and mandatory requirements for health centers are steeper and more exhaustive than what other health care organizations confront. They now need flexibility in VBC models that allow them to tailor their approaches to best meet the needs of their patients and communities.

As health centers consider ways to align their infrastructure to succeed in a more value-driven payment landscape, they need accurate and timely PPS reimbursements that account for the current costs of care and set a solid foundation to build towards value-based payment.
Value starts with primary care and prevention. It gains momentum with useful, timely data that informs clinical practice improvements and more effective care coordination. And it multiplies with greater ties between safety net health care providers and community-based social service organizations.

NACHC will continue to engage all federal agencies, including CMMI and HRSA, who share this vision.

Jerin Philip is NACHC’s Deputy Director of Federal and State Policy. Along with helping coordinate Medicaid policy responses, Jerin advises health centers on VBC policy and helps formulate policy positions with federal partners and national coalitions.

Ryan Smith, Specialist, PCA and Network Relations, has been convening internal and external collaboration with NACHC, and PCAs, and health centers to inform NACHC’s VBC policy positions.