Impact on Heath Services Utilization, Payment, and Quality in Federally Qualified Health Centers of Washington State's Value-Based Payment Model.

Abstract

Impact on Heath Services Utilization, Payment, and Quality in Federally Qualified Health Centers of Washington State's Value-Based Payment Model Douglas A. Conrad, PhD (bio), Bailey Ingraham, MS, PhC (bio), Paul Fishman, PhD (bio), Lingmei Zhou, MS (bio), David Grembowski, PhD (bio), Norma B. Coe, PhD (bio), Aniyar Izguttinov, MPH (bio), Suzanne J. Wood, PhD (bio), Jordan Banks, PhD Candidate (bio), and Lydia Andris, MPA (bio) Federally qualified health centers (FQHCs) were created in 1965 to provide comprehensive primary, behavioral health, and dental care as well as enabling services that include transportation, translation, and case management services to all Americans regardless of their insurance status or ability to pay.1 As of 2021, more than 1,400 health centers with over 12,000 care sites provided health services to nearly 30 million individuals (8% of the United States population).2 Federally qualified health centers must either be in medically underserved areas (MUA) or serve medically underserved populations (MUPs), as a result, FQHCs are a critical source of care for the most vulnerable Americans. For example, approximately half of all FQHC patients are insured through Medicaid, one third of whom live in poverty, 1.4 million are homeless, and 885,000 are children served at school-based clinics.2 Federally qualified health centers are funded through two federal programs: the Health Center Program and the Community Health Center Fund2 which was established through the Affordable Care Act (ACA). Together these programs provided [End Page 1905] $5.78 billion in funding to FQHCs in fiscal year 2021—more than twice the amount allocated 10 years earlier. In 29 states, FQHCs receive state-specific support to supplement federal resources. Increased federal and state support for FQHCs was motivated in large part by the increased demand for their services from individuals newly insured through the ACA.2 The growth in demand for FQHC services and increased ACA-driven funding has focused attention on these centers as models for providing value-driven care designed to achieve the triple aims of patient-centered, high-quality, and cost-efficient care. To support this effort, the Centers for Medicare and Medicaid Services (CMS) are transitioning primary care payment from the prevailing prospective payment per encounter (PPS) model2 to alternative payment models (APMs) in the form of value-based care delivery and payment.2 The Centers for Medicare and Medicaid Services also gave states the option to create APMs, provided the affected FQHCs did not receive lower payments than would have occurred under PPS. For example, Washington State Medicaid adopted prospective per member per month (PMPM) for primary care, with financial incentives to meet population quality and performance indicators set at the beginning of the contractual period. Several states have explored APMs for FQHCs,2 but there is little current peer-reviewed evidence of their impact on health, use, cost, and quality of care. The best evidence to date is from Oregon's experience with an FQHC APM introduced in 2013.3,4,5 Oregon FQHCs are paid a capitated PMPM with quality-based financial incentives tied to colorectal cancer and depression screening, blood sugar control for individuals with diabetes, and measures related to childhood nutrition and weight and hypertension control. Cottrell et al.'s3 qualitative examination of the Oregon initiative found innovations in scheduling (longer patient visits; dedicated time for care coordination); changes in visit types (group visits; telephone visits); transformations in use of human resources (use of an online patient portal); and changing team composition (adding a clinical pharmacist; altering role descriptions [e.g., for medical assistants]). Initial results among the first 10 centers that participated in the APM showed small reductions in ER visits and hospital use, with some increases in quality, patient experience, and access.3 Ukhanova et al.5 examined the APM's impact on preventive service use and found that it "did not negatively impact delivery of preventive care,"5[p.1] based on screening rates among affected clinics not falling as much as those in comparator clinics. Lindner et. al estimated that the Oregon APM led to a 42.4% relative reduction in price-weighted primary care services compared with comparator clinics, almost fully due to the decline...