An Overview of Federally Qualified Health Centers. Meaghan McCamman Assistant Director of Policy California Primary Care Association

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An Overview of Federally Qualified Health Centers Meaghan McCamman Assistant Director of Policy California Primary Care Association Clinic Alphabet Soup Where We Came From Origins in the broader movements
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An Overview of Federally Qualified Health Centers Meaghan McCamman Assistant Director of Policy California Primary Care Association Clinic Alphabet Soup Where We Came From Origins in the broader movements for civil rights and social justice in the early 1960s. Organizers: Community Action Agencies with a purpose of increasing the safety net for the poor. President Lyndon Johnson: War on Poverty. Office of Economic Opportunity established. Where We Came From South Africa model of community-oriented primary care Vision: to empower communities to take charge and find solutions to their own health needs 1965: First neighborhood health centers established in Mississippi, Boston and Denver Where We Came From : Community Health Center program first authorized by Congress : Federally Qualified Health Centers grants administration established under Medicaid and Medicare 1996: Section 330 of the Public Health Service Act (PHSA) provides for federal grants to CHCs included provision for consumer majority board 2000: Prospective Payment System (PPS) authorized : Bush Administration initiates 5-year initiative to increase health center funding 2010: Passage of Health Reform Today 2014 & 2015: Health Reform Implementation Nationally (since 2013) 16.4 million Americans have obtained health coverage 14.1 million Americans have obtained health coverage through the expansion of Medicaid Current uninsured rate has dropped from 20.3% to 13.2% California (2 nd enrollment period only) More than 495,000 new enrollments in Covered CA More than 779,000 new enrollments in Medi-Cal Approximately 3 million remaining uninsured California CCHC Profile California CCHC Profile CPCA Mission To lead and position community clinics, health centers, and networks through advocacy, education and services as key players in the health care delivery system to improve the health status of their communities. CPCA Eligibility Criteria Any organizational entity which meets the following minimum requirements as a Community Health Center: Licensed as either a community clinic or free clinic by the State under California Health & Safety Code 1204(a)(1) and (2), or is exempt from licensure under Section 1206; Has a written policy of non-discrimination based on ability to pay and has either: a sliding scale fee based on income and family size, or a no-fee policy; Provides medical diagnosis and treatment services to children and adults. CPCA s Membership CPCA was founded to create a unified, statewide voice for community clinics and health centers. Members are comprised of: Community Clinics Free Clinics Federally Qualified Health Centers (FQHCs) FQHC Look-Alikes Rural Health Clinics Migrant Health Centers Healthcare for the Homeless Indian Health Service Clinics Planned Parenthood Affiliates of California Some clinics also provide dental, specialty care, and/or psychology services, as well as staff school-based clinics. CPCA s Membership Free Clinics no charges directly to the patient for services rendered or for drugs, medicines, appliances, or apparatuses furnished. Rural Health Clinics (RHC) RHCs may be either for-profit, physician controlled entities, or non-profit community clinics.* Migrant Health Centers FQHCs that receive federal funding to specifically target seasonal and migrant farmworkers. Healthcare for the Homeless FQHCs that receive federal funding to specifically target homeless populations. May be exempt from some Board/Governance requirements. Indian Health Services Includes Tribally Operated Facilities as well as Urban Indian Health Organizations Planned Parenthood Affiliates of California Federally Qualified Health Centers (FQHC) A Federally Qualified Health Center (FQHC) A FQHC may be a public or a private nonprofit entity that: Receives a grant under Section 330 of the Public Health Services (PHS) Act; Was considered a comprehensive federally funded health center as of January 1, Is a program or facility operated by a tribe or tribal organization pursuant to the Indian Self-Determination and Education Assistance Act of 1975; or Is an urban Indian organization that receives funding for the provision of primary care services under Title V of the Indian Health Care Improvement Act. Requirements of a FQHC Community-based and patient-centered Patients must constitute the majority (51%) of the governing board Provide preventive and primary care services for all ages Open to all, regardless of their ability to pay Must use a sliding fee scale What are the Benefits of being a FQHC? Enhanced reimbursement from Medicaid based on a prospective payment system (PPS) rate Eligible for 1. Malpractice coverage through the Federal Tort Claims Act (FTCA) coverage program 2. Federal loan guarantees through HRSA 3. Participation in Section 340(b) federal drug pricing programs 4. Automatic Health Professional Shortage Area (HPSA) 5. Special safe harbor protection under federal and state anti-kickback statutes. FQHC Covered Services Services by a Physician, Nurse Practitioner, Physician Assistant, Certified Nurse-Midwife, Clinical Psychologist, Licensed Clinical Social Workers and Comprehensive Perinatal Services Program (CPSP) Practitioners Services and supplies incident to the services by the above providers Ancillary services - not billable Visit Definition A face-to-face encounter between a FQHC patient and a billable provider Same day billing not authorized except: If patient (after the first visit) suffers an illness or injury that didn t exist at the previous visit requiring another diagnosis or treatment Patient receives dental services Federal law effective January 1, 2001 Prospective Payment System (PPS) Rate Approximates the FQHC s reasonable cost-per-visit Medi-Cal pays FQHCs an all-inclusive per visit payment amount based on reasonable costs as reported and audited Following Medicare reasonable cost guidelines Rate setting for new FQHC locations PPS in California PPS rate changes Medicare Economic Index (MEI) rate adjustment Scope of service change request Managed care payment reconciliation process Payment Reform: Opportunities for FQHCs State Environment If you were running the Medi-Cal Program, what would you see? Escalating healthcare costs Medi-Cal growth 7M beneficiaries ( 10) 10.1M (est 14-15) FQHC growth 400 ( 01) to over 1300 ( 14) FQHCs/RHCs = 64% of all Medi-Cal primary care visits in clinic/doctor office setting (FY 09-10) Managed care expansion.fqhc utilization is not managed State Environment Solid ROI From Health Centers: Medi-Cal rates for non-fqhc primary care: 3rd lowest in nation at 43% of Medicare fee schedule and 10% cut sustained It takes more $ than DHCS pays others to provide quality primary care for vulnerable populations FQHCs represent 40-80% of Medi-Cal access varies by region California already has one of lowest spends per capita in Medicaid overall FQHCs provide value to the overall delivery system in access, quality of care and keeping total cost of care down Health Center Challenges Increasing federal and state pressure on health centers National Association of Medicaid Directors California Department of Health Care Services Covered California Other States Experiences Health Center Delivery Model Data collection and systems Large uninsured populations Current structures do not account for social determinants of health Delivery System Transformation to achieve the Triple Aim Health Center Opportunities CPCA Payment Reform CPCA Payment Reform CPCA Payment Reform An alternative to paying the Prospective Payment System (PPS) rate Congress allows use of an APM as long as: 1. It results in payment to the center or clinic of an amount which is at least equal to the amounts otherwise required to be paid to the center or clinic under PPS 2. It is agreed to by the state and the individual FQHC or RHC 3. The APM should be described in the approved State plan Source: Section 1902(bb) of the Social Security Act [42 USC 1396a(bb)(6)] CPCA Payment Reform Translate site-specific wrap payments into PMPM equivalent for 4 aid categories Different PMPM rates for aid categories Adult, Kid, SPD Medi-Cal Expansion still being discussed Duals excluded HPs bear limited financial risk 2-way risk corridor FQHCs bear limited utilization risk Non-assigned enrollee utilization paid same as today Reconciliation between FQHC and HP to ensure PPS floor is met per APM requirement CPCA Payment Reform Reconciliation is rare if triggers are met DHCS proposes reconciliation between HP and health center (but accounted for in risk corridor) CHCs bear risk for transformed care and have protection for unanticipated face-to-face utilization Proposed DHCS-side protection in event of drastic declines in utilization CPCA Payment Reform Simplicity in Design: Keep DHCS costs per capita the same Provide flexibility to transform care Health centers will continue to: Have site-specific rates Have ability to do scope change Receive annual MEI increases Comply with timely access requirements Report access and quality metrics to health plans, OSHPD and HRSA (UDS) Key Metrics Proposed Evaluation Framework 1) Help reduce avoidable utilization of high cost services 2) Achieve improved patient outcomes 3) Enhance patient experience 4) Position CA for future payment reform efforts that better address social determinants of health Payment Reform The Future Environment The Culture of Managed Care and Capitation Accountable Care Organizations (ACOs) and Communities (ACCs) Care Coordination and Case Management ICD-10 Alternative models of care delivery and access Health Information Exchange Consolidations and Shared Services Competition Questions Meaghan McCamman Assistant Director of Policy California Primary Care Association
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