Image via http://www.pineshealth.org
“The price of our vitality is the sum of our fears.”
The coming wave of value-based payments surges on January 2023. How did we get here? and why am I so excited?
Federally Qualified Health Centers (FQHCs) emerged from the countercultural movement of the 60s, with the express goal of taking care of those individuals who fell in the interstices of mainstream healthcare: African Americans, the extremely poor, those without formal immigration status, those suffering from mental illness, from homelessness, along with others. The ever-growing list of groups suffering from bias is depressingly long so FQHCs never lacked for opportunities. As a movement, we have been amazingly successful. Yet, it stands to reason that we are constantly trying to fit square pegs into round holes. How do you provide exceptional primary care when the issue might be a lack of a source of fresh food, the need for a well-functioning air conditioner, a support group, legal advice or a culturally and linguistically congruent doula? At its best, Value-based Payment (VBP)1 allows social justice institutions to invest in tailored interventions, in ways that are not possible through the fee-for-service (FFS)2 prism.
In all likelihood, on January 1, 2023, twenty thousand LCHC patients will flip from an FFS mode of payment to a VBP model. It seems like a radical event, but the path has been clear for some time.
In 2017, building on its already successful near-universal health insurance3, Massachusetts took a five year long ambitious step towards transforming health care delivery. Providers caring for patients with MassHealth4 were given incentives to form Accountable Care Organizations (ACOs)5. Strong emphasis was put on developing interventions for higher risk patients through precise and relevant data on patients and delivering quality outcomes that mattered to patients. Ultimate payment was based on annual reconciliation to predicted total costs of care: if your interventions helped patients feel better, they used less expensive resources and you got part of the savings. Health care institutions were being directly incentived to focus on wellness, on measures that mattered daily to patients, whether ill or not, whether they were showing up for their visits or not.
Traditionally, ACOs are “vertical” organizations, putting a system together including outpatient primary care, specialists, tertiary care hospitals and even rehabilitation/nursing home systems. LCHC took an unusual step: it helped found Community Care Cooperative6 (C3), a “horizontal” ACO. C3 members are all FQHCs, with little specialty care and certainly no hospitals. The foundational idea is to use the power of policy and market transformation to further our proven work in chronic disease management for medically complex patients, within the context of our singular focus on healing the most underserved segments of our community.
VBP is the natural evolution of a policy of increasing insurance coverage. Flexibility in resources and services provided is the next natural step for patient-centered and community-oriented social justice health care institutions.
In your experience, in what ways has the current system of FFS shown itself to not be ideal for the care of your patients?
1Value Based Payment is a concept by which purchasers of health care (government, employers, and consumers) and payers (public and private) hold the health care delivery system at large (physicians and other providers, hospitals, etc.) accountable for both quality and cost of care.
2Fee-for-service is a system of health insurance payment in which a doctor or other health care provider is paid a fee for each particular service rendered, essentially rewarding medical providers for volume and quantity of services provided, regardless of the outcome.
3In 2006, under Governor Romney, Massachusetts Instituted universal health care for all legal residents. In the wake of Obamacare almost ten years later, that move was christened “Romneycare”.
4MassHealth is the name of the Medicaid product in Massachusetts. It provides insurance to almost two million MA residents. It is run by the state of MA and is funded in collaboration with the federal government. Medicaid is a program designed to help US residents without the economic means to purchase commercial insurance.
5An accountable care organization is a healthcare organization that ties provider reimbursements to quality metrics and reductions in the cost of care. ACOs in the United States are formed from a group of coordinated healthcare practitioners. They use alternative payment models, normally, capitation.
6C3 is a MassHealth Accountable Care Organization created by Federally Qualified Health Centers to better serve their communities. Our health centers are committed to providing more opportunities for individuals to receive coordinated, holistic, and culturally appropriate care in the communities where they live and work.
CEO, Lynn CHC
Inspired by a childhood divided between a war-affected third world country – the Congo – and a high performing first world one (Switzerland), as well as parents intimately involved in rural development NGOs, Dr. Kiame Mahaniah brings a deep passion for social justice and the fight against inequities to his work as CEO at the Lynn Community Health Center in Lynn, Massachusetts.