Developing Federally Qualified Health Centers into Community ...

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• HRSA’s affiliation policies, which limit third-party involvement in the governance, management, and operation of FQHCs. • Federal Tort Claims Act coverage, which generally covers only FQHC services and sites within the approved scope of project and provided to the FQHC’s patients by its providers furnishing services within their scope of employment/contract (with certain limited exceptions). • Section 340B Discount Drug Pricing Program, which is available solely for outpatient prescription drugs provided to FQHC patients (as defined by the 340B program). • Preferential Medicaid and Medicare reimbursement, which generally is available only for services approved under the FQHC’s scope of project (although exceptions may exist based on a particular state’s Medicaid plan). • Federal anti-kickback safe harbor for FQHC grantees, which protects certain low-cost and no-cost arrangements among grantees and other providers, suppliers, and vendors that could otherwise implicate the federal fraud and abuse laws. 39 The Affordable Care Act presents numerous opportunities for FQHCs and Primary Care Associations to assume new roles in the health care delivery system. <strong>Community</strong> networks led by FQHCs or Primary Care Associations could be an important resource for accountable care organizations or other integrated delivery systems, particularly for managing the treatment of patients who are dually eligible for Medicare and Medicaid, have complex conditions, or have social/behavioral health needs. As CMS and states develop ―risk-based payment models‖ as part of the Affordable Care Act or as part of state delivery system reform, FQHCs and Primary Care Associations may be uniquely situated to serve in an expanded capacity. To prepare for these new roles, FQHCs and Primary Care Associations will need to work together to demonstrate their ability to be financially competitive with other community providers, assume risk-based contracts, and demonstrate outcomes for an entire episode of care. CONCLUSION The creation of community-based networks to provide care management and greater access to health care services may enable states to hold down Medicaid costs while providing better care for beneficiaries. With 20 million more Medicaid beneficiaries being added to the rolls in 2014, states will be challenged to help already-strained primary care practices take on additional patients. Helping practices function more efficiently as medical homes—particularly for patients with chronic illnesses—can help improve access to high-quality care and control costs. In order for practices to function as 32
medical homes, they will need resources to ensure the delivery of timely, coordinated, and comprehensive primary care. Many FQHCs have the infrastructure and expertise to help practices meet medical home requirements and may be ready partners for states to develop as community networks. There are many possible arrangements that states may choose to pursue. Table 2 highlights key arrangements and characteristics of the projects in Montana, North Carolina, and Indiana. Table 2. Featured <strong>Community</strong> Network Models Montana HIP* Patients served • Active care management: about 2,050 • On-demand care management: about 1,600 • 5% of population served 33 CHP CCNC Network** • Active care management: about 670 • Potentially eligible patients: about 33,500 • 2% of population served Staffing 32.5 FTEs 12 FTEs 5.5 FTEs Funding model Medicaid pays $3.75 PMPM to host FQHCs Note: PMPM is per member per month. * Figures as of Jan. 2011. ** Figures as of Feb. 2011. *** Figures as of Dec. 2010. • Medicaid pays $3.72 PMPM for non-Aged Blind and Disabled (ABD) members • $13.72 for ABD members Southway Urgent Care*** Patients served: 7,848 in 2010 Over 80% of patients are covered by public or private payers. The public payers reimburse for urgent care services using FQHC cost-based reimbursement system. An immediate concern for states to consider is finding ways to ensure patients have timely access to care to prevent them from visiting the emergency department for nonurgent care. Indiana’s FQHC-based urgent care center provides an example of one way to build after-hours systems of care. States also will need to consider how to foster relationships between urgent care centers and private practices so that information is communicated across sites. States can play an important role in helping practices that do not have the resources and capacity to manage the care of complex patients. By sharing resources across practices through Medicaid-funded FQHC-based networks, states may be able to improve care while holding down costs. There is promising evidence that Medicaidfunded practice-based networks are able to share resources among multiple sites—
Page 1: DEVELOPING FEDERALLY QUALIFIED HEAL
Page 4 and 5: ABOUT THE AUTHORS Mary Takach, M.P.
Page 6 and 7: • National experts: › Associati
Page 8 and 9: populations. This report features t
Page 10 and 11: are many federal, state, and instit
Page 12 and 13: complement of health care and suppo
Page 14 and 15: In 2008, Montana Medicaid’s disea
Page 16 and 17: KEY ASPECTS OF THE MODEL Participat
Page 18 and 19: • Promoting use of the NurseFirst
Page 20 and 21: Lessons for States Develop a cultur
Page 22 and 23: • HIP provides a stream of insure
Page 24 and 25: the local providers. North Carolina
Page 26 and 27: three sites, which means that the o
Page 28 and 29: Consider a public-private governanc
Page 30 and 31: KEY ASPECTS OF THE MODEL In 2007, O
Page 32 and 33: • Staff are covered by federal ma
Page 34 and 35: Health centers need to stop acting
Page 36 and 37: Wide variance in FQHC capabilities.
Page 38 and 39: • develop[ing] and implement[ing]
Page 40 and 41: ADDITIONAL POLICY OPTIONS TO PROMOT
Page 44 and 45: potentially improving patient care
Page 46 and 47: in offering timely and appropriate

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