Reporting From the Front Lines

Abstract

Alternative payment models have been proposed as a way to facilitate patient-centered medical home model implementation, yet little is known about how payment reform translates into changes in care delivery. We conducted site visits, observed operations, and conducted interviews within 3 Federally Qualified Health Center organizations that were part of Oregon's Alternative Payment Methodology demonstration project. Data were analyzed using an immersion-crystallization approach. We identified several care delivery changes during the early stages of implementation, as well as challenges associated with this new model of payment. Future research is needed to further understand the implications of these changes. Keywordscapitation; Federally Qualified Health Center; Medicaid; patient-centered medical home; payment methodologyThe patient-centered medical home model of primary care strives to provide accessible, comprehensive, and coordinated team-based care that responds to the full range of individuals' health care needs (Jackson et al., 2013). Adoption is widespread and emerging evidence points to multiple benefits of this model, including increased provision of preventive services and improvements in the experience of care for both patients and staff (Carlin et al., 2016;Jackson et al., 2013).However, under traditional fee-for-service payment methodologies that link payment to the volume of face-to-face visits, health care organizations are not reimbursed for the many patient-centered medical home activities that occur outside of the visit, such as phone consultations, medication management, patient education, or panel management (Olson, Correspondence: Glenn Kautz, MPH, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (kautz@ohsu.edu). No conflicts of interest were declared by any of the authors. et al., 2014;Merrell & Berenson, 2010). HHS Public AccessRecent changes in the health care landscape, including the implementation of the Patient Protection and Affordable Care Act (ACA), led some states to experiment with alternative payment methodologies as a way to achieve the triple aim of reducing utilization and costs while improving the quality and experience of care (Edwards et al., 2014;Kocot et al., 2013). At the forefront of this movement is Oregon's Alternative Payment Methodology (APM) demonstration project, which provides Federally Qualified Health Centers (FQHC) the option of shifting from a prospective payment system to receiving a capitated permember-per-month rate for their Medicaid patients. FQHCs are nonprofit health centers committed to providing high quality comprehensive primary and preventive care to persons of all ages, regardless of their ability to pay or health insurance status. FQHCs primarily serve uninsured and Medicaid populations and are a critical component of the health care safety net. In 2015, more than 24 million patients were served by 1375 FQHCs, 68% of which were recognized as patient-centered medical homes (HRSA, 2015).Three FQHC org...

The impact of integrating medical assistants and community health workers on diabetes care management in community health centers

“…Limited reimbursement of non-clinical staff is a major limitation to the dissemination of team-based models that expand the role of these allied health workers to aid patients in diabetes care management. Innovative payment models, such as the Federally Qualified Health Center Alternative Payment Methodology in Oregon [ 41 ], which incentives containment of total costs of care, might stimulate the use of team-based diabetes care management models that include CHWs and MAs, as well as peers [ 42 ].…”

Health Centers and Value‐Based Payment: A Framework for Health Center Payment Reform and Early Experiences in Medicaid Value‐Based Payment in Seven States

“…Past research has documented that health centers have sought additional funds over and above PPS and additional flexibility under FQHC APM to reduce provider burnout while delivering the full range of team-based care services with a variety of care team members under a patient-centered medical home care model. 25 Given that early VBP models related to hospital readmissions and Medicare ACOs disadvantaged safety-net providers, it is critical to redesign health center payment with a keen eye for avoiding adverse consequences for these important safety-net providers while mitigating, rather than exacerbating, disparities for the patients that health centers serve. [26][27][28]…”

Association Between Capitated Payments and Preventive Care Among U.S. Adults

“…6 , 7 By removing incentives to achieve a certain volume of visits, capitated models may permit clinicians (and practices) the time and flexibility to more effectively partner with patients on preventive care. 8 Capitation may also promote activities that support prevention and comprehensiveness, such as education and counseling on lifestyle factors, and team members, such as health coaches and peer navigators, who are either not captured or nonbillable under FFS. Indeed, evidence from the 1990s suggested that capitation was associated with a greater likelihood to receive health counseling and other preventive services.…”