Payment and Delivery Reform

Across the nation, health care delivery systems and payment models are transforming to respond to the tenets of the Quadruple Aim: improving patient and provider experiences and population health while reducing system costs.

What does payment reform look like for health centers?

Read the issue brief Health Centers and Payment Reform: A Primer

What is helping health centers strategically engage in payment and delivery reform initiatives? 

Read the issue brief Navigating and Advancing Health Center Payment Reform: Lessons from Primary Care Associations

Is your health center ready to enter into new payment arrangements or advance its level of engagement? 

Utilize NACHC’s Payment Reform Readiness Assessment Tool.

The Payment Reform Readiness Assessment Tool identifies key competency areas needed for successful engagement in the most prevalent and emerging payment reform models. It is designed to help health centers self-assess their current state of readiness, and to identify opportunities and tailored resources for advancement. Check out the tips for utilizing the tool.

Contact state@nachc.org for more information.

 

FQHC Alternative Payment Methodologies

In recognition of the critical role health centers play and the value that they deliver for Medicaid beneficiaries, Congress created a specific payment methodology for them, known as the FQHC Prospective Payment System (PPS). To provide increased flexibility, the law also allows states to design and implement an alternative payment methodology (FQHC APM) so long as:

  • The total FQHC APM reimbursement is not less than what the FQHC would have received with the FQHC PPS methodology;
  • Each participating FQHC individually agrees to the FQHC APM; and
  • The FQHC APM is documented in the state’s approved Medicaid State Plan.

As of 2017, over 20 states have chosen to use a FQHC APM to reimburse health centers for primary care and preventative services provided to Medicaid patients. An increasing number of health centers, in partnership with their state-level colleagues, are utilizing the flexibility within federal Medicaid law to develop FQHC APMs that allow for a more transformative use of the medical home.

The FQHC Alternative Payment Methodology Toolkit: Fundamentals of Developing a Capitated FQHC APM provides PCAs and health centers with knowledge and best practices for developing a capitated FQHC APM.

Learn more about emerging FQHC APM models:

 

State Payment & Delivery Reform Efforts

In addition to reforms specific to health center payment, health centers are also engaging in a variety of broader payment and delivery reform initiatives. Learn about these efforts and the role health centers are playing.

2703 Health Homes

Created as part of the Affordable Care Act, the Section 2703 Health Homes program (now in operation in 20 states and the District of Columbia) aims to create new opportunities through Medicaid to boost health services to beneficiaries, especially people who suffer from complex health care needs (such as mental health, substance abuse, asthma, diabetes and heart disease). To be eligible, Medicaid beneficiaries must have or be at risk for two or more chronic conditions.

Many states are connecting their Health Homes program to other initiatives to provide enhanced support to targeted patient populations. Learn about how a health center in New York is participating in a pilot that focuses on justice-involved patients.

State Innovation Models

The State Innovation Models (SIM) Initiative was launched by the Center for Medicare and Medicaid Innovation in 2012. SIM was a targeted effort to accelerate broad scale development and testing of new service delivery and payment models that have the potential to increase the quality of health care while lowering total costs.

 

Health Center and Hospital Partnerships

In the emerging landscape of value-based care, health centers and hospitals are exploring new partnerships to improve health outcomes and patient experiences while reducing system costs.

Emergency Department Coordination

Many health centers and hospitals have identified reducing avoidable ED use as a key area for collaboration. Explore the following resources to learn more:

  • An issue brief that provides an overview of strategies to reduce ED utilization, federal and state initiatives, and case studies of health centers that have implemented ED care coordination programs.
  • webinar recording focused on the legal issues as well as operational and financial challenges and benefits of engaging in these partnerships.
  • fact sheet summarizing important legal and policy issues that are key to successfully establishing ED care coordination programs for health centers.
Access to Specialty Care

 

Additional Resources