FQHCs and Value-Based Care: What’s the Risk?

As an active member in the community health center industry for the bulk of my career, I know that FQHCs have been doing “value-based care” long before it was a known term across healthcare. By their very nature, FQHCs take on the added risk of managing the care and support services needed by our nation’s most vulnerable populations.

From a financial standpoint, they often receive certain bonus payments by federal and state Medicaid programs, but those payments come with complicated management systems that yield little return on investment. FQHCs also rely heavily on grants but knowing that the shift to value based payments (VBP) is coming, now more than ever, leaders are thinking about how to get meaningful, actionable insights that turn VBP risk into revenue.

Why now?

When CMS started moving the entire healthcare industry away from fee-for-service payment models into pay-for-performance models, FQHCs remained largely unaffected. Besides, this is what they were created to do—manage the health and outcomes of the communities they serve.

However, as the Medicaid and CHIP population has dramatically increased in recent years (88.3M individuals as of April 2022—a 26% increase over two years) and 39 states have now implemented Medicaid expansion, the commercial payers who manage these state Medicaid programs are pushing for even more financial accountability and risk for the populations FQHCs serve.

I have the fortunate opportunity to speak and work with business and clinical leaders within FQHCs every day, and up until about a year ago, I was a clinical leader at an FQHC. I see first-hand the shift toward more financial risk that’s going on, and it is alarming. FQHCs are already under extreme pressure, from workforce shortages and increasing regulatory requirements to the ever-growing number of services required to meet the complex needs of their communities.

As mission-driven organizations, FQHCs don’t operate like traditional acute and ambulatory care providers. They’re not just caring for the sick. They are taking on the health of a population that often doesn’t have the financial means or ability to care for themselves. They’re delivering hygiene kits, holding nutrition education classes, offering transportation to/from doctor visits for pregnant women, and many more things that hospitals don’t do. These are things you don’t get a prescription for and cannot be found on a medical claim. They don’t fit neatly into traditional value-based payment models with standard quality measures.

But as MCOs start pushing for FQHCs to take on greater financial responsibility within the context of value-based payment models, the sustainability and independence of FQHCs are at risk. Porter Research recently investigated this issue by surveying more than 50 FQHC leaders. A summary of that research can be found here.

What’s next?

Today, most FQHCs work closely with like-minded organizations, such as HCCNs and PCAs, in their communities. While these partnerships are great, there is an emerging need for leaders to take a higher-level view of things. As the pressure mounts, so does the need for a more data-driven and collaborative approach.

One of my responsibilities here at NextGen Healthcare is to lead initiatives that are focused on helping FQHCs get access to more data and information that can help them make informed decisions, whether it is about care needs or payment models. For example, I’m digging in deep around the topic of interoperability, or the sharing of data. Clinicians don’t just need mountains of claims data; they need instant access to relevant data, such as medication reconciliation or proactive insights based on social determinants of health data, so they can ensure patient safety while making care decisions within a “whole-person” approach. We’re investing in technology to automate FQHC-specific workflows and deliver relevant data that is so vital to their missions.

Another initiative is the NextGen® Community Health Collaborative. Under this program we’re establishing forums for CEOs who are managing all kinds of risks and plans. By helping FQHCs share their perspectives on community health populations in other geographies with similar challenges, the Collaborative is helping leaders make better decisions to administer care patterns and to learn from the clinical and operational results observed. Building a community of community health centers means improving clinical outcomes to help patients manage their own outcomes and destiny for their population, which is the mission of community health in the first place.

I’m grateful for my many years of service to our nation’s most vulnerable populations, but I’m even more excited about the opportunity to be on this side of the equation so I can help providers come together over data and find new ways to use technology to create and share the insights they need to successfully navigate this new wave of value-based care payment models.