Case Study October 2013 Establishing a Coalition to Pursue Accountable Care in the Safety Net: A Case Study of the FQHC Urban Health Network The mission of The Commonwealth Karen E. Schoenherr, Aricca D. Van Citters, Kathleen L. Carluzzo, Fund is to promote a high performance Savannah Bergquist, Elliott S. Fisher, and Valerie A. Lewis health care system. The Fund carries out this mandate by supporting independent research on health care ABSTRACT: The Federally Qualified Health Center Urban Health Network is a coalition issues and making grants to improve of 10 federally qualified health centers (FQHCs) in the Minneapolis–St. Paul area that health care practice and policy. Support pursued an accountable care organization (ACO) through a Medicaid demonstration proj- for this research was provided by ect with Minnesota. Under the ACO model, the coalition has assumed responsibility for The Commonwealth Fund. The views presented here are those of the authors the total cost and quality of care delivered for an assigned patient population. This case and not necessarily those of The study explores: the state context under which the ACO contract emerged; origins of the Commonwealth Fund or its directors, coalition; the members’ motivations to participate; strategies and processes established to officers, or staff. work toward cost and quality benchmarks; challenges faced in pursuing accountable care; and the organizational strengths that facilitated the health centers’ shift from competition to collaboration. The keys to the coalition’s success include a committed leadership team focused around a singular purpose; the partnership with its administrative services partner; and the diversity of programs, services, and experiences among the 10 FQHCs.      For more information about this study, please contact: OVERVIEW Karen E. Schoenherr The Federally Qualified Health Center Urban Health Network (FUHN) is a coali- Health Policy Fellow The Dartmouth Institute for tion of 10 federally qualified health centers (FQHCs) in the Minneapolis–St. Health Policy & Clinical Practice Paul area that came together to pursue an accountable care organization (ACO) karen.e.schoenherr@dartmouth.edu contract with the state of Minnesota. Under an ACO contract, the FQHCs will collectively be held accountable for meeting established quality and cost bench- marks for a defined Medicaid patient population, and the coalition will be eligible To learn more about new publications to share in any savings they achieve during the three-year contract.1 FUHN’s when they become available, visit the delivery system consists of nearly 40 service sites across seven counties. The clin- Fund's Web site and register to receive ics provide care to approximately 150,000 patients, of which nearly 23,000 are Fund email alerts. Medicaid patients that will be served by the ACO.2 Commonwealth Fund pub. 1710 Vol. 28 2T he  C ommonwealth F und FUHN is one of the nation’s first safety-net strengths that facilitated the FQHCs’ shift from compe- ACOs. In forming an ACO, the FQHCs have transi- tition to collaboration. tioned (in the words of one FUHN board member) The ACO model developed by FUHN may be from “fierce competitors to fierce collaborators.” The of interest to organizations pursuing a coalition-based 10 FQHCs view accountable care as a mechanism to ACO and may provide insights to safety-net organiza- leverage resources and foster collaboration in the face tions considering accountable care. Based on FUHN’s of limited funding and a geographically dispersed and model, it appears each of the following may be impor- diverse network. By participating in accountable care tant to the development of a coalition-based ACO, par- at an early stage, FUHN hopes to demonstrate the ticularly in the safety net: capacity of an FQHC-based ACO to deliver high-qual- ity, low-cost care for safety-net patients. • aligning leadership through the identification of This case study was written as contract nego- a shared vision; tiations between FUHN and the state of Minnesota • establishing a strong governance structure were nearing a close; the final contract was executed tasked with overseeing and driving progress;3 and the ACO’s performance period began in January 2013 (Exhibit 1). The study explores the state context • developing a unified strategy for using data to under which the ACO contract emerged; origins of measure progress and identify improvement the coalition; the health centers’ motivations to par- opportunities; and ticipate; strategies and processes established to work • prioritizing the development of care coordina- toward cost and quality benchmarks; challenges faced tion infrastructure. in pursuing accountable care; and the organizational Exhibit 1. FQHC Urban Health Network (FUHN): Contract Features Contract feature Length of contract Three years, starting January 1, 2013. Patients Attribution method Performance year attribution.* Attributed patients Approximately 23,000 Medicaid beneficiaries. Covered patients include both fee-for-service and managed care beneficiaries, excluding dual eligibles. Financial model Risk model Upside shared savings only (no downside risk). Shared savings rate Savings achieved are shared equally between FUHN and the state. Covered services in total A range of services including inpatient, ambulatory, pharmacy, laboratory, and mental health services. Excluded cost of care services include dental, supplies, transportation, and most long-term supports and services. Baseline spending calculation Calculated using fee-for-service claims and managed care encounter data from the base year. Risk adjustment Adjusted Clinical Groups (ACG) risk scores weighted to reflect differences in the health risk between attributed and nonattributed populations. Upfront payments No upfront payments received from the state. Quality performance Year 1: 25% of shared savings contingent on reporting quality and patient experience measures. Year 2: 25% of shared savings tied to relative improvement on clinic-based measures and absolute performance on hospital-based and patient experience measures. Year 3: 50% of shared savings tied to relative improvement on clinic-based measures and absolute performance on hospital-based and patient experience measures. * V. A. Lewis, A. B. McClurg, J. Smith et al., “Attributing Patients to Accountable Care Organizations: Performance Year Approach Aligns Stakeholders’ Interests,” Health Affairs, March 2013 32(3):587–95. E stablishing a C oalition to P ursue A ccountable C are in the S afety N et 3 STATE CONTEXT providers, and patients. The Minnesota Association of Community Health Centers has served as a hub for Health System Performance and Reforms some collaboration, mainly in response to policy issues Minnesota has one of the most advanced state at the state and national levels. From this association, health care systems in the nation. According to a subset of urban FQHCs and community clinics met The Commonwealth Fund’s 2009 State Scorecard, regularly to coordinate efforts around emergency pre- Minnesota leads on many indicators of population paredness, billing support, and a limited number of health and is ranked third in the country in rates of local quality improvement initiatives. insurance coverage.4 The state passed health care reform legislation in 2008 designed to achieve the Impact of Market Consolidation and “triple aim” of improved patient care, improved popu- Managed Care lation health, and reduced per capita costs of care.5 The Horizontal and vertical integration in Minnesota’s law included provisions to develop standard quality insurance, hospital, and purchasing sectors has resulted measures, establish a statewide health improvement in a highly consolidated marketplace, with high lev- program, increase consumer engagement, and promote els of managed care and several large, hospital-based the patient-centered medical home model.6 Despite systems.9 The FQHCs have often felt dwarfed in a these factors, Minnesota experiences high levels of marketplace dominated by large systems with greater racial, ethnic, and socioeconomic health disparities, resources and managed care plans, and thus view the ranking only 17th nationally on measures of health ACO demonstration as an opportunity to better repre- equity.7 sent their collective interests within this consolidated marketplace. Safety-Net Efforts Seventeen FQHCs in Minnesota serve as safety-net ORIGINS OF FUHN providers for 170,000 patients, 45 percent of whom are In May 2010, Minnesota passed legislation mandat- enrolled in public health insurance programs and 40 ing the Department of Human Services to develop percent of whom are uninsured. The health centers pro- and implement the Health Care Delivery Systems vide care to disadvantaged patients from a range of cul- (HCDS) demonstration to test innovative delivery tural backgrounds. Ninety-four percent of health center systems, including accountable care organizations for patients have incomes below 200 percent of the federal Medicaid beneficiaries. Later that year, the Minnesota poverty level, and many of the clinics make efforts to Association of Community Health Centers held a board provide culturally competent care to specific popula- meeting focused on health reform activities at the state tions (e.g., Somali, Native American, Latino, African level. This resulted in the formation of a planning com- American, or Hmong).8 Patients seeking care from mittee tasked with investigating the future of ACOs. the health centers often have complex medical and The committee members―chief executive officers social needs, including multiple chronic conditions, from four of the 10 organizations that would eventu- low health literacy, and hardships such as poverty and ally compose FUHN―saw the HCDS demonstration homelessness. as an opportunity for the health centers to participate Despite sharing the goal of providing high- in accountable care.10 They studied the principles quality care to low-income and medically underserved and concepts of accountable care and gauged interest populations, the state’s FQHCs—particularly the 12 among the other FQHCs in pursuing an ACO contract. in the Minneapolis–St. Paul region—describe their Resulting from this investigation, the 10 CEOs that historical relationship as competitive. The health cen- would form FUHN’s board of directors began meeting ters have had to vie for grant funding, service areas, 4T he  C ommonwealth F und in July 2011 to develop a response to the state’s request FUHN’s clinics provide care to patients who for proposals for the demonstration program. may benefit greatly from strong care coordination. The HCDS demonstration’s covered beneficiary population Participating FQHCs and Patients Served includes all Medicaid fee-for-service and managed care FUHN includes 10 of the 12 FQHCs in the beneficiaries, except those who are dually eligible for Minneapolis–St. Paul area, totaling 40 service sites Medicare and Medicaid. Among FUHN’s patient popu- that provide care to 150,000 patients annually. One lation in the ACO demonstration, 43 percent sought member’s predecessor clinic was founded in the 1930s, care at the emergency department over a one-year and the newest health center formed in 2008 to serve period, often for nonemergent conditions such as respi- the Somali and other East African communities. The ratory illness, nonpsychotic mental health conditions, 10 FQHCs vary greatly in their size and capabili- and dental pain. FUHN’s adult patients (ages 20 to 64) ties. For example, the smallest, the Native American also experience high levels of chronic disease: 36.2 Community Clinic, serves just 4,000 patients at one percent have a depressive condition; 17 percent have location, whereas the largest, West Side Community been diagnosed with asthma; and 11.8 percent are dia- Health Services, serves 33,000 patients across 18 loca- betic. The high chronic disease burden and potentially tions (Exhibit 2). avoidable use of emergency departments represent key cost drivers among FUHN’s patient population. Exhibit 2. Member Organizations of the FQHC Urban Health Network (FUHN) Number of Patient insurance Year Clinic Target population Number of sites patients* status* founded Axis Medical Center** Somalis, East Africans, residents of 1 medical 4,500 9% uninsured 2008 Stevens Square & Loring Heights 89% public 2% private Community-University Health Children and low-income families in South 1 medical, dental 12,000 28% uninsured 1966 Care Center Minneapolis & behavioral health 58% public 14% private Indian Health Board of American Indian community in 1 medical, dental 5,000 51% uninsured 1971 Minneapolis Minneapolis & behavioral health 38% public 11% private Native American Community Native American families in metro area 1 medical, dental 4,000 26% uninsured 2003 Clinic & behavioral health 53% public 21% private Neighborhood HealthSource Community members of North & Northeast 4 medical & 10,000 39% uninsured 1971 Minneapolis behavioral health 43% public 18% private Open Cities Health Center African Americans, Southeast Asians, 2 medical, dental 14,000 38% uninsured 1967 immigrants, refugees & behavioral health 47% public 15% private People’s Center Health Services Economically disadvantaged and socially 2 medical & 10,000 28% uninsured 1970 disenfranchised behavioral health, 61% public 1 dental 11% private Southside Community Health Low-income women & children from 2 medical, 1 dental 10,000 37% uninsured 1971 Services Southside Minneapolis & vision 50% public 13% private United Family Medicine** Medically uninsured, underinsured, 1 medical & 15,000 20% uninsured 1971 underserved residents of St. Paul behavioral health, 47% public 1 satellite 33% private West Side Community Health Latinos, Hmong, adolescents, immigrants, 18 medical & 34,000 51% uninsured 1969 Services low-income community behavioral health, 38% public including 2 dental 11% private * Data from the Bureau of Primary Health Care’s 2011 Uniform Data System, http://bphc.hrsa.gov/uds/view.aspx?q=rlg&year=2011. ** Data from the Bureau of Primary Health Care is unavailable for FQHC Look-Alikes. Patient information based on organization’s annual reports. E stablishing a C oalition to P ursue A ccountable C are in the S afety N et 5 Organizational Formation upfront care management payments. Neither Optum The FQHCs’ proposed ACO was selected for con- nor the member FQHCs went into the demonstration tract negotiations under the HCDS demonstration in blindly: they worked with a nonprofit health plan in December 2011.11 The group identified early on that Minnesota to analyze data on 9,000 patients served by lack of data would be a significant barrier to imple- the FQHCs and concluded there was potential for sig- mentation of a new care delivery model, particularly nificant shared savings under an ACO contract. Optum given the absence of integrated electronic medical advised the FQHCs on the development of FUHN’s records to connect the FQHCs. To overcome this, proposal to the state and is providing an array of exper- FUHN pursued a partnership with an administra- tise, services, and technology to support FUHN in tive services organization for data management and meeting cost and quality benchmarks. population health analysis. FUHN interviewed four organizations before contracting with Optum (a sub- Governance and Leadership sidiary of UnitedHealth Group) to provide data tools, The democratic and collaborative nature of the FUHN strategic and operational insight, and other administra- coalition is firmly rooted in its governance structure tive services to support clinic-level improvements and (Exhibit 3). FUHN’s board of directors consists of network-wide infrastructure. the executive director or CEO from each of the 10 The FQHCs worked with Optum to develop FQHCs. Board members convene weekly with Optum a care delivery model that includes performance to discuss program development and implementa- improvement coaching, quality analysis and moni- tion. According to FUHN’s members, the coalition’s toring, and information technology infrastructure. success has come in large part from the fact that its Because of the limited funding available among the leaders have devoted significant time to the effort. An FQHCs, Optum has taken on significant financial risk Optum-employed program director supports the execu- for the ACO’s infrastructure investments. FUHN’s tives, working closely with them to establish a program leaders considered the investment from Optum as nec- development office charged with documenting policies essary to pursuing the ACO contract because the state and processes, and creating reporting templates, data did not provide any upfront or advance funding for the reports, and job descriptions for new care coordination demonstration, such as advances on shared savings or and analytic staff. Exhibit 3. Governance Structure of the FQHC Urban Health Network (FUHN) Community- Indian Health Native American Axis Medical Neighborhood University Board of Community Center HealthSource Health Care Center Minneapolis Clinic Southside West Side Open Cities People’s Center United Family Community Community Health Center Health Services Medicine Health Services Health Services Financial Management Board of Directors Clinical Quality & Reporting Committee FQHC CEOs Improvement Committee Consumer Satisfaction Access Improvement Optum Improvement Committee* Program Director Committee* * Committee outlined in FUHN’s “Response to Request for Proposals,” but not yet established. Source: West Side Community Health Services, Inc., “Response to Request for Proposal,” Letter to Minnesota Department of Human Services Health Care Administration, Nov. 4, 2011, St. Paul, Minnesota. 6T he  C ommonwealth F und FUHN’s Financial Management and Reporting Committee, consisting of the chief financial officers “We saw the opportunity to demonstrate that we or finance directors from each of the health centers, can manage care as effectively, or in fact maybe is tasked with forecasting operational needs and more effectively, than some of the big health establishing the coalition’s policy on the distribution systems in our market here.” of shared savings across sites. The Clinical Quality Financial Management and Reporting Committee Improvement Committee, which includes medical directors, senior physicians, and quality personnel, is the majority of Medicaid patients into value-based con- working to share best practices, determine standard tracts should the HCDS demonstration prove success- treatment protocols for common chronic conditions, ful. A number of executives also expressed concern for set performance targets for improvement, and moni- the overall future of the FQHCs, fearing that failure to tor quality results achieved by FUHN and the member participate in the demonstration would result in either FQHCs. Both committees are supported by the Optum- absorption by a larger hospital-based system or mar- employed FUHN program director. ginalization. Of the six projects selected to participate in the first phase of the HCDS demonstration, FUHN MOTIVATIONS TO PARTICIPATE IN THE is the only participant in the HCDS demonstration ACO INITIATIVE that is not an integrated delivery system but is instead The health center executives view the move toward coalition-based.12 FUHN sought to demonstrate the value-based payment as inevitable and believe the effectiveness of an alternate model that was “primary formation of a coalition (with its increased patient care–led and community-based, rather than hospital- volume and strengthened political voice) is the best led and system-based.”13 way to ensure the health centers’ survival and success in an evolving health care system. Within this context, Leading Health Reform three main motivations drove the FQHC’s pursuit of an Some health centers also wanted to play a leading ACO: the opportunity to demonstrate the effectiveness role in health reform. FUHN’s leaders believe that as of the FQHC model, the desire to lead health reform, a coalition they have been able to exert much greater and the ability to leverage scarce resources and par- influence on the state’s health reform process than ticipate in shared learning. The relative importance of any one of the FQHCs would have been able to do these motivations varied for each FQHC, often because on its own. of the size and capabilities of the organization. The HCDS demonstration marked the first time the health centers felt they had an opportunity to Demonstrating the Effectiveness of the guide state-level policies affecting a large proportion FQHC Model of their patient population. Their ability to take part in Many members chose to participate in FUHN in hopes contract negotiations and shape the ACO model to the of demonstrating that FQHCs can provide high-qual- benefit of the FQHCs was a significant departure from ity, low-cost care. With increased numbers of newly past payment arrangements with the state. Previously, insured individuals coming under the Affordable Care the health centers negotiated primarily with managed Act, the FQHCs saw the formation of an ACO as a care organizations that were under contract with the way to transition (in the words of its board chair) from state. For the HCDS demonstration, they have instead “default provider to preferred provider.” been able to negotiate directly with Minnesota’s In particular, the FQHCs viewed their partici- Department of Human Services. FUHN hopes its par- pation as a defensive move to more permanently secure ticipation in the demonstration will serve as a model, their relationship with their Medicaid patients. Many providing lessons for other states and health centers clinic leaders thought the state might eventually move considering Medicaid ACO initiatives. E stablishing a C oalition to P ursue A ccountable C are in the S afety N et 7 Leveraging Scarce Resources and utilization of care and relative risk; 3) high-risk patient Participating in Shared Learning management reports will use quality measures, evi- Finally, the opportunity to leverage scarce resources dence-based care protocols, and predictive analyses to and participate in shared learning motivated some of identify opportunities to help patients at highest risk the health centers to participate. Executives and clini- of hospitalization; and 4) clinic-specific performance cal staff saw FUHN as a vehicle for sharing resources reports will track each FQHC’s progress in meeting (e.g., after-hours care, transportation, and administra- overall cost and quality benchmarks. The reports aim tive and psychiatric services), standardizing policies to drive continuous improvement activities and mea- and procedures, and sharing best practices for the sure their impact in reducing utilization and improving treatment of common chronic conditions. Regular the quality of care. meetings among clinic leaders provided opportunities for mentorship and guidance around issues such as Performance Improvement Coaching performance measurement, risk-management, work- To enable effective use of the data available through force planning, and health information technology sup- ImpactPro, FUHN plans to place performance port. Additionally, some executives were eager to take improvement advisors at each of the FQHCs. advantage of the added resources and business exper- Performance improvement advisors and medical direc- tise they felt Optum could provide. The ability to lever- tors will work directly with staff to analyze clinic per- age scarce resources and participate in shared learning formance, identify improvement strategies, and moni- held greater importance for some of the smaller and tor their implementation. In particular, they will help less established organizations, while the desire to lead design care coordination processes aimed at reducing health reform served as a greater motivation for the emergency department and inpatient utilization, in larger FQHCs. The executives of the larger FQHCs particular for high-risk populations and patients with often saw shared learning as more of a byproduct of high hospital utilization. Additionally, performance the collaboration and less as a primary motivation for improvement advisors will study high-performing participating in FUHN. clinics and bring recommendations to the governance committees for spreading effective practices across ACCOUNTABLE CARE DELIVERY MODEL the network. In addition to forming a strong governance structure, FUHN’s leaders identified three interdependent ele- Patient-Centered Medical Home ments of their accountable care delivery model: 1) data Certification analytics, 2) performance improvement coaching, and FUHN strives to strengthen primary care by having 3) patient-centered medical home certification. each of its members attain Health Care Home certifi- cation, Minnesota’s version of patient-centered medi- Data Analytics cal homes. Introduced by the state’s 2008 health care FUHN is working with Optum to implement an ana- reform legislation, health care home certification is a lytic tool called ImpactPro, which is designed to rigorous process that requires the use of effective team improve the utility of administrative claims data by care delivery, patient registries to identify gaps in care, monitoring cost, utilization, and quality trends for indi- previsit planning, care plans to track patients’ progress vidual patients, as well as for providers and clinics. It over time, patient experience surveys, and ongoing will produce four types of reports: 1) patient follow-up partnerships with community resources.14 The FQHCs reports will identify opportunities for preventive ser- in the network are at varying stages of becoming vices and follow-up care; 2) panel view reports will health care homes, with four having already obtained give physicians information on their patients’ historical certification. 8T he  C ommonwealth F und CHALLENGES IN PURSUING structure has been established to facilitate coordina- ACCOUNTABLE CARE tion across the 10 independent organizations, but this In developing and implementing its new care delivery requires time and effort. The board operates by consen- model, FUHN’s leaders have identified three internal sus to facilitate full inclusion of all members. Despite challenges: 1) providing significant upfront invest- the benefits of this approach, decision-making at the ment of time and resources; 2) establishing a means board level is often time-consuming and slow. for effective communication, decision-making, and In addition, FUHN must decide when to stan- standardization among coalition members; and 3) man- dardize across the FQHCs and when to foster clinic- aging performance variation among member organiza- specific strategies and programming. To date, efforts tions. FUHN hopes to address these challenges through have centered on identifying protocols to be standard- the careful design of its care delivery model, the terms ized, such as policies for emergency preparedness and reached in its contract negotiations with the state, and for patients seeking pain medication. Going forward, the strength of its governance structure.15 FUHN’s leaders will need to think about broader strategies, including the standardization of provider Investment of Time and Resources and patient engagement efforts. Care management FUHN’s leaders have made significant upfront invest- approaches will likely remain site-specific, adapted by ments, both in terms of time and money, in order to performance improvement advisors to address local launch the ACO initiative. The CEOs devoted sub- needs. For example, Community-University Health stantial time to gain expertise in accountable care. In Care Center anticipates making more extensive use of addition, the subset of CEOs that served as the FUHN case managers for serious and persistent mental illness negotiating team invested significant time during the because of its higher prevalence of patients with behav- negotiation process with the state. FUHN’s workgroup ioral health needs. and committee meetings demand hours of time from the CEOs, financial directors, and medical directors Managing Performance Variation of member organizations. This investment of time FUHN’s member organizations vary widely with presents a particular challenge for the smaller FQHCs, respect to their size and staffing, relationships with whose leaders often have a hard time balancing the hospitals, implementation of electronic medical needs of their own clinics with those of FUHN. records, provider engagement in care delivery reform FUHN also has had to overcome significant efforts, and progress toward health care home certifica- resource constraints among its members. For example, tion. These differences will likely affect each health FUHN determined early on that it would be unafford- center’s ability to meet cost and quality benchmarks. able for the FQHCs to develop a health information FUHN’s leaders must address fundamental questions exchange to connect their disparate electronic medical about how to achieve equity among the 10 organiza- records. Although FUHN’s partnership with Optum tions, including how to help underperforming sites may address some resource constraints through the improve and how to distribute shared savings. provision of analytic tools and performance improve- The Financial Management and Reporting ment advisors, FUHN must continue to work with the Committee is designing a formula to distribute shared limited resources available to safety-net organizations. savings among the FQHCs while accounting for vari- ance in their size and performance. Thus far, the CFOs Cross-Site Communication, Decision- have developed a conceptual framework that includes Making, and Standardization three levels of distribution: 1) a lump-sum payment, FUHN faces a number of logistical issues in trying to equally shared among the FQHCs; 2) a payment tied work effectively as a coalition. A strong governance to each health center’s performance; and 3) a payment E stablishing a C oalition to P ursue A ccountable C are in the S afety N et 9 indexed to the number of attributed patients at each health center. The committee still needs to develop and “Optum’s participation with us is critical, because implement a specific formula for distributing savings. they are going to provide some of the infrastructure that we need to be able to positively influence ORGANIZATIONAL STRENGTHS utilization. And that’s a whole set of tools and tasks FUHN intends to rely on a number of the coalition’s that none of us, individually or collectively, could strengths to overcome challenges and facilitate the bring to bear.” transition to accountable care. These strengths include Financial Management and Reporting Committee a committed leadership team focused on a singular purpose; the partnership with Optum; and the diversity have started connecting outside of committee meetings of programs, services, and experiences among the to discuss progress and share materials, such as previsit 10 FQHCs. checklists. Committed Leadership Team with a Partnership with Optum Singular Purpose According to clinic leaders, Optum played a key role in FUHN has been a CEO-led initiative since its onset, supporting the development of FUHN’s care delivery and members say that their CEOs’ commitment and model. Through this innovative partnership, Optum has creativity has been critical to the coalition’s develop- provided critically important data analytics software, ment. FUHN’s leaders feel their singular purpose—to staff, and business expertise. Additionally, Optum and succeed under the ACO model—has enabled unprec- its program director have set up the pathways for com- edented levels of collaboration. This collaboration has munication by facilitating committee meetings. For depended on strong governance, including a clearly example, the program director is responsible for coor- designed board and committee structure and the active dinating agenda items with FUHN’s leaders as well as and regular engagement of clinic leaders. The board of distributing notes and reminders for meetings. directors and each committee has a charter that defines Optum is taking on significant financial risk its purpose, outlines key responsibilities, and estab- for the resources it provides to FUHN.16 Over the lishes membership representative of all 10 FQHCs. course of the three-year demonstration, Optum will Clear delineation of roles and responsibilities has invest in both upfront and implementation costs, fostered the enthusiastic and sustained participation including costs for hiring new staff members (e.g., the of clinic leadership. The active engagement of a num- program director and performance improvement advi- ber of leaders from each FQHC (CEOs, medical and sors), analytic tools, and data warehouse infrastructure finance directors, and quality personnel) differentiates and maintenance. FUHN must meet cost and quality the FUHN initiative from the FQHCs’ past efforts to benchmarks and achieve shared savings in order for work together. Optum and the 10 FQHCs to recoup their investments. The health center executives believe their Without this financial investment, FUHN’s leaders devotion of significant time each week has been essen- believe it would not have been possible for them to tial for successful collaboration. Through weekly board pursue the ACO contract. meetings, for example, clinics’ CEOs and executive directors have established informal relationships and Diversity of Programs, Services, a level of trust that they hope will facilitate the shar- and Experiences ing of resources and insights. Similarly, clinics’ quality The diversity of FUHN’s member organizations may and medical leaders have built stronger ties through strengthen opportunities for collaboration. The 10 the Clinical Quality Improvement meetings. Members FQHCs have tailored their services to be responsive to the unique needs of the underserved, low-income 10T he  C ommonwealth F und communities they serve.17 With each FQHC providing care to different subsets of the population, the coali- “I’m excited about the opportunity to collaborate tion hopes to benefit from sharing best practices among with the other clinicians. As you can see, we’re all FQHCs. For example, Neighborhood HealthSource trying to reach the same goals, but we all have a requested culturally tailored information on diabetes different set of resources, we all have a different set and nutrition for its Latino patients from West Side of skills and ideas, and we should be bringing those Community Health Services, the member organiza- together to improve quality.” tion that serves the largest number of Latino patients in Neighborhood HealthSource the network. Similarly, when United Family Medicine opened its first dental clinic, they lacked the expertise have established formal referral relationships with ter- to hire dental staff. The dental director from Open tiary care centers, the majority make referrals on an ad Cities Health Center assisted in the hiring process hoc basis. Given the geographic spread of the FQHCs, and helped United Family Medicine establish dental FUHN does not plan to standardize these relationships, procedures and protocols. Although the integration of but instead will look to each clinic to develop its own 10 disparate organizations will prove challenging, the activities for engaging hospitals and accessing timely diversity among the FQHCs means the coalition has a admissions and discharge information.19 Perhaps most large pool of experience, resources, and knowledge to important, FUHN must finalize how shared savings draw upon. will be distributed among the member organizations. Its leaders anticipate considerable performance varia- MOVING FORWARD IN THE PURSUIT OF tion across clinics and are developing strategies to help ACCOUNTABLE CARE underperforming sites improve. FUHN hopes to improve population health and achieve Along with these implementation barriers, shared savings by increasing preventive health care FUHN faces additional challenges in serving a highly services, reducing the number of hospital admissions vulnerable patient population. The long-term success and readmissions, and reducing emergency department of FUHN will hinge in part on the clinics’ ability to use. As they move forward in the performance period, meet the behavioral health and social service needs the coalition expects to encounter a variety of emerging of their patients. FUHN clinics plan to collaborate in challenges. Their experiences may provide lessons for order to optimize increasingly scarce resources and to community health centers and other groups pursuing learn from each other how to better integrate physical accountable care. health, behavioral health, and social services. Emerging Challenges Lessons for the Field FUHN anticipates a new set of challenges will emerge FUHN’s transition to accountable care may be of inter- as it implements its care delivery model and is held est to other FQHCs as well as organizations outside of accountable for the overall care and cost of its clin- the safety net that are pursuing coalition-based ACOs ics’ underserved patient population. For example, the in a fragmented system of care. Despite serving dis- performance improvement advisors will need to be advantaged patients, FUHN faces many of the same effectively integrated into the clinic workflow. FUHN challenges as does any organization seeking to pursue must develop a standardized process for accurately accountable care. collecting and reporting data on clinical quality and Based on FUHN’s experience, it appears the patient experiences.18 The FQHCs also must improve following approaches may be important to the develop- their relationships with local hospitals and specialists ment of a coalition-based ACO (Exhibit 4): to better coordinate care across settings. While some E stablishing a C oalition to P ursue A ccountable C are in the S afety N et 11 Exhibit 4. FQHC Urban Health Network (FUHN) ACO Implementation Facilitators Establishing strong governance Aligning leadership through the structures tasked with overseeing identification of a shared vision and driving progress Developing data analytic capabilities to Facilitators Prioritizing care coordination through identify opportunities for improvement of ACO partnerships with community health and progress toward goals Implementation and service organizations Securing financial investments for care delivery transformation • aligning leadership through the identification of CONCLUSION a shared vision; FUHN’s performance period began on January 1, • establishing a strong governance structure 2013. As the ACO evolves, its members will continue tasked with overseeing and driving progress;20 to address the challenges of: procuring sufficient resources; communicating, decision-making, and stan- • developing a unified strategy for using data dardizing across sites; and managing cross-site varia- to routinely measure progress and identify tion. To address these challenges and advance toward improvement opportunities; the provision of lower-cost, higher-quality care, FUHN • prioritizing the development of care coordina- plans to rely on the strength of its leaders; its partner- tion infrastructure, which may involve commu- ship with Optum; the diversity of its member organi- nity partnerships to overcome size and resource zations; and the growing ability of the health centers limitations or collaboration with an administra- to learn from one another and jointly problem-solve. tive services group such as Optum; and Success in the HCDS demonstration could lead FUHN to pursue additional ACO contracts with payers other • securing financial investments for care delivery than the state, though for now FUHN remains focused transformation. on its Medicaid contract.21 FUHN looks forward to full implementation of its new care delivery model and sees accountable care as a pathway to providing high- quality, low-cost care in the safety net. 12T he  C ommonwealth F und A bout T his S tudy In late September 2012, a team from The Dartmouth Institute for Health Policy & Clinical Practice conducted a five-day site visit with each of the 10 members of the Federally Qualified Health Center Urban Health Network (FUHN) in Minneapolis–St. Paul, Minnesota. Information in this case study was collected through in-person interviews with the CEOs, medical and finance directors, and quality personnel at the 10 FQHCs. The site evaluation team also attended meetings with FUHN’s Clinical Quality Improvement Committee; Financial Management and Reporting Committee; board of directors; and administrative services partner, Optum. Additional information was derived from a review of internal and external documents, including FUHN’s response to the Minnesota Department of Human Service’s request for proposals, press releases, relevant presen- tation slides, annual reports, job descriptions, and committee charters. N otes 5 D. M. Berwick, T. Nolan, and J. Whittington, “The Triple Aim: Care, Health, and Costs,” Health Affairs, May/June 1 2008 27(3):759–69. FUHN is participating in an upside-only risk arrangement with the state; therefore the coalition is not liable for 6 costs that exceed the established cost benchmark. Laws of Minnesota 2008, Ch. 358, Art. 2. 7 2 Under the Health Care Delivery Systems (HCDS) McCarthy, How, Schoen et al., Aiming Higher, 2009. demonstration, patients who receive the plurality of their 8 R. Degelau, Minnesota’s Federally Qualified Health primary care services at one of FUHN’s member clinics Centers (Minneapolis: Minnesota Association of Com- will be attributed to the ACO. FUHN is responsible for munity Health Centers). Available at http://www.health. the overall cost and quality of its attributed patients’ care, state.mn.us/healthreform/ship/events/degelauppt.pdf. The regardless of whether the ACO delivers the services. At- FQHCs have tailored their workforce and services to be tributed patients face no network restrictions and are free responsive to the unique characteristics of the commu- to receive care outside of FUHN’s member clinics. The nities and cultures they serve. For example, 60 percent demonstration’s covered beneficiary population includes of the 250 employees at West Side Community Health all Medicaid fee-for-service and managed care beneficia- Center are bilingual and bicultural. Similarly, at United ries, except those who are dually eligible for Medicare Family Medicine all clinic signs are posted in English, and Medicaid. Spanish, Russian, Hmong, and Somali. 3 Strong governance refers to the design and commitment 9 In the Minneapolis–St. Paul area, four insurance plans of FUHN’s board of directors and committees. Each (Blue Cross Blue Shield, HealthPartners, Medica, and committee has a charter that defines its purpose, outlines UCare) and three multihospital systems (Allina, Fairview, key responsibilities, and establishes committee member- and HealthEast) dominate the market. The January 2013 ship representative of all 10 FQHCs. In addition to clear merger of HealthPartners and Park Nicollet is the most roles and responsibilities, FUHN’s governance has active recent indication of Minnesota’s consolidated market- commitment and engagement of participants, including place and marks a growing trend of strategic partnerships regular meeting attendance and active participation from between different types of health care organizations. The committee members. new organization, which goes by the name HealthPart- 4 D. McCarthy, S. K. How, C. Schoen, J. C. Cantor, and D. ners, is both a health insurer and a health care delivery Belloff, Aiming Higher: Results from a State Scorecard system that includes five hospitals. See http://www. on Health System Performance, 2009 (New York: The healthpartners.com/public/newsroom/newsroom-article- Commonwealth Fund, Oct. 2009). In Minnesota, 91.6 list/1-1-2013.html for HealthPartners January 2013 press percent of the adult population is insured, owing to the release. Among the more than 50,000 Medicaid benefi- state’s strong base of employer-provided insurance and ciaries served by the 10 member organizations of FUHN, large, state-sponsored programs that subsidize coverage approximately 70 percent are enrolled in managed care for the poor and near-poor, including Medical Assistance plans. (its Medicaid program) and MinnesotaCare (the state’s public insurance program for the near-poor). E stablishing a C oalition to P ursue A ccountable C are in the S afety N et 13 10 The four-person planning committee has since evolved 18 To become accountable for the quality of its patients’ into FUHN’s Executive Committee, a subset of the board care, FUHN must overcome technical challenges in of directors that led contract negotiations with the state. collecting performance measures specific to the HCDS 11 demonstration. Although FQHCs have long reported FUHN became a legal entity later that month through the on performance as required by the Bureau of Primary repurposing of the Neighborhood Health Care Network, Care, the demonstration uses measures from Minnesota’s the subset of urban FQHCs and community clinics that Statewide Quality Reporting and Measurement System met regularly to coordinate efforts around emergency (Minnesota Statutes 62U.02; MN Rules, Chapter 4654). preparedness, billing support, and a limited number of Performance measurement and reporting may present local quality improvement initiatives. Eight of FUHN’s greater difficulty for the less-resourced FQHCs. 10 member organizations were already members of the Neighborhood Health Care Network. The organization 19 Although the coalition does not include a hospital part- submitted a Doing Business As (DBA) application in or- ner, FUHN’s total cost of care will include inpatient and der to repurpose the Neighborhood Health Care Network emergency care services. Because of this, FUHN is work- to support the activities of the demonstration project. ing to improve care transition management and hopes to FUHN was approved as a legal entity by the state of Min- reduce preventable readmissions and emergency depart- nesota after the FQHCs not participating in the FUHN ment visits through strengthened community partnerships initiative resigned and the two FQHC Look-Alikes (Axis with local hospitals and specialists. Medical directors Medical Center and United Family Medicine) joined the and performance improvement advisors plan to work repurposed organization. with clinic staff to implement methods for ensuring that 12 primary care physician designations are understood by FUHN is classified as a virtual delivery system under the hospitals caring for FUHN’s patients. HCDS demonstration. In the demonstration’s request for proposals, the Minnesota Department of Human Services 20 Strong governance refers to the design and commitment defines a virtual delivery system as “primary care provid- of FUHN’s board of directors and committees. Each ers and/or multispecialty provider groups that are not committee has a charter that defines its purpose, outlines formally integrated with a hospital or integrated system key responsibilities, and establishes committee member- via aligned financial arrangements and common clinical ship representative of all 10 FQHCs. In addition to clear and information systems.” roles and responsibilities, FUHN’s governance has active 13 commitment and engagement of participants, including West Side Community Health Services, Inc., “Response regular meeting attendance and active participation from to Request for Proposal,” Letter to Minnesota Depart- committee members. ment of Human Services Health Care Administration, Nov. 4, 2011, St. Paul, Minnesota. 21 Because the core of the clinics’ patient population is un- 14 insured or enrolled in Medicaid, FUHN does not antici- “Health Care Homes Certification Assessment Tool,” pate pursuing additional ACO contracts in the immedi- Minnesota Department of Health, http://www.health. ate future. Currently, the commercial payer mix varies state.mn.us/healthreform/homes/index.html. widely at each FQHC, and only United Family Medicine 15 sees a significant number of Medicare beneficiaries (ap- FUHN’s contract negotiations with the state ended in proximately 13 percent of their overall patient popula- January 2013. The exact terms of the final contract tion). With upcoming Medicaid expansion and the open- (including the performance measures used to determine ing of state insurance exchanges under the Affordable eligibility for shared savings) have not been released. Care Act, however, the payer mix at the FQHCs could 16 Three administrative services organizations other than change significantly. This may affect FUHN’s decision to Optum expressed interest in partnering for the demonstra- participate in additional ACO contracts. FUHN will do so tion. One of these was willing to take on similar financial only if regulatory concerns, such as antitrust laws, can be risk. overcome. 17 For example, People’s Center Health Services is located within five blocks of a high-density housing complex that is home to over 10,000 Somali refugees and immigrants. The FQHC operates disease-specific programs targeting the needs of its Somali patients, including programs for hepatitis and post-traumatic stress disorder. 14T he  C ommonwealth F und A bout the A uthors Karen E. Schoenherr is a health policy fellow at The Dartmouth Institute for Health Policy & Clinical Practice. Her research examines the formation and development of Accountable Care Organizations and the impact they may have on vulnerable populations and the safety net. Previously, Ms. Schoenherr worked in the social services sector as a caseworker for homeless families and individuals. She holds a bachelor’s degree in social epidemiology from Harvard University. During her undergraduate career, Ms. Schoenherr worked extensively with patients at community health centers to connect them to community resources. Aricca D. Van Citters, M.S., has more than 14 years of experience conducting qualitative and quantitative pro- cess and outcomes evaluations in a variety of health care settings. Her recent research projects focus on under- standing the formation and performance of accountable care organizations; developing an integrated care path- way for hip and knee arthroplasty that considers safety, efficacy, efficiency, and the patient experience of care; and understanding factors that contribute to rapid improvement in hospital quality, costs, and mortality. She has provided coaching to hospitals around methods to improve the patient experience of care and has provided technical assistance to numerous organizations in implementing evidence-based interventions. Ms. Van Citters received a master of science degree in evaluative clinical science from Dartmouth College. Kathleen L. Carluzzo is research manager for Patient Reported Measures at The Dartmouth Institute for Health Policy & Clinical Practice, where she is also pursuing a master of science degree in health services research. Her research is focused on population health, including evaluation of accountable care organizations and patient- reported outcome measures. She has experience performing qualitative and quantitative data collection and analysis. Savannah Bergquist, M.S., is a health policy fellow at The Dartmouth Institute for Health Policy & Clinical Practice. In this role, Ms. Bergquist contributes to implementation and analysis of the National Survey of Accountable Care Organizations (NSACO), including tracking the growth and spread of accountable care orga- nizations and analyzing issue areas such as physician compensation and post-acute care. Prior to joining The Dartmouth Institute, Ms. Berguist received her master of science degree in health and population studies from the London School of Economics and her bachelor's degree in political economy from Georgetown University. E stablishing a C oalition to P ursue A ccountable C are in the S afety N et 15 Elliott S. Fisher, M.D., M.P.H., is director at The Dartmouth Institute for Health Policy & Clinical Practice and the James W. Squires Professor of Medicine and Community and Family Medicine at the Geisel School of Medicine at Dartmouth. He is also codirector of the Dartmouth Atlas of Health Care and a member of the Institute of Medicine of the National Academy of Sciences. Dr. Fisher’s early research focused on exploring the causes and consequences of the twofold differences in spending observed across U.S. regions and on the development and testing of approaches to performance measurement and payment reform that can support improvement. His cur- rent policy work focuses on exploring the determinants of successful formation and development of accountable care organizations. Dr. Fisher received his undergraduate and medical degrees from Harvard University and com- pleted his internal medicine residency and public health training at the University of Washington. Valerie A. Lewis, is an assistant professor at The Dartmouth Institute for Health Policy & Clinical Practice. Her work focuses on evaluating the impact of delivery system and payment reform on disadvantaged groups. Dr. Lewis earned doctoral and master’s degrees in sociology from Princeton University. She completed postdoctoral training at the Kennedy School of Government at Harvard University. Editorial support was provided by Martha Hostetter. www.commonwealthfund.org