Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment MARCH 2018 Authors About MacColl at KPWHRI MacColl Center for Health Care Innovation at Kaiser Kaiser Permanente Washington Health Research Institute Permanente Washington Health Research Institute (KPWHRI) is the nonproprietary, public-interest research Katie Coleman, Clarissa Hsu, Heidi Berthoud, center within Kaiser Permanente Washington, a nonprofit Brian Austin, and Ed Wagner health system based in Seattle. Its mission is to improve health and health care for everyone through leading- JSI Research & Training Institute, Inc. edge research, innovation, and dissemination. Within Rachel Tobey, Kiely Houston, Jim Maxwell, KPWHRI, the MacColl Center for Health Care Innovation and Sofia Rojasova has a 25-year history of developing and disseminating Carolyn Shepherd, Leibig Shepherd LLC models to improve care delivery, patient experience, and clinical outcomes, especially for vulnerable populations. Jeff Hummel, Qualis Health For more information, visit www.kpwashingtonresearch.org. Acknowledgments The authors are grateful to the expert advisors and key informants listed in Appendix A for their commitment to About JSI promoting solutions to strengthen the health care safety JSI Research & Training Institute, Inc. (JSI) is a public net. This group provided thoughtful reflections and com- health consulting and research organization dedicated ments, and they gave generously of their time and ideas. to improving the health of individuals and communities Expert advisors were selected for their expertise in health in the United States and around the world. JSI works center operations and financing, policy, primary care, across a full range of public and community health areas, and/or partnerships. They reviewed an early draft and strengthening health systems to improve services — and provided ideas for improvement. The authors are grate- ultimately people’s health. JSI works at local, county, ful for their partnership. Key informants were selected for state, and national levels on advancing safety-net sus- their ability to share insights and best practices related to tainability and supporting more efficient, effective, and delivering high-quality care and addressing social needs equitable health systems. in the context of value-oriented payment programs. Care For more information, visit www.jsi.com/california. was taken to identify a range of high-performing health centers, consortia, and independent practice asso- ciations (IPAs) that represent different sizes, affiliation About the Foundation relationships, and geographic locations. Thanks also to The California Health Care Foundation is dedicated to Bobbie Wunsch and Melissa Schoen for their comments advancing meaningful, measurable improvements in the on a late draft. Finally, much gratitude to Robert Frazier way the health care delivery system provides care to the of KPWHRI, who helped bring this to fruition. people of California, particularly those with low incomes and those whose needs are not well served by the status The authors also acknowledge Kathryn E. Phillips, senior quo. We work to ensure that people have access to the program officer at the California Health Care Foundation, care they need, when they need it, at a price they can for her support in developing this project and paper. afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemak- ers to create a more responsive, patient-centered health care system. For more information, visit www.chcf.org. California Health Care Foundation 2 Contents 4Executive Summary 6Introduction: Advancing the Health Center Mission of Providing High-Quality Care for All in a Value-Based Environment 7A Close Look at California’s Small Health Centers 10Creating High-Quality, Comprehensive Primary Care 11Succeeding Under Value-Based Payment 14Infrastructure: Four Pillars People Care Systems/Strategies Data Business Model 19 Partnerships Partnerships with Community-Based Agencies and Organizations Partnerships with Hospitals Consortia Management Services Organizations and Clinically Integrated Networks Health-Center-Led Independent Practice Associations Partnerships with Health Plans Mergers and Acquisitions Partnering to Succeed: A Road Map for Health Centers 37Recommendations for Organizations That Support Small Health Centers Opportunities for Consortia, IPAs, MSOs, and CINs Led by Health Centers Opportunities for Policymakers, Health Plans, State and/or Regional Associations, and Funders 38 Conclusion 39Case Studies Hill Country Community Clinic Health Center Partners of Southern California and Community Health Systems, Inc. Community Health Center Network Parktree Community Health Center 52Appendix A. Expert Advisors and Key Informants 54 Endnotes Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 3 Executive Summary S ince their inception in the 1960s, community health To help clarify the way forward for small health centers, this centers (CHCs) have provided access to care for paper presents a Model for Advancing High Performance millions of Americans, including some of the most (MAHP) (see Figure 1). Based on research and expert vulnerable individuals and families. As the economic opinion, it describes the actions and infrastructure CHCs environment of CHCs has changed, most recently with will need to thrive in this new environment and contribute the expansion of Medicaid under the Affordable Care Act to a sustainable primary care safety net that achieves the (ACA), these institutions have had to adapt quickly. quintuple aim — better care, better health, lower costs, happier staff, and reduced health disparities. In California, CHCs serve more than 4 million people annually. Many CHCs in California and nationally are As Figure 1 shows, engaging in the actions required experimenting with strategies to improve and expand to achieve the quintuple aim necessitates supportive care, such as finding ways to integrate behavioral health, infrastructure in four major areas: people, care systems/ bolster team-based care, and proactively reach out to strategies, data, and a business model. Infrastructure ele- patients with unmet preventive or chronic care needs. In ments such as meaningful patient engagement in care, tandem, health centers are increasingly participating in well-defined patient panels, and the ability to create value-based payment. These actions require consider- actionable data reports are important to support both able infrastructure, with many components necessary for care transformation and value-based payment. both endeavors. All health centers struggle to put this infrastructure in place, but small health centers — defined For small health centers that are not in a position to cre- for the purposes of this paper as having fewer than 10,000 ate extensive infrastructure on their own, partnerships patients or an annual budget of $10 million or less — face and alliances can be critical. When done well, such col- unique challenges in securing access to capital, building laborations can help health centers fulfill their missions strong data capabilities, and negotiating favorable rates by supporting and supplementing primary care activities with vendors and contracts with health plans. to leverage resources and improve health. Figure 1. A Model for Advancing High Performance (MAHP) ACTIONS A thriving & financially Creating High-Quality Comprehensive sustainable safety net that Primary Care results in: » better care » better health » lower costs Succeeding Under Value-Based Payment » happier staff » reduced health disparities INFRASTRUCTURE People Care Systems/ Data Business Strategies » Data from inside Model » Leadership » Workforce » Patient panels and outside of » Managed care » Care teams primary care expertise » Patient » QI infrastructure » IT infrastructure » Negotiating clout engagement » Responding to » Capacity to » Scale, if bearing create internal/ downside PARTNERSHIPS social needs external reports financial risk beyond PPS California Health Care Foundation 4 This paper presents seven types of partnerships: Individual small health centers may make use of one or many of these partnerships depending on an array of fac- 1.Partnerships with community-based agencies and tors. This white paper provides a detailed review of these organizations (local government and nonprofit). factors, along with the advantages and disadvantages Health centers can offer patients comprehensive of each partnership type. In addition, four case studies care that addresses medical, behavioral, and social highlight the experiences of small health centers partner- needs by partnering with public agencies and ing in these ways. community-based organizations. 2.Partnerships with hospitals. A local hospital part- To be ready for potential partnership opportunities, CHCs nership can serve many functions, including care can take the following concrete steps to get started. coordination; data sharing; access to specialists, lab $$ Assess health center infrastructure. Make an services, and pharmacy services; additional fund- honest assessment of the CHC’s internal infrastruc- ing for staff positions; and potential grants from a ture in terms of people, systems and strategies, hospital community benefit program. data, and business model. 3.Consortia. Consortia can help individual health $$ Understand the local context. Each community centers to monitor and influence policy, engage in operates with different partners and politics. What quality improvement, share best practices, and cen- partnerships are available in the area? Which tralize select nonmedical functions such as training partners are the best cultural fit and most mission or managing volunteers. aligned? What are the managed care contracting 4.Management services organizations (MSOs) and practices in the region? clinically integrated networks (CINs). MSOs and $$ Weigh the options. Not all partners offer the CINs are designed to assist health centers with same breadth, depth, and quality of services, needed nonmedical functions. For some, these regardless of their organizational type. A partner functions extend to collective clinical quality work may be strong in one area but weak in another. and negotiations for incentive payments (upside risk) with payers. $$ Reach out. Starting conversations with potential partners can result in collaborations and part- 5.Health-center-led independent practice associa- nerships that take shape through exploratory tions (IPAs). IPAs allow health centers to contract discussions. collectively for risk-based payments and to distrib- ute savings, if they occur, based on quality and cost $$ Build readiness. Even if a health center is not outcomes of an assigned member population. ready to partner, it can build infrastructure and improve care now. Health centers are undertak- 6.Partnerships with health plans. Partnerships ing a broad range of activities that are achievable with health plans, often in the form of contracts under a prospective payment system (PPS) and for value-based care and payment, such as pay- that also prepare them for value-based pay. for-performance incentives or care management payments, can help health centers secure additional Health centers have a history of working well together on flexibility or revenue to innovate in care delivery. advocacy and other policy-related topics. The demands 7.Mergers and acquisitions. A merger or acquisition of care transformation and value-based payment increase strategy can stabilize health centers by increas- the need for collaboration and partnerships, especially ing economies of scale. The right partnerships can for small organizations. In this dynamic environment, enhance services to the community. partners that bolster a health center’s capabilities will be a key ingredient for success. There are opportunities for consortia, health center-led IPAs, policymakers, health plans, and funders, among others, to support partner- ships and accelerate progress. Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 5 Figure 2. TheACAincreasedCaliforniaHealthCenters’Post-ACA Introduction: Advancing Health Centers in California, Pre- and financialstability. the Health Center Pre-ACA Post-ACA Mission of Providing Uninsured 39% 26% High-Quality Care for patients: (2012) (2014) All in a Value-Based Environment Medi-Cal patients: 39% (2012) 56% (2014) Community health centers (CHCs) provide access to care CA health for millions of Americans, including some of the most center revenue: $1.6B $2.9B vulnerable individuals and families,1 and they have done (2014) (2016) so since their inception in the 1960s. The health care Median environment has changed dramatically in the intervening years, particularly in California, with the advent of man- operating margins: 1.9% 2.8% (2011) (2014) aged care, and, more recently, with the rapid expansion +28% of the Medicaid program under the Affordable Care Act Health center visits increased by: (ACA). Medicaid expansion accelerated the pace of care delivery experimentation2 and ushered in a wave of finan- cial stability for many health centers, with improvement demonstrated across a wide range of indicators (see Total number of health center sites reached 1,454, increasing by: +66% Figure 2).3 Sources: Health Resources and Services Administration, Uniform Data System, 2012-2015. Blue Shield of California Foundation,“ California Community Health Centers: Financial & Operational Performance Analysis, However, this stability may be jeopardized if Medicaid 2011-2014,” 2016, www.caplink.org (PDF). expansion is rolled back or if Medicaid becomes a block grant or per capita capped program. Health centers Additionally, under a wide range of future political sce- would likely see an increase in the number and propor- narios, the shift from volume-based to value-based tion of uninsured patients, and to continue fulfilling their payment is predicted to continue. This is evidenced missions, they may need to do more with less.4 by increased activity in California through pay-for-per- formance programs through Medi-Cal managed care,7 Regardless of these uncertainties, the care delivery inno- state plans to implement Health Homes8 in 2018, and vations that CHCs have undertaken during this period continued explorations of a health center Alternative — including proactive, population-based care; behav- Payment Methodology (APM). The changes to payment ioral health integration; and team-based care — are likely represent a fundamental shift for health centers that have to stay. Research continues to emphasize the importance long relied on volume-based reimbursement through of a strong primary care system and the crucial role CHCs the prospective payment system (PPS). New payment play in improving health.5, 6 methodologies promise more flexibility, but they require health centers to assume greater responsibility for their patients’ care experiences and health outcomes. CASE STUDIES Included at the end of the report are four case studies from diverse geographic regions across California. These case studies show how small health centers have taken advantage of partnerships to enhance their ability to sustain high-quality, comprehensive care for their patients and/or better position themselves for participation in value- based payment. They represent the wide range of partnership options discussed in this paper. The sites were recommended as compelling examples of relationships that can support small health centers. California Health Care Foundation 6 California’s CHCs, which serve more than 4 million patients annually, must evolve to keep up with these Methods changes.9 Many of these organizations are accustomed This paper is based on expert opinion and research, to adapting to change; however, the pace and breadth of including summary findings from a semi-structured change now confronting both care delivery and payment literature review of 113 articles and an environ- infrastructure raises the stakes. Small health centers — mental scan. In addition, executive teams from 22 defined in this paper as having fewer than 10,000 patients “bright spot” organizations were interviewed; these or an annual budget of $10 million or less — may face included small CHCs in California and throughout particular challenges succeeding under emerging value- the United States, independent practice asso- ciations (IPAs), and consortia. Finally, an all-day based payment models and the practice transformations meeting with a team of expert advisors from across these models require. the health care landscape was convened to provide feedback on early analysis and generate new ideas This paper presents a Model for Advancing High on how to best support small health centers and Performance (MAHP) that describes the capabilities and strengthen the capacity and efficiency of the primary infrastructure California CHCs will need to thrive in this care safety net. new environment (see Figure 1, page 4). The paper spe- cifically explores how partnerships can help small health centers advance their care and contribute to a sustain- able primary care safety net that achieves the quintuple aim — better care, better health, lower costs, happier A Close Look at staff, and reduced health disparities.10 California’s Small The following sections of this paper explain the content Health Centers and activities set out in the MAHP model: This paper focuses on what small health centers need to have and what they have to do to thrive in the changing $$ A close look at California’s small health centers health care environment.11 In the absence of a consensus $$ What it takes to create high-quality, comprehen- definition of a “small” health center, this paper defines it sive primary care that achieves the quintuple aim as having fewer than 10,000 patients or an annual budget of up to $10 million. Defining size is complex because a $$ New skills needed to financially sustain care and health center can be variously measured by number of succeed under value-based payment patients, total budget, or number of providers. Each of $$ Infrastructureelements needed to support both these descriptors is a continuum, and the presence of care and payment: people, care systems/strate- extreme outliers makes creating natural groupings diffi- gies, data, and business models cult. For example, in 2015, one California health center served 656 patients whereas another served 188,122. $$ Partnerships that can support small health centers Further, size is not static and cannot be understood in to build or share those critical infrastructure isolation; it is in dynamic relationship with other factors elements such as organization maturity, number of physical loca- $$ A road map for small health centers as they con- tions/sites, and total population. Figure 3 shows how sider potential partnerships small health centers compare with medium and large health centers in terms of patients served and budget $$ Recommendations for organizations that support size (see page 8). health centers $$ Case studies demonstrating how various partner- Approximately 44% of California health centers meet ships are supporting small health centers this paper’s definition of “small” (78 health centers by patients served and 77 by budget). These two groups are not all the same health centers, although there is overlap between them (see Figure 4, page 9). Among these two groups of health centers, approximately 85% (66 health centers) overlap and fit into both categories of small. Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 7 Figure 3. Distribution of California Health Centers, by Patients Served and Budget (N=178*) UNDUPLICATED PATIENTS BUDGET (IN MILLIONS) *180 identified health centers excluding Community Medical Wellness Centers USA and Behavioral Health Services. These two health centers were missing data — either number of patients or budget. Source: Unaudited financial data obtained from the Health Resources and Services Administration’s Bureau of Health Professions, the Office of State Health and Planning Department, 2015 and 2016. California Health Care Foundation 8 Figure 4. Identifying California’s Small Health Centers About half of all 178 health centers (89) that were studied by Patients Served and Budget meet either criterion. Together, these small health cen- ters serve more than 350,000 Californians, approximately 9% of all of the state’s health center patients. 89 Health Centers meet either criterion Small health centers provide vital access to underserved Patients Served ≤ 10,000 Budget ≤ $10M communities throughout California. Some offer care for (78 health centers) (77 health centers) distinct ethnic communities in urban settings, others are new access points, and still others serve rural areas. Budget ≤ $10M & Although some of these organizations are thriving, many Patients Served ≤ 10,000 (66 health centers) face challenges with regard to capacity and sustainability, two concepts explored in more detail in this paper. Larger health centers outperform smaller ones on a range of financial measures associated with viability, and those Patients Served ≤ 10,000 & Budget ≤ $10M & Budget > $10M Patients Served > 10,000 that perform better financially may also score higher (12 health centers) (11 health centers) on some standardized measures of clinical quality.12, 13 However, additional research is needed to understand the Source: Unaudited financial data obtained from the Health Resources and Services Administration’s Bureau of Health Professions, the Office of State relationships among size and other important indicators, Health and Planning Department, 2015 and 2016. such as patient experience, per capita cost, and provider/ staff satisfaction. As shown in Figure 5, large health cen- ters (by patients served) in health-center-led IPAs and consortia are more likely to have internal resources for quality improvement (QI) activities and participate more Together, California’s small health centers often in care transformation recognition programs such as the Patient-Centered Medical Home (PCMH) Recognition serve more than 350,000 people. Program of the National Committee for Quality Assurance (NCQA). (This pattern is similar using the budget cutoff; among health centers with a budget up to $10 million, 12% report PCMH recognition, 13% participate in CHC- led IPAs, and 75% participate in consortia.) Figure 5. Patient-Centered Medical Home Recognition and Participation in Selected Partnerships, by Patients Served Participation in CHC-led PCMH Recognition Professional Risk IPA Participation in Consortia Patients Served ≤ 10,000 (n = 78) 10% 13% 76% Patients Served 44% 30% 90% > 10,000 (n = 100) Note: CHC is community health center. IPA is independent practice association. Source: Unaudited financial data obtained from the Health Resources and Services Administration’s Bureau of Health Professions, the Office of State Health and Planning Department, 2015 and 2016. Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 9 Creating High-Quality, “Never before in our nation’s history has there Comprehensive been such a large-scale attempt to change Primary Care clinical health care delivery while placing the In the 60 years since the founding of the CHC move- patient in the forefront of redesign efforts.” ment, much has been learned about how to deliver care — Ben F. Miller et al. that improves health, addresses social and behavioral “Payment Reform in the Patient-Centered needs, and puts patients at the center of their care.14-16 Medical Home: Enabling and Sustaining Research has demonstrated the centrality of primary care Integrated Behavioral Health Care” American Psychologist, 2017 in creating more effective and efficient health care sys- tems17, 18 and has shed light on the core components of primary care — first-contact care, continuity of care, com- The provider team relationship with patients and their prehensive care, and coordination of care.19 Primary care families is the core of all value in the health system. practices, including many CHCs, have experimented Finding ways to strengthen that relationship by support- with moving from a largely reactive, physician-centered ing long-term continuity of care is critical to addressing model of care based on individual face-to-face office vis- the social and medical needs of patients.23 The box its to a more proactive, team-based approach based on below outlines an emerging consensus — from across addressing the health needs of a patient population. This the health care sector, including commercially insured move has resulted in substantive improvements in care, practices and CHCs of varying size — about how best to especially for people living with chronic illness.20 Care bolster that relationship. delivery transformation initiatives like the Chronic Care Model or PCMH have helped to spread these changes Community health centers are committed to providing beyond the vanguard. Recent studies of high-perform- access to preventive, chronic, and acute care for their ing clinics are providing more granular insights into how patients. Ensuring that all patients get the care they need high-quality, comprehensive primary care is created.21, 22 can be daunting; one study estimated it would take 22 hours per day to deliver all the care a panel of 2,500 patients would need.24 Team-based care enables a wider We know that the provider team range of professionals to be involved during and between visits, better supporting patients and enabling health relationship with patients and their centers to manage complex acute needs with targeted resources. Having a defined panel of patients allows the families is the core of all value in the care team to use data and identify patient care gaps, and to reach out to those who may need follow-up or are due health system. for important preventive or chronic care services. It also fosters a long-term relationship between care teams and Creating High-Quality, Comprehensive Primary Care In collaboration with informed, activated patients, a prepared, proactive practice team does: » Planned Care » Population Management » Medication Management » Referral Management » Self-Management Support » Clinic-Community Connections » Behavioral Health Integration » Care Management » Oral Health » Communication Management » Enhanced Access California Health Care Foundation 10 patients. When patients come into the clinic for care, the $$ Payers are interested in authentic practice transfor- team is ready to address their needs, knowing both the mation and are willing to pay primary care differently patients’ priorities and what labs or procedures are due. to achieve these goals.32 Care teams are prepared to offer and follow up on refer- $$ Both practice change and payment reform require rals to other medical specialties and leverage oral health, new capabilities, infrastructure, and ways of working, behavioral health, and connections to community ser- much of which is not currently reimbursable. This is a vices to address other social needs. Care teams can also challenge for small health centers or those with nar- address polypharmacy and medication reconciliation. row operating margins.33 Finally, they take a proactive role in engaging patients as equal partners in care, facilitating behavior change and self-management support. Succeeding Under For health centers in which these activities are not regu- larly occurring, the research sheds light on how to best Value-Based Payment undertake improvements. Experimentation has led to Health centers have long received the majority of their some important insights: revenue based on volume of visits through the PPS. Yet new payment reforms emphasize the value of care rather $$ Practicesand health centers can change to imple- than volume of services. Though health centers continue ment the features of high-performing primary care.25 to struggle with broadening the care team to include $$ There is a sequence of changes that facilitates trans- staff who are not eligible for reimbursement through the formation,26 specifically: PPS, widespread value-based payment is changing that equation. Value-based payment for primary care comes $$ Engage leadership at all levels. in three main forms for health centers: $$ Match providers and patients together to create $$ Additional payment — or in some cases potential panels so patients have a continuous relationship financial loss — contingent on outcomes (e.g., pay with the care team of their choice. Regularly adjust for performance and/or financial arrangements with the size and complexity of those panels to make 27 both upside and downside risk)34 good access and continuity possible.­­ $$ Supplemental payment for providing care manage- $$ Choose and use a QI strategy, including putting in ment and coordination services that are not included place a data collection infrastructure that supports in the base payment proactive population outreach, panel manage- ment, and creative improvement. $$ Conversion of the PPS base payment from a volume- based payment into a capitated equivalent under $$ Pair medical assistants with providers. Create a an APM that meets federal requirements for being core team that works together regularly to ensure voluntary and at least equal to what would have been that the social and medical needs of patients received under PPS are met. $$ Systematicallybuild care processes to ensure the Both the California Primary Care Association (CPCA) and conduct of the activities shown in box on page 10. the National Association of Community Health Centers (NACHC) have articulated how these multiple forms of $$ Many of these changes require a long-term commit- value-based payment could work together in a com- ment to training and improvement.28 prehensive health-center payment reform model.35 $$ When clinics implement these features well, patients In recent years, both the Medicare Access and CHIP are healthier and more satisfied with their experi- Reauthorization Act of 2015 (MACRA) and the American ence, provider burnout declines, and inappropriate Academy of Family Physicians have put forward similar and expensive utilization is reduced.29 Incomplete or multilayered alternative payment models for primary symbolic implementation — such as pursuing PCMH care.36-38 Although each of these types of payment recognition without truly transforming care practices reform could be pursued independently, together they — does not result in meaningful changes30 and can can provide a health center with increased flexibility to destabilize organizations.31 deliver care, new resources for care management and Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 11 coordination services, and incentives for achieving cost new payments to health centers for care manage- and quality outcomes. ment for Medicare beneficiaries.42 California is also slated to begin a phased implementation of Health The goal of exploring payment reforms for health centers Homes in 29 counties starting in July 2018. Under is to create financial structures that incent and support Health Homes, plans will contract community- improved health and reduced costs. Similar to other based care management entities to manage and primary care payment reform models aimed at improv- coordinate care for individuals with multiple chronic ing outcomes,39 the notion of pairing multiple reforms conditions in exchange for supplemental payment. together could support high-quality, comprehensive care In addition, in both instances, these payments are both within the current PPS system and under a scenario considered supplemental to PPS. without PPS protections. Explicitly or implicitly, payment demonstrations are operating on the assumption that 3.California health centers and the state proposed high-quality, comprehensive primary care — facilitated in a Federally Qualified Health Center (FQHC) APM part by payment reforms — will respond to most social demonstration that would translate PPS rates and medical needs for patients and will involve the coor- into PPS-equivalent per-member-per-month dination of care across settings. (PMPM) payments for health centers volunteer- ing for the demonstration. The goal was to align Many California health centers are pursuing or are partici- health center financial incentives with the managed pating in all three categories of payment reform depicted care system and give health centers more flexibility in NACHC and CPCA comprehensive payment reform to use nontraditional providers and modalities of models: care to address patient needs. It was essential to the state that health centers also bear some financial 1.Most California health centers are participat- risk. In 2017, the Centers for Medicare & Medicaid ing in at least one of two arrangements that tie Services indicated that the state’s desire to have payment directly to outcomes. First, 18 of 22 health centers bear even limited financial risk could managed care Medi-Cal plans have implemented or be done only through a Medicaid waiver, which was plan to implement pay-for-performance programs not pursued. CPCA and interested health centers with their providers.40, 41 Second, health-center- continue to explore future directions for payment led professional risk-bearing IPAs are providing reform that do not involve waiving PPS protections. incentive payments to member health centers for performance on quality outcomes and total cost of The payment reform initiatives described above show professional services. that value-based payment is already here for many health centers in California, and they provide the opportunity 2.Additional dollars for care management and to understand how participation in value-based pay coordination services are a new and growing changes life day-to-day activities for health centers. To aspect of payment reform for California health create high-quality, comprehensive primary care and to centers. For instance, Medicare recently instituted succeed under value-based payment (see box), health Succeeding Under Value-Based Payment » Population-based mindset based on members » Care management/coordination to reduce costly hospital utilization » Value of care articulated using data California Health Care Foundation 12 centers must do some things differently from how they $$ Articulating the value of the care provided, based have done them in the past. These actions include: on data. Delivering high-quality, comprehensive primary care is necessary but not sufficient for suc- $$ Shifting to a population-based mindset based on cess under value-based payment. Health centers members, not just patients. Within California’s ubiq- must be able to prove that their care results in better uitous managed care context, value-based payment outcomes. Depending on the payment arrange- requires health centers to manage the health of an ment, such outcomes could include quality outcomes assigned member population, regardless of whether (often measured by Healthcare Effectiveness Data those members come into the health center for pri- and Information Set [HEDIS] scores), reduced total mary care. This includes understanding who assigned costs (via reducing utilization of high-cost services), members are and then proactively reaching out to and improved patient experience (often measured by ensure that all members have received preventive the Consumer Assessment of Healthcare Providers screenings, disease management, and appropriate and Systems [CAHPS], a patient satisfaction survey referrals to specialists or social services. Most pay-for- required by managed care Medi-Cal plans). Being performance contracts calculate incentive payments able to track, improve upon, and report outcomes based on quality outcomes and sometimes hospital requires increased sophistication around data analyt- utilization rates for all assigned members. ics. It also requires being intentional and systematic about measuring and improving the effectiveness of $$ Providing care management and coordination interventions that have long been part of the fabric services for the purpose of reducing costly hos- of health centers but in a variable or fluid way (see pital utilization and preventable morbidity. Many Response to Social Needs sidebar on page 16). health centers have long provided care coordination and some care management for patients between visits. Value-based payments, such as supplemental payment under Health Homes, require that provid- ers demonstrate to the state and managed care Delivering high-quality, plans that this payment reform results in reduced hospitalizations, skilled-nursing facility stays, and comprehensive primary care emergency department visits. For many health centers, this means expanding their care manage- is necessary but not sufficient ment and coordination skillsets and workforce to be able to stratify their population and then provide for success under value-based intensive care management services to individuals at the greatest risk for experiencing high-cost utiliza- payment. Health centers must tion. This also means a health center must have the be able to prove that their care real-time data and processes in place to respond when a member goes to the emergency department results in better outcomes. or the hospital. For example, whether a health center receives supplemental care management payments, has a shared savings contract, or participates in a professional-risk-bearing IPA, being able to obtain and act on admission/discharge/transfer (ADT) data from hospitals becomes an essential capability. Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 13 Infrastructure: Workforce recruitment, retention, and training. These Four Pillars are essential to developing the care teams, workflows, and analytics required to create high-quality, compre- Creating high-quality, comprehensive care and succeed- hensive primary care and succeed under value-based ing under value-based payment are not independent payment. Although they can be challenging for all health efforts. In fact, there are four major areas — or pillars — centers, workforce issues can be particularly hard for small of infrastructure that health centers need to support both organizations. With limited patient volume for primary care and payment: people, care systems/strategies, data, care and behavioral health, small health centers may not and business model (see box below). Some health cen- be able to afford the array of skilled staff needed (e.g., ters may need to strengthen these elements or develop a full-time diabetes care manager). Thin operating mar- them from scratch. For small health centers that are not gins make it difficult to create competitive compensation well positioned to strengthen or develop infrastructure packages that attract quality leadership and providers, on their own, partnerships can play a key role. The four and these margins may not be able to support full-time pillars can be broken down as described below. staff in key roles, such as a chief technology officer (CTO). Attracting talent is particularly challenging in rural areas. Training presents another challenge; sending providers People and staff to a training can mean foregoing critical rev- Leadership. Leadership is essential for creating the kind enue, whereas building in-house training expertise may of change necessary to improve care and succeed under be difficult to sustain. value-based payment.43 For small health centers with limited administrative resources, organizational leaders Engaging patients. Actively engaging patients in the must do it all — champion improvement and maintain a design, improvement, and governance of the health cen- strategic vision while managing day-to-day operational ter — as well as in the decisions that impact their own demands. A notable shared characteristic of the high- care — is essential to good care and payment reform.44 performing small health centers interviewed as part of Patients can help prioritize organizational changes as this project was the presence of an informed and creative members of focus groups or ongoing quality-improve- leader — or team of leaders — who were meaning- ment teams. They can participate in governance as fully engaged in continuous learning and championing members of boards. Health centers that have developed improvement in care and the patient experience. These the capacity to engage patients at multiple levels are leaders also had a long-term strategy that incorporated able to better invest limited dollars in ways that address financial creativity, ensuring that resources were in place patient needs. For example, patients who have strong to sustain the gains they were making. relationships with their care teams are less likely to use Infrastructure What health centers need to have to support care and payment redesign People Care Systems/ Data Business Model » Leadership Strategies » Data from inside » Managed care » Workforce » Patient panels and outside of contracting primary care expertise » Patient » Care teams engagement » IT infrastructure » Negotiating clout » QI infrastructure » Capacity to » Scale, if bearing » Responding to create internal/ downside financial social needs external reports risk beyond PPS California Health Care Foundation 14 the emergency department and other expensive down- QI infrastructure. Teams need a strategy for making stream services.45 Partnerships may be helpful in building change. Choosing and using a QI strategy (e.g., Lean, these capacities, especially for small health centers with Six Sigma, and Model for Improvement) is essential to limited administrative overhead. improving care. Along with leadership, care teams, and patient panels, QI infrastructure is one of the four building blocks of high-performing primary care, the Care Systems/Strategies foundation for value-based pay.46, 47 Working closely with Patient panels. Prioritizing health outcomes and pre- other health centers to share best practices and leverage paring for value-based payment means shifting toward external QI expertise can be transformative, especially for proactive care for populations — rather than the tradi- small health centers without an in-house QI department. tional reactive mode. Health centers work together with See Case Studies 2 and 3 for more on how health centers patients to define panels so that patients and care teams leverage partnerships to build QI capacity, improve care, recognize each other as partners in care. Under value- and generate additional revenue. based payment, this includes reaching out to patients who have been assigned to the health center by a Responding to behavioral and social needs. health plan. When a patient needs care, health centers Comprehensive care means responding to the most promote continuity by scheduling patients with their pro- common needs of patients.48 For safety-net health cen- vider team as often as possible. Access is preserved by ters, that involves addressing behavioral needs around closely monitoring panel size and composition. Thinking mental health and substance use as well as connect- in terms of patient panels is a radical change for many ing patients with social services that focus on housing, health centers, but it is critical to achieving both quality employment, and food security. Because patients’ health and financial success. Without partners, it can be hard and well-being are often deeply impacted by poverty, for health centers with low patient volume to justify the racism,  poor housing, lack of education, and limited technology and time investment needed to initiate or job opportunities, many health centers view responding maintain patient panels. to patients’ social needs as central to their care model despite limited ability to bill for these services through Care teams. This work requires a team effort. In fact, for traditional fee-for-service mechanisms. health centers to compete for payment or to improve care, clinicians and administrative staff must contribute The expectation of health centers to systematically meaningfully to patient care activities, be willing to take respond to behavioral and social needs is increasing on new work and new roles, and spend time meeting and as more is known about the impact of social needs on coordinating with one another. In payment models that health, and as providers “go upstream” to intervene in give providers additional flexibility to provide care, using the hopes of improving health. Health plans are becom- a well-defined care team to support patients can be both ing involved in identifying  and addressing patients’ financially sound and patient centered. Small health cen- social needs as means to reduce the long-term cost of ters that find it difficult to recruit and support behavioral care.  One CHC leader with years of experience taking health counselors, care management nurses, and clini- financial risk advised health centers interested in pur- cal pharmacists can experiment creatively with sharing a suing risk-based payment to view working to address single staff member between sites, cross-training existing patients’ social needs as a prerequisite for risk-bearing staff, or leveraging alternative visit types like phone or because addressing social needs can control costs and virtual visits. result in better quality outcomes. For small health cen- ters, partnering may be crucial to addressing patients’ social and behavioral needs. Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 15 Response to Social Needs Services to address patients’ social needs are of great interest to health centers. Best practices have not yet coalesced, but a great deal of experimentation is going on. Because patient populations are diverse, and health centers vary widely in size, funding sources, and location, there is a range of approaches for addressing social needs. Activities in urban areas include partnering with a local gang outreach organization to implement a mobile health unit, and developing relationships with opioid assistance/needle exchange sites, homeless shelters, and supportive hous- ing to deliver health care at these sites. Rural health centers are addressing the barrier of distance to care, including home-to-clinic transportation and community-based mental health and primary care outreach. Key informants described a range of services they provide to address patients’ social needs. These include: $$ Linkage services like transportation, translation, and benefits enrollment $$ Housing, rental assistance $$ Literacy, tuition scholarships, backpack programs $$ Legal advocacy and immigration services $$ Nutrition, food pantry $$ Substance abuse treatment $$ Funeral planning services Some health centers are trying universal screening for social needs or adverse childhood events; referrals are then made to external agencies or more formal partnerships through regular deployment of a mobile unit to a social ser- vice agency. Others are trying full co-location and integration with social service providers. Health centers are positioned to play a key role in building the field’s understanding of the value of social needs interventions. Still required are systematic collection and reporting of social needs data and solid documentation of interventions and their impacts on health. These data could help shape care, payment, and policy. Data structured data reflecting the strategic priorities of the Data from inside and outside primary care help to health center. (These forms might include the Patient bridge some of the most costly and dangerous gaps in Health Questionnaire [PHQ-9], cardiovascular risk calcu- medical care — between the primary care provider and lation, asthma control test, and SBIRT [Screening, Brief the hospital, and between the lab and the specialist. Intervention, and Referral to Treatment] forms.) Closing Comprehensive primary care and value-based payment such care gaps can help a health center perform bet- models envision that data from within primary care will ter on pay-for-performance measures and prove the be used for clinical decision support to help clinicians see value of primary care services to payers in negotiating gaps in care for the patients on their daily schedule, as for supplemental payment. Value-based payment that well as for members who may be assigned but not yet aligns financial incentives with reducing total cost of care seen. Clinical decision support can be used to improve requires that health centers also use data from outside cancer screening,49 immunization,50 and chronic illness primary care to identify high-risk patients, especially dur- management.51 ing care transitions, to ensure linkage with primary care for follow-up and care management. Examples of clinical decision support that support all members of the care team include a dashboard display- Information technology infrastructure. Comprehensive ing each patient’s care gaps used by clinical assistants primary care under value-based payment requires infor- when preparing for a huddle,52 templates prompting mation technology (IT) infrastructure that optimizes clinical assistants when rooming a patient to document electronic health records (EHRs) and population health information that merges with the clinician’s chart note,53 management systems and that facilitates data interfaces and data entry forms to gather condition-specific with other providers. This allows for communication with California Health Care Foundation 16 respect to referrals or knowing when a patient is going Business Model to be discharged from the hospital. IT infrastructure may Because most health centers still receive the major- include clinical data stored in a reporting server or cloud- ity of their revenue through the PPS, making wholesale based data warehouse that is accessible via robust and changes to care delivery and investing in infrastructure flexible analytics software. Small health centers that lack can be difficult and financially risky. Going forward, health the economies of scale needed to diffuse the upfront and centers can benefit from expanding their business model ongoing costs of IT infrastructure may look to partnering from one relying largely on PPS to one that leverages to achieve their goals. value-based payment in order to: $$ Change care delivery, such as adding intensive Analytic capacity to create internal and external care management at the primary care level reports. Health centers benefit from the ability to gen- erate meaningful information from data at the provider $$ Sustain high-quality, comprehensive care services and patient level for guiding care, QI, and reporting over where PPS does not various time periods and for different patient popula- $$ Build capacity in an organization so that it can take tions. Data should feed into an organized QI strategy. on additional value-based pay arrangements and/ To be helpful in value-based payment, health centers or perform better under value-based payment need the data and the analysts to understand and track contracts assigned members by health plan and to monitor and act upon clinical quality data tied to financially incentiv- For example, IPAs and consortia that participate in ized outcome measures. For payment contracts that hold value-based payment described “a virtuously reinforcing financial reward and/or risk for managing specialty costs cycle of payment and delivery system reform” that can and/or total cost of care, health centers also need the be entered either through changes in payment or care analytic capacity to stratify and the clinical capacity to (see Figure 6). They observed that some health center manage high-risk patients. Reporting functionality should networks with value-based payment contracts reported include both automated and customizable reports that using performance incentive payments to invest in the can be run at a local level, including an ability to “drill capacities needed to deliver care that was not reimbursed down” to the care team level and to “roll up” to the clinic or system level.54 Such functionality can be used for both internal efforts to close care gaps or analyze health Figure 6. Cycle of Payment and Delivery System Reform disparities and for external reports to health plans or gov- ernment entities. Regardless of the internal or external nature of the reports, health centers need staff who can make infor- mation out of data. Analytic capacity covers a broad range of functions including managing incoming data, maintenance of data, data extraction, basic and complex analysis, and data governance. Each of these functions requires an increasing level of training and experience. Small health centers report having trouble recruiting and retaining the necessary workforce of analysts who know the questions to ask of the data regarding health and financial outcomes, and who also have the programming and analytics acumen to answer the questions. Note: CHC is community health center. ED is emergency department. Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 17 by PPS, such as care management and coordination ser- only if an organization has a threshold amount of finan- vices. This kind of performance-driven care produced cial reserves and a minimum number of lives over which outcomes that resulted in increased pay and the confi- to spread the risk. Multiple sources have estimated that dence to negotiate for more value-based contracts. The taking downside risk as a single organization or a network additional value-based payment dollars were then used requires at least 20,000 lives.55 In addition, health centers to sustain the capacities for delivering high-quality, com- and payers have indicated that providers have less nego- prehensive care, such as maintaining care managers and tiating power when they approach plans individually. If behaviorists on staff and investing staff time to engage a health center represents a small slice of a plan’s mar- in ongoing QI activities. In California, fewer small health ket share, it is easier for the plan to exclude them from centers participate in health-center-led IPAs than large value-based contracting. Similarly, health plans can also health centers (see Figure 5, page 9). find the process of contracting with many small health centers burdensome and may be interested in fostering Regardless of the exact form of value-based pay in which health center networks to reduce the cost of negotiating a health center might participate, all California health and managing contracts with many small health centers. centers will contract with Medi-Cal health plans for some, if not all, of their value-based payment arrangements. Small size can be a challenge when engaging with pay- Thus, health centers need the ability to understand the ers. For example, payer representatives indicated a goals and regulatory frameworks that guide managed preference for working with larger entities that they per- care plans and translate the value that health centers ceive as having a greater capacity to implement change. bring to the managed care system into contracted pay- Networks or health-center-led IPAs reported many more ments. Having such expertise can support relationships examples of implementing novel payment and care pro- with plans and can be an essential element of a busi- grams with their plans compared with individual health ness model for sustaining high-quality, comprehensive centers. Size was also mentioned as a factor when primary care. To achieve the cost reductions and qual- seeking capital funding to invest in care and infrastruc- ity improvements that plans are interested in paying for, ture changes. Research also illuminated a connection health centers will need specially trained staff and man- between size and financial stability; a 2016 Capital Link agers who are monitoring and improving utilization and study found that larger clinics tend to have stronger oper- quality outcomes. For example, health-center-led IPAs ating margins and perform better on other key financial that showed that their utilization management tech- metrics.56 Furthermore, small health centers explained niques lowered ambulatory-sensitive hospitalizations how staffing changes, unexpected absences, new regu- were able to translate that value into dollars in the form lations — or even sending providers to training — could of a partial capitation payment for care management. be financially destabilizing. Health centers need a business model that includes the necessary expertise to align health center value with the Developing new administrative skillsets, care teams, clini- goals of the managed care system. cal functions, analytical capabilities, and business models involves, at a minimum, redesigning work flows, retrain- A business model that supports ongoing operational ing existing staff, and reworking job responsibilities. In and financial stability is another key component of infra- most cases, it also involves securing additional staff, tech- structure for care and payment. Having size and scale nology, and data infrastructure. Although there are a few — whether as an individual organization or as part of a activities that can be done in-house and can generate network of other health centers — can be advantageous revenue while preparing for the future, most small health if it supports stability. Size and scale are particularly centers will need to explore partnerships with other important when assuming financial risk and for having the health centers or entities in order to have the necessary negotiating clout to obtain favorable contract terms with infrastructure to support high-quality, comprehensive pri- a payer. When it comes to risk-based contracting, most mary care and success under value-based payment. experts agree that assuming risk is actuarially advisable California Health Care Foundation 18 Partnerships Interviews with bright spot health centers revealed exam- ples of ways that small health centers’ challenges can For many small health centers, executing such changes lead to opportunities: on their own is neither efficient nor feasible, particularly $$ Several small health centers collaborated to share if their financial and operational infrastructure is already a full-time bilingual diabetes care manager that strained. Partnerships and alliances can be critical to neither could support on their own. securing resources and leveraging the skills of another entity. In fact, participating in partnerships emerged as a $$ A small rural health center forged a close part- promising strategy for small health centers for attaining nership with the county behavioral health the infrastructure needed to deliver high-quality, compre- organization (see Case Study 1). hensive care and succeed under value-based payment $$ IPAs and clinically integrated networks helped (see box below). health centers to obtain, analyze, and use data in ways they had not been able to do alone. This Partnerships fall on a wide spectrum that includes link- enabled the health centers to proactively manage ing to community agencies to ensure needed social and their member populations, including outreach behavioral health services, working with other health to people who were assigned but never seen in centers individually or through consortia to share clinical primary care (see Case Study 2 and 3). or administrative services, and networking through IPAs to exert market pressure on health plans and negotiate $$ IPAs and health plans helped health centers to shared savings or other financial benefits. close care gaps through care management and case coordination while also helping to garner Individual small health centers may make use of one or funding for these activities. many of these partnership strategies. When done well, $$ Two health centers merged in order to leverage such collaborations can help health centers and the com- each of their strengths, preserve their missions, munity by supporting and supplementing primary care and achieve better financial and operational activities to leverage resources and improve health. The stability (see Case Study 4). partnerships described by the bright spot interviewees for this project shine a light on the path forward for other Health centers engage in many types of partnerships small health centers in California. for a wide range of reasons, including to advance their missions, improve patient care, and strengthen their business model. Nonmerger partnerships might involve linking to community agencies or schools for services » Partnerships with Community-Based Agencies and Organizations » Partnerships with Hospitals » Consortia » Management Services Organzations (MSOs) and Clinically Integrated Networks (CINs) » Health Center-led Independent Practice Associations (IPAs) » Partnerships with Health Plans » Mergers/Acquisitions PARTNERSHIPS Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 19 like behavioral health, working with other health cen- In deciding on partnership strategies, each health center ters through consortia to share clinical or administrative needs to weigh internal considerations, such as capabili- services, and networking through IPAs to negotiate risk- ties of staff and the culture of the board and leadership, based contracts and/or other financial benefits. Much as well as external factors, such as the local competitive work has been done to characterize the variety of col- market, the local managed care plans, the policy context, laboration types that nonprofit organizations pursue.57, 58 and other service providers in the catchment area. This paper does not detail every potential partnership type nor does it cover ways that health centers grow Below are key questions a health center might answer capacity by expanding geographically or to new popula- when considering each partnership type. (A more tions. Rather, it focuses on a subset of partnerships that detailed look at factors to consider is provided in the emerged most prominently in the research about what Partnering to Succeed: A Road Map for Health Centers health centers must do and must have in terms of infra- section on page 34.) structure to support and sustain their performance. It is important to note that the partnership strategies that emerged from the literature and interviews are not mutually exclusive; many health centers pursue multiple In deciding on partnership strategies, strategies concurrently. This section presents seven part- nership strategies organized roughly in order of ease of each health center needs to weigh initiation by small health centers. Because the require- ments (cost, data, relationship, sophistication) to begin or internal considerations, such as sustain these partnerships varies greatly by the individual organizations in a given market, the order is not identical capabilities of staff and the culture for each health center. of the board and leadership, 1.Partnerships with community-based agencies and organizations (local government and nonprofit) as well as external factors, such as 2.Partnerships with hospitals the local competitive market, the 3.Consortia local managed care plans, the policy 4.Management services organizations and clinically integrated networks context, and other service providers 5.Health-center-led IPAs in the catchment area. 6.Partnerships with health plans 7.Mergers and acquisitions California Health Care Foundation 20 Partnerships with Community-Based Advantages Agencies and Organizations Health centers can offer patients comprehensive care Health centers recognize that their patients have health- that addresses medical, behavioral, and social needs related needs far beyond direct medical care. With by pursuing partnerships with public agencies and limited capacity to serve these needs, health centers are community-based organizations (CBOs). Through these partnering with community-based agencies and organi- arrangements, the patient’s needs can be addressed zations — both local government and community-based by the organization that best delivers that service. nonprofits — to leverage expertise and resources. Community-based partners can also help health centers expand their footprint to serve to new populations or What Is It? new geographic areas. For small health centers that can- Health centers are forming a wide range of partnerships not support all such services in house, partnering with with community-based agencies and organizations. They public agencies and/or CBOs can be critical. (See Case tend to be driven by two primary goals: addressing the Study 1 about how Hill Country has partnered with com- behavioral health and social needs of their patients. munity organizations to improve access to a wide range Interviewees reported that partners include entities of essential services.) It should be noted that although such as: addressing social needs reflects all health centers’ mis- sions to best serve their community, health centers that $$ County mental health agencies are in risk-bearing arrangements have additional incen- $$ Substance use providers (and the local Drug tives to address them. In fact, having partners to support Medi-Cal Organized Delivery System) patients’ social needs was cited by several interviewees as a prerequisite for taking risk for Medicaid populations. $$ County social services agencies $$ Food banks and nutrition assistance (e.g., Women, Infants, and Children [WIC]) Clinics “need to have the self-knowledge $$ Publichousing, homeless shelters, and housing/rental assistance to say, ‘I know what I’m good at, and $$ Literacy programs I know what I’m not . . . so I need $$ Job-training programs to bring in a partner.’” $$ Legal advocacy organizations — Louise McCarthy, CEO Community Clinic Association of Los Angeles County $$ Transportation service providers $$ Domestic violence organizations Key Considerations and Challenges $$ Funeral planning services Forming partnerships with public agencies and CBOs to address behavioral and social needs requires strong lead- Across interviews and the literature, integration with ership, ability to navigate fragmented funding streams, behavioral health — including mental health and, increas- identification of limited resources in the community, ingly, substance use treatment — was widely viewed as and coordination and navigation services for patients. one of the highest priority partnerships for providing Furthermore, although screening for social needs and high-quality, comprehensive primary care. referrals have been shown to result in improved out- comes,59 more research needs to be done to establish which social interventions in the clinical setting are effec- tive and cost-efficient. Finally, other partners, such as consortia, might be in a better position than individual small health centers to reach out to and build relation- ships with CBOs and public agencies. See Table 1 on page 22 for more details. Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 21 Table 1. Areas of Consideration When Establishing Partnerships with Community-Based Agencies and Organizations INTERNAL CONSIDERATIONS EXTERNAL CONSIDERATIONS (ORGANIZATIONAL CAPACITY) (ENVIRONMENT/MARKET/POLICY) Leadership and $$ Are leaders committed to responding to social $$ Has there been a community needs assessment Staffing needs as part of the health center’s approach done recently that addresses social needs of to care? the community? $$ Is there leadership/staff time dedicated to $$ Might your local consortia help you and other developing and maintaining the partnership? small health centers to establish relationships with CBOs and public agencies? $$ Does your health center use community participatory-based research to assess what social needs of the community should be prioritized? $$ Do you have social work staff who can coordinate and track referrals to CBOs? Care Delivery and $$ Do you provide integrated behavioral health $$ Do you have a shared care plan or way to know Infrastructure for individuals with mild to moderate when a referral to a CBO or county agency has behavioral health needs? Do you provide been fulfilled? primary care services to those with serious $$ What CBOs exist in your service area? and persistent mental illness? $$ What are the relative strengths of local CBOs $$ Do you have a process in place to screen for for meeting nonmedical needs of patients? behavioral and social needs? (For example, are there CBOs skilled in $$ What are your relative strengths for meeting providing services for substance use nonmedical needs of patients? treatment in your community?) Financial $$ Are you addressing some social needs within $$ Would the county contract with you for your health center using grant funds that behavioral health services for individuals could be addressed more sustainably by a with serious and persistent mental illness? community partner? $$ Are there opportunities in your county to contract for care coordination services under a whole-person care pilot? $$ Are there opportunities to approach payers for a joint contract to address health and social needs? Data and Analytics $$ Are you capturing behavioral and social needs $$ Is there a local directory of resources available using standardized data that can be leveraged in your community (e.g., Purple Binder)? for evaluation, payment reform, and identifying $$ Is new data infrastructure being established needs for new partners? under a Whole Person Care demonstration that allows sharing data between health, housing, behavioral health, and other county data systems? California Health Care Foundation 22 Partnerships with Hospitals Advantages Health center partnerships with hospitals have the poten- A local hospital partnership can be essential for a wide tial to improve care coordination and specialist access. variety of functions: care coordination; data sharing; However, health centers are cautious about entering access to specialists, lab services, and pharmacy ser- financial arrangements that involve shared risk with hos- vices; additional funding for staff positions; and potential pital partners. grants from a hospital community benefit program. Some health centers achieve these benefits by co-locat- What Is It? ing with a hospital partner. Hospitals have also provided Partnering with local hospitals takes a number of forms, health centers with a shared EHR — and prorated licens- including data sharing, funding a workforce for care ing fees — that can facilitate care coordination and boost coordination and transitions, access to specialists, provider satisfaction. Many providers are accustomed to philanthropy, and in some cases shared financial-risk working within large hospital-system EHRs and feel they arrangements. Because of the importance of managing are state of the art. In certain cases, hospital partners care across settings, receiving real-time ADT data from have provided health centers with information technol- hospital partners can be essential for ensuring coordi- ogy and legal support. nated and timely follow-up in primary care for health center members. CHCs also reported having hospi- tals fund care managers and coordinators to serve as a point of contact in order to link hospital and emergency “I think the biggest benefit of participating in department patients back to a PCMH. Some health cen- consortia is learning from each other. Other ters described being the recipient of hospital community benefit funds. In markets such as Los Angeles there are members try things first and they have the examples of health-center-led IPAs and hospitals splitting funding to do that, and we get to learn from capitated risk from health plans with a shared risk pool if quality and utilization outcomes are achieved. Although things that work and things that don’t.” Medicaid accountable care organizations (ACOs) com- — Deborah Howell, CEO prising hospitals and health centers are emerging in Alexander Valley Healthcare some states, there has been no movement toward this type of partnership in California. Key Considerations and Challenges Health centers in states that have participated in ACOs with hospitals found that hospitals tend to take the larger “I don’t think we would be able to achieve share of the financial benefit from these partnerships, whereas primary care takes on a disproportionate share the kind of results we have in terms of of the clinical and administrative burden. Although verti- seven-day follow-up for inpatient visits cal integration with a hospital, or acquisition by a hospital, may be of interest to some health centers, such arrange- if we didn’t have care coordinators here ments must carefully consider the Health Resources and who actually knew the patients, who could Service Administration (HRSA) policy for independent FQHC boards. See Table 2 on page 24 for more details. literally walk over to the hospital and meet the patients while they were in the hospital to generate those kinds of relationships.” — Dan Fulwiler, CEO Esperanza Health Center Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 23 Table 2. Areas of Consideration When Establishing Partnerships with Hospitals INTERNAL CONSIDERATIONS EXTERNAL CONSIDERATIONS (ORGANIZATIONAL CAPACITY) (ENVIRONMENT/MARKET/POLICY) Leadership and $$ Do you have a leader who acts as the liaison $$ Do you have a clinical point of contact for the Staffing to your local hospitals? emergency department or inpatient discharge to link a patient back to primary care? $$ Are there any staff positions that your hospital would be interested in funding? $$ Is there alignment of your mission and the missions of the hospital or hospital system to serve the uninsured and underinsured in your community? Care Delivery and $$ Are there opportunities to have closer $$ Are there opportunities to build innovative Infrastructure coordination with specialty consultants access to specialist services for your patients to promote community-based rather than (e.g., e-consult)? hospital-based specialty care? $$ Have you appealed to your local hospital community benefit department for nonmedical programs addressing social needs? Financial $$ Do you have a need for capital that your $$ Do you have more than one hospital where hospital might be interested in helping you patients can be referred? If so, is there a to meet via a low-cost loan? hospital known for providing higher value care (better outcomes for lower price)? Data and Analytics $$ Do you receive and act on a daily ADT feed $$ Would your hospital consider funding from your local hospitals? implementation of a second generation EHR in your CHC that both meets your needs and links with their EHR systems? Consortia Advantages By participating in consortia, health centers have a col- Consortia can help individual health centers to monitor lective voice in national and regional advocacy and can and influence policy at the local and state levels, engage benefit from a range of technical assistance and shared in QI, share best practices, and centralize select nonmed- functions. Consortia vary in their roles, capacity, and ical functions such as training, managing volunteers, and offerings; some are predominantly advocacy entities, building partnerships with hospitals. Some consortia also whereas others may offer robust support and many of the serve in the role of a health-center-specific MSO, helping functions of a management services organization (MSO). health centers to access services, particularly admin- istrative ones, that would be difficult or more costly to What Is It? develop on their own. Strong consortia reported provid- Consortia are the primary form of health center collabo- ing the following key functions and services to member ration in California. There are 13 consortia — organized health centers: predominantly by geographic region — in addition to $$ National and regional advocacy the statewide CPCA. Some began as early as the 1970s, whereas others started as recently as 2010.60 Health $$ Helping health centers stay informed on center consortia serve as “hubs for information, techni- policy change cal assistance, and shared functions in areas including $$ QI programs general administrative and billing services, managed care contracting, management, fundraising, develop- $$ County contract negotiations ing EHRs, clinical assistance (such as care management $$ Serving as a grant recipient and administrator approaches), and advocating for and adjusting to policy changes,” as well as giving health centers a stronger, col- lective voice.61 California Health Care Foundation 24 $$ Peer/affinity groups (chief financial officer [CFO], $$ Technology procurement (vetting and chief medical officer [CMO] roundtables) negotiating with EHR and population health management system vendors) $$ Workforce training programs (e.g., motivational interviewing, security, Health Insurance Portability $$ Servingas Health Center Controlled Networks and Accountability Act [HIPAA]) (HCCNs) under HRSA $$ Uniform Data System reporting Key Considerations and Challenges $$ Engaging hospitals to align community benefit Depending on a consortium as a key partner requires resources with health center priorities that it have sufficient capacity and that there is a good a fit between what the consortium provides and what $$ Facilitatingmemoranda of understanding (MOUs) the individual health center needs. Some health centers with other members for shared services described consortia membership as positive and helpful. (e.g., ob/gyn and dental) Others were less clear about the benefits. In one case, $$ Sharing best practices health centers were actively participating in a neighbor- ing consortium because of their own consortium’s limited $$ Pharmacist of record capacity. See Table 3 for more details. For more infor- $$ Interactingwith medical education and mation on developing consortia, see Recommendations volunteer workforces (e.g., AmeriCorps) for Organizations That Support Small Health Centers on page 37. $$ Compliance $$ Credentialing See Case Study 2 for an example of how Health Center Partners’ work with local consortia helped them improve $$ Recruitment quality and secure additional resources. Table 3. Areas of Consideration When Establishing Partnerships Through Consortia INTERNAL CONSIDERATIONS EXTERNAL CONSIDERATIONS (ORGANIZATIONAL CAPACITY) (ENVIRONMENT/MARKET/POLICY) Leadership and $$ Do you feel informed about local policy and $$ Are there local advocacy opportunities Staffing do you feel that health centers are being (e.g., town halls) where more coordinated adequately represented in local politics? efforts among health centers could benefit all CHCs and the communities they serve? Care Delivery and $$ Are there clinical services that you would $$ What centralized and support services does Infrastructure prefer to outsource to allow your CHC your consortia offer? to deliver higher quality care to patients $$ Are there opportunities to build partnerships (e.g., pharmacist of record, QI, clinical and/or negotiate data-sharing agreements protocols)? with local hospitals (e.g., getting ADT data) that would have more promise if a consortium initiated the effort? Financial $$ Are there services that you are doing internally $$ Is there opportunity to build capacity — and that might be more efficiently outsourced to economies of scale in certain administrative your consortia (see list under the Advantages functions — at your consortia for the benefit subsection above)? of multiple CHCs? Data and Analytics $$ Do you struggle to get responsiveness from $$ Do you and other health centers share a common your EHR vendor for change requests? health plan partner(s) for whom studying the value of CHCs in the region would be beneficial $$ Would it be helpful to understand best for negotiating payment reform? practices from other CHCs and/or negotiate vendor requests collectively? $$ Are there external resources available for HCCNs for which your consortia could apply? Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 25 Management Services Organizations “We now have data that indicate networked and Clinically Integrated Networks Engaging with MSOs might offer health centers greater health centers outperform non-networked administrative efficiency, competitive pricing for services health centers clinically, including UDS and supplies (including negotiating with health IT ven- dors), and collective contracting — while enabling them data that indicates our HCCN outperforms to maintain autonomy. MSOs can assist with many of others across the country in 10 of 13 clinical the nonmedical functions of running a health center and clinically integrated networks to build shared clinical and measures, and HEDIS data that indicates operational capacity without assuming downside risk. our CIN is posting the highest minimum What Is It? performance level scores Molina Healthcare MSOs are designed to assist health centers with needed has ever posted in California, by any nonmedical functions. These can include centralized administrative functions such as human resources, pay- provider group. What that says to me is roll, billing and collections, procurement of supplies that the time has come for FQHCs to work and services (using the consolidated volume of multiple health centers to negotiate better pricing), and leasing together in networks, locally and regionally, office space. MSO functions can also include individu- alized services such as financial analytics, staff training, to ensure the delivery and continuity of high- compliance, credentialing, operations consulting, vendor quality health care and the highest possible selection, risk management, contracting with payers, and tracking and analyzing data for value-based payment outcomes, at reduced cost, for the patients contracts. entrusted to their care. How one does that, An MSO can charge health centers a single member- through an IPA or a CIN or other vehicle, will ship fee for a package of services or offer an a la carte have its own pros and cons depending upon menu. For instance, Health Center Partners of San Diego uses this model with its group purchasing and sharing the business model and the business goals QI services across member health centers (see Case of the organization.” Study 2). For commercial private practices, MSOs some- times hold an ownership stake in a practice. Even though — Henry Tuttle, President and CEO Health Center Partners MSOs can provide much of the infrastructure needed under value-based care models, they do not enter into risk-based contracts with payers. Advantages An MSO can help an individual health center to pay the Health center clinically integrated networks (CINs) often best prices for services and supplies, to have access to fulfill MSO functions but also perform collective clinical pre-vetted vendors for services and technology products, quality work and collective negotiations for incentive and to focus on clinical care and developing strategic payments (upside risk) with payers. The one health cen- relationships in the community. An MSO or a CIN may ter partnership that described itself as a CIN (see Case also aggregate data and use it for QI. A CIN can leverage Study 2) assisted member health centers with improving negotiating power, data, and quality work to bring more performance on outcomes through data analytics and QI resources to a health center through collective contract- activities. ing for pay-for-performance from health plans. California Health Care Foundation 26 Table 4. Areas of Consideration When Establishing Partnerships with MSOs and CINs INTERNAL CONSIDERATIONS EXTERNAL CONSIDERATIONS (ORGANIZATIONAL CAPACITY) (ENVIRONMENT/MARKET/POLICY) Leadership and $$ Are there staffing-related functions, such as $$ What administrative services does your Staffing credentialing or training, that might be more consortia offer? Is there opportunity to build efficiently outsourced? MSO-like capacity at your consortia? Care Delivery and $$ Are there clinical or administrative services, $$ What care delivery infrastructure and QI does Infrastructure such as technological expertise or data your consortia offer? analytics for population health management, $$ Are there other health centers that you trust that you do internally that might be more that could work with you on QI activities? efficiently outsourced? Financial $$ Are you not ready to take downside risk $$ Would your health plans prefer to have a single through an IPA but interested in collectively point of contact and negotiate with a network of negotiating upside payments? health centers rather than individual CHCs? Data and Analytics $$ Are you considering a second-generation $$ Is there a health information exchange in EHR? Would it be helpful to negotiate with your community? vendors collectively? $$ Do you need assistance with data analytics for QI? Key Considerations and Challenges What Is It? An MSO approach requires buying services from a trusted IPAs are corporations that contract with managed care MSO that can perform the health center’s nonmedical health plans on a capitated basis for either all primary services under a clear contractual arrangement. One area care services or, more frequently, all professional ser- in which group contracting has proven challenging is with vices (both primary and specialty care). IPAs effectively IT support and EHR hosting, given individual health cen- allow health centers to contract collectively for risk-based ters’ IT needs. Key challenges for a CIN doing collective payments and to distribute savings, if they occur, based contracting include building in mechanisms to ensure on quality and cost outcomes of the assigned member that all members are contributing to quality outcomes population. and establishing a fair way of distributing performance payments from a payer. (For example, would members Some health-center-led IPAs have been functioning as see it as more fair to distribute payments based on mem- “virtual Medi-Cal ACOs”62 in that they assume limited ber lives or degree to which a member influenced the financial accountability and risk for a defined member group’s quality scores?) See Table 4 for more details. population and reward providers if cost and quality out- comes are achieved. Some thought leaders have posited that the presence of IPAs within managed care Medi-Cal Health-Center-Led Independent are a reason that there has been no movement toward Practice Associations Medicaid ACOs in California to date, despite the emer- As a mechanism for risk-based collective contracting, gence of ACOs in the commercial and Medicare markets health-center-led IPAs offer health centers a way to in California and in Medicaid markets in other states. enter the virtuous cycle of increased revenue linked to Some health-center-led IPAs are also functioning like improved care and outcomes. However, there are chal- ACOs in that they actively help health centers transform lenges to both formation and participation, including care through data analytics, care management, and coor- regional managed care Medi-Cal contracting practices, dination of care between settings. the demands of managing utilization outside of primary care, and building trust and discipline among members. Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 27 IPAs pay health centers either on a fee-for-service basis IPAs reported conducting data analytics, including ana- or via primary care capitation for primary care services. It lyzing claims, supporting complex care management, should be noted that health centers are protected from and facilitating specialty care access. Health center and financial risk for FQHC services by virtue of the state health-center-led IPA leaders reported that participating paying a “wraparound” and conducting an annual recon- in IPAs has resulted in financial benefit to health centers. ciliation to make up any difference from what the health Although health-center-led IPA contracts are techni- center would have received under PPS. These processes cally both upside and downside risk, none of the health can delay cash flow for health centers but ultimately centers interviewed for this project reported incurring ensure that health centers receive their PPS rate for all financial losses as a result of IPA participation. eligible visits. Key Considerations and Challenges Pursuing an IPA strategy requires having a managed care Medi-Cal plan that is willing to contract with an IPA, a “I think the clinics are really leaning on us to minimum number of lives to take collective risk safely make them smarter with their managed care (often estimated at about 20,000 lives,63 and trust and discipline among IPA members. Health centers reported participation. They value what we’ve done that forging new financial risk-taking partnerships within so far. We have a very active board, active the entrenched managed care infrastructure and con- tracting habits of a given region can be a barrier. Despite strategic planning committee .... We offer interest among health centers in forming IPAs in certain regions, some payers have dictated whether health cen- support as an IPA, such as access to patient ters can contract through IPAs. navigators or certified coders, for things that Forming a health-center-led IPA also requires leadership, maybe clinics can’t afford on their own.” administrative bandwidth, managed care expertise, and — Iris Weil, Executive Director a deep sense of mutual trust and discipline among mem- Health Care Los Angeles Independent Practice Association bers. Taking collective risk can create an incentive for IPAs to admit only new health centers that meet quality- Advantages of-care standards and demonstrate a commitment to QI, Being part of a health-center-led IPA can bring additional including a clear commitment and capacity to manage revenues to health centers through shared savings-type utilization outside of primary care. For small health cen- payment arrangements while also fostering efforts to ters, the lack of capacity to manage utilization outside of redesign the care system. For example, health centers primary care, including behavioral health integration and within risk-taking IPAs tend to engage in advanced data care management and coordination, can pose a barrier analytics and in care management and case coordination to participation. for their members; they are financially rewarded when such efforts are successful in preventing unwarranted IPAs may not be interested in having health centers with a hospital utilization and achieving quality outcomes. small number of additional lives and the unknown capac- These additional dollars can be used to sustain the care ity to manage care of members. This may be particularly management functions, creating a virtuous cycle of pay- challenging if a small health center brings a high-risk ment and improvement in care delivery. Both health population without commensurate capacity to manage center members and Community Health Center Network the utilization of high-risk members outside the primary (CHCN) leaders described this virtuous cycle. See Case care setting. It is perhaps owing to these challenges that Study 3 for an example of how CHCN has helped its small health centers are less likely to participate in health- member health centers to build capacity in providing center-led IPAs compared with their larger counterparts. comprehensive primary care and to negotiate with plans Some interviewees suggested that small health centers and local hospitals to help sustain improved care. might gain entry into an IPA by bringing a unique care approach that other members can use, such as having IPAs allow health centers to keep their autonomy while a robust system for caring for homeless individuals. See achieving many of the benefits from increased size. Table 5 on page 29 for more details. California Health Care Foundation 28 Table 5. Areas of Consideration When Establishing Partnerships with Health-Center-Led IPAs INTERNAL CONSIDERATIONS EXTERNAL CONSIDERATIONS (ORGANIZATIONAL CAPACITY) (ENVIRONMENT/MARKET/POLICY) Leadership and $$ Do you have managed care contracting $$ Does your Medi-Cal plan(s) contract through Staffing expertise within your team? IPAs? $$ Are leaders amenable to entering into a $$ Is there a health-center-led IPA in your area or risk-bearing arrangement? are there other local health centers interested in forming an IPA? $$ Do you have care managers and case coordinators on your care teams? Care Delivery and $$ Do you have a demonstrated commitment $$ Are local payers open to delegating care Infrastructure to and practice of QI that has been proven management and coordination services? to reduce avoidable hospital utilization $$ Would a local health plan be willing to make (a valuable skillset to payers)? upfront investment in staffing and data $$ Do you have clinical capacity to manage and infrastructure necessary to manage utilization coordinate care outside of primary care? outside of primary care? $$ Do you have a system for sending specialty $$ Do your patients have a choice of hospitals referrals to high-quality, low-cost specialists? and specialists? $$ Have you established partnerships with CBOs to address social factors for your patients to help you perform under risk-based payment? Financial $$ Do you have the financial stability to take on $$ Is there money to be made in risk-based IPA downside risk? contracts in your region given the competitive IPA environment and hospital environment? $$ Would a health-center-led IPA have at least (For example, would a hospital or specialty 20,000 lives? group with monopoly power likely raise prices $$ Do you have the financial resources to invest if utilization goes down?)  in the necessary data systems and new staff to manage financial risk? Data and Analytics $$ Do you have data on your members’ utilization $$ Have you established data linkages with hospitals and cost outside of primary care? (e.g., ADT feeds) that would allow you to manage care transitions and coordinate care? $$ Do you have the analytic capacity to review cost and utilization trends of services rendered outside primary care? $$ Do you have the ability to report on IPA quality metrics? Partnerships with Health Plans What Is It? Partnering with payers for value-based payment can Health center partnerships with health plans often take yield the financial resources to achieve and sustain care the form of contracts for value-based care and payment. transformation but may require sophisticated data and Pay-for-performance incentives and care management/ contracting capabilities. The local managed care context case coordination payments are the most common forms heavily shapes potential opportunities for health centers of value-based payment that health plans use. A 2015 to engage with plan partners. In counties with only one survey showed that 18 of 22 Medi-Cal plans had a pay- Medi-Cal plan or a local initiative, health centers may be for-performance program. Within these 18 programs, able to leverage aligned missions to improve care and five domains for measurement were most prevalent: clin- outcomes for their community. ical quality (e.g., HEDIS), utilization (e.g., readmissions, avoidable emergency department visits); encounter Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 29 submission (i.e., records of health care services for which Key Considerations and Challenges plans pay in capitated arrangements); access to care Partnering more closely with health plans for value-based (e.g., extended office hours); and patient experience.64 payment requires that health centers modify data systems Medi-Cal managed care plans in 29 California counties to understand who their assigned members are and how are planning to implement Health Homes in 2018-2019. to reach out to those needing care. For health centers to Health centers have an opportunity to contract as com- negotiate for supplemental payment for care manage- munity-based care management entities to provide care ment and coordination of care inside and outside primary management/case coordination services for high-risk care, they will need to demonstrate capacity to perform members with multiple chronic conditions. such functions. For example, CHCN and its member health centers demonstrated to their health plans that a Plans were also envisioned as a critical partner in the pro- novel care management and coordination program they posed California FQHC APM demonstration, in which piloted improved quality outcomes and reduced hospital volunteer health centers would receive a PPS-equivalent utilization; the plans were convinced by the results to pay capitation rate from their plan(s) for all assigned Medi- to sustain the new program (see Case Study 3). Cal beneficiaries. The APM was designed both to give health centers more flexibility in delivering care and to Partnering directly with a health plan might not be an align payment with the way managed care is paid — for option for individual small health centers. Many Medi-Cal members, not just patients who are seen for visits. In the health plan payers in California prefer to negotiate with wake of the Centers for Medicare & Medicaid Services larger medical groups that assume accountability for sig- not allowing the APM to proceed without a waiver, select nificant numbers of health plan members. This includes plans and CPCA continue to explore how to achieve QI initiatives, training, and capacity-building for provid- many of the goals of the APM without pursuing a waiver ers. In such cases, small health centers can still work of PPS. through other organizations (e.g., IPAs, CINs, consortia) to partner with their health plan(s). See Table 6 on page In certain markets, plans are even more collaborative. For 31 for more details. example, Partnership Health Plan of California piloted an intensive outpatient care management program, worked with clinics on provider recruitment, and provided innova- tion grants to health centers to address community-level “As an HCCN, we have traditionally worked social determinants of health. In another example, Inland with UDS data as we test population health Empire Health Plan invested in new staff and training for delivering integrated behavioral health in health centers. management strategies. But with 100% of our Medicaid market in capitated managed Advantages Partnering closely with a plan can help a health center to care, and the formation of our CIN two initiate care transformation that is not supported by their current payment model and sustain that care by earning years ago, our members have made the financial rewards related to keeping members healthy move from fee-for-service to value-based and out of the hospital. In many regions, consortia and/ or health-center-led IPAs can play a key role in facilitating care, using HEDIS data to measure quality. such infrastructure and care improvement opportunities However, since we function as both HCCN between plans and health centers. For example, Health Center Partners of Southern California was instrumental and CIN, we are always evaluating our in building capacity in data and QI in a small member performance based on both the UDS and health center. This led to the health center improving quality outcomes and receiving improved pay-for-perfor- HEDIS value sets.” mance payments from health plans that could sustain its — Nicole Howard, Executive VP new data and QI infrastructure (see Case Study 2). Health Quality Partners of Southern California California Health Care Foundation 30 Table 6. Areas of Consideration When Establishing Partnerships with Health Plans INTERNAL CONSIDERATIONS EXTERNAL CONSIDERATIONS (ORGANIZATIONAL CAPACITY) (ENVIRONMENT/MARKET/POLICY) Leadership and $$ Do you have a leader who acts as the liaison $$ Could your plan be a partner in advancing Staffing for your health plan(s)? workforce policy change as a way of increasing access? Care Delivery and $$ Do you have capacity to provide care manage- $$ Are you located in a county that plans to Infrastructure ment and coordination services to high-risk implement Health Homes? individuals? If not, what training do you need? $$ Have you asked your plan if there are services Have you discussed Health Homes with your such as care management and coordination health plan? that they would delegate and pay for? Financial $$ Have you reviewed your pay-for-performance $$ Does your plan prefer to contract directly or program with your plan to determine where through IPAs/networks? there are opportunities? $$ Do your payers have programs that pay for $$ Are you interested in converting your PPS rate performance outcomes and/or reward providers into a capitated equivalent that would allow for lowering total cost of care? more flexibility to provide care through $$ Are your pay-for-performance measures and nonbillable providers and modalities targets changing in response to the California (e.g., email or phone) in exchange for court case ruling against double payment for limited risk under an APM? services in pay-for-performance? $$ Do you address social needs in a care $$ Is the proposed California health center APM management/coordination program that moving forward? a plan might be willing to fund? $$ Are you located in a whole-person care pilot county where payers (the plan or the county) may have additional funding for housing navigation, care coordination, and so on? Data and Analytics $$ Can you prove the financial value of your $$ Is your plan willing to share hospital and specialty current services by showing that your utilization for your patients? members utilize fewer hospital services $$ Is your plan sharing monthly membership than the health plan average? assignment with you? $$ Are you able to assign all members to a $$ What HEDIS measures matter most to your plan? panel in your EHR for the purposes of outreach for preventive services and measuring quality metrics for all members (to improve HEDIS measures)? $$ Do you have the data-reporting capability and QI practices in place to monitor and improve the outcomes for which you receive performance payment? Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 31 Mergers and Acquisitions Advantages Health centers that are able to come together through A merger or acquisition strategy can bring about rapid a merger stand to gain economies of scale in staffing growth in lives and revenue, increase economies of (including attracting leadership talent) and administrative scale for administrative functions and negotiations on functions. They also achieve greater clout in developing payment, and result in a health center that maintains partnerships or negotiating contracts and increased capi- autonomy going forward. Combining the service offer- tal to invest in infrastructure needs. ings of two small organizations can also be a pathway to offering comprehensive primary care using an expanded What Is It? care team. Further, mergers and acquisitions can lever- Mergers and acquisitions are strategies for increasing age top leadership talent in the safety net by having size, economies of scale, breadth of services, and market strong, visionary leaders take charge of larger organiza- clout by fusing two or more distinct organizations into tions using the combined resources. For example, given a single entity. Other industries, including the nonprofit that California health centers are having to compete with sector, pursue them to stretch administrative capac- Silicon Valley for CTOs, one thought leader commented, ity and leadership talent over more service provision.65 “When competing with tech companies, it might be pos- Some CHCs use mergers to achieve the benefits of size sible to find 50 high-level CTOs, but unlikely to find 176.” and expand services for their patient population. For Additionally, mergers and acquisitions can responsibly example, HealthRight360 in San Francisco is the result of maintain access points by allowing underperforming a series of mergers of multiple CHCs, behavioral health, or financially at-risk organizations to remain open and and community-based organizations. It leverages the improve via buyer support. When a larger, stronger orga- strengths of each of the small organizations that came nization results from a merger, a community can benefit together to provide a comprehensive set of services, from expanded services available in more locations. including primary care, dental care, substance use disor- der treatment, and mental health services. Key Considerations and Challenges Some CHCs resist the idea of merger unless driven to it by financial distress, and some local board structures favor local control. Other institutional barriers include “The future requires mergers. We can’t strong organizational culture and the need for approval by lenders or oversight agencies such as HRSA. Despite support 40 small health centers to each these obstacles, merger may be the best option — or have a piece of the population. Maybe only viable option — for struggling CHCs or those in areas that lack other partnership organizations capable small specialized little hubs, but we can’t of providing shared services. Indeed, some mergers have 40 [distinct] primary care clinics. We have further advanced individual health centers’ missions in their communities through leveraging the strengths won’t get efficiencies of costs, won’t use of both organizations. See Table 7 on page 33 for more HRSA dollars appropriately, or be able to details. make public private partnerships because See Case Study 4 for an example of how Parktree — cre- people won’t invest in 40 small things. ated through an organizational acquisition — preserved access and expanded services for patients. Health centers should embrace bold innovation.” — Karen McGlinn, CEO Share Ourselves Corporation California Health Care Foundation 32 Table 7. Areas of Consideration When Establishing Partnerships Through Mergers and Acquisitions INTERNAL CONSIDERATIONS EXTERNAL CONSIDERATIONS (ORGANIZATIONAL CAPACITY) (ENVIRONMENT/MARKET/POLICY) Leadership and $$ Would your board be amenable to exploring a $$ Is there another local health center that has a Staffing merger as a strategy for sustainability and/or similar mission and/or target population and improving quality of care?  has strong leadership capable of managing an expanded organization? $$ Are you struggling to hire and retain leadership talent? Would a larger organization with more $$ Would health plans and other key stakeholders resources at the administrative level help support a merger? recruit the talent you need? $$ Are you close enough geographically to another $$ Are there staffing capacities that would CHC that sharing staff would make sense? be easier to leverage over more lives (e.g., bilingual disease management, finance, data analyst)? Care Delivery and $$ Is using a care team to manage population $$ Is there a strong local health center that has Infrastructure health inhibited by small panel size? clinical and administrative infrastructure that would benefit your health center and your patients? $$ Would a local hospital be more likely to collaborate with a single larger health center? Financial $$ Would investing in new infrastructure, $$ Is capital available at reasonable rates to fund administrative staff, technology, and training integration of administrative and IT systems, to be more viable if the cost could be spread cover potential losses of an acquired clinic, and over more patient lives? to do necessary work to bring teams together? $$ Would local payers be more interested in partnering with a larger health center organization for value-based payment? Data and Analytics $$ Is there data infrastructure, analytic capacity, $$ Would hospitals or health plans be more likely or technology savvy that seems unaffordable to share data with your health center if you had for the size of your health center? more patient lives? Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 33 Partnering to Succeed: Weigh the options. Partnering can bring tremendous A Road Map for Health Centers benefit to small health centers that may otherwise strug- The questions in Figure 7 can help a health center select gle to acquire the resources for adequate infrastructure. which partnerships to pursue. It can serve as a road map But not all partners offer the same breadth, depth, and for making the most appropriate partnership decisions. quality of services, regardless of their organizational type. A partner may be strong in one area but weak in another. Assess health center infrastructure. Health centers Health centers need to be clear on what their biggest interested in creating financially viable organizations that gaps are in order to find the best fit. Because partner- deliver high-quality, comprehensive primary care need ships take time and often require relationship building, infrastructure in terms of people, systems and strategies, it may be wise to reach out before circumstances com- data, and a business model. It is important for a health pel a change. This gives the health center some time to center to make an honest assessment of its strengths engage its board and ensure that a partner is well aligned as well as the areas that would benefit from additional with the mission. support. Does the health center have the right scale and scope of services to match patient needs? Is the right Reach out. The only way to really know which partner- team in place to deliver those services? ships would work best is to start building relationships. The case studies in the last section of this paper show Understand the local context. Each community oper- how varied the path to partnership can be. Simply start- ates with different partners and politics. The table below ing conversations with potential partners can result in shows the key advantages of different kinds of partner- collaborations and partnerships that take shape through ships. Health centers need to consider the following: the exploratory discussions. Reaching out to potential What partnerships are available in your area? Which partners requires a health center to solidify its own case make the most sense for you to pursue based on cul- as a desirable partner organization. The strengths that tural fit and mission alignment? What are the managed it brings to the table — from a particular expertise, or care contracting practices in the region? Is there a natural unique patient population, or strong community reputa- hospital partner? What history or politics might need to tion — need to be well understood and shared. be confronted? Figure 7. Road Map for Partnering: Key Questions UNDERSTAND THE LOCAL CONTEXT What relevant partnerships are available in your area? REACH OUT How do local context, funding, Who do you need to reach 1 and competition shape your 3 out to, to develop these 5 health center’s ability to participate in partnerships? relationships? ASSESS HEALTH CENTER WEIGH THE BUILD INFRASTRUCTURE 2 OPTIONS 4 READINESS What are your Which partnerships are What can you get started infrastructure strengths? the most likely to result on improving internally? in progress toward the Where do you need help? quintuple aim? » People » Systems/Strategies What are the costs and » Data benefits of participating? » Business Model PARTNERSHIPS California Health Care Foundation 34 Build readiness. Even if a health center is not ready are using medical assistants to act as scribes in order to to partner or has limited opportunities to do so in its improve efficiency and boost patient volumes.  Others area, it can build infrastructure and improve care now. leverage volunteers or students through AmeriCorps or Health centers are undertaking a broad range of activi- other professional training programs to do proactive out- ties that are achievable under PPS and also prepare them reach to patients. for value-based pay. For example, some health centers Table 8. Key Advantages of Each Partnership Type, continued KEY ADVANTAGES [THIS PARTNERSHIP CAN HELP A HEALTH CENTER TO…] Community $$ Better respond to and/or address social and behavioral health needs Agencies $$ Expand access to care by engaging with patients in the community (e.g., the YMCA, the school, a food pantry or farmers’ market) $$ Expand grant-funding opportunities Hospitals $$ Improve care coordination by: $$ Establishing contact points between hospital and primary care staff to manage care transitions $$ Providing data when patients are in the hospital (to ensure follow-up in primary care and decrease avoidable hospital utilization) $$ Embedding and funding nursing and other staff in health centers to provide care coordination (in select cases) $$ Leverage hospital community benefit requirement for grants Consortia $$ Leverage shared best practices, centralized technical assistance, and a collective health center voice in policy discussions and advocacy efforts. A consortium can also fulfill multiple other partnership roles in select cases: $$ Connect peers to share and spread best practices related to infrastructure through training and technical assistance (TA) $$ Facilitate introductions among likely partners; help facilitate partnership discussions $$ Provide QI and health IT technical assistance and explore health information exchange (HIE) infrastructure through their role as an HCCN $$ Provide reporting and analytic capacity for members MSOs and $$ Outsource infrastructure and nonmedical functions to an entity that specializes in such infrastructure and CINs functions. An MSO can do the following: $$ Optimize health IT infrastructure — both related to human resources (e.g., analysts) and capital investments (e.g., EHR, HIE) $$ Provide services such as billing, physician recruitment, credentialing $$ Provide QI infrastructure such as training in specific QI methods and data for evidence-based practice change $$ Negotiate better pricing on purchased supplies and services $$ Additionally, some MSOs serve a collective QI and group contracting function (sometimes termed clinically integrated network) by doing the following: $$ Conducting data analysis and coaching to improve outcomes $$ Negotiating performance payments with greater clout while allowing member health centers to maintain independence Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 35 Table 8. Key Advantages of Each Partnership Type, continued KEY ADVANTAGES [THIS PARTNERSHIP CAN HELP A HEALTH CENTER TO…] IPAs $$ Collectively contract for risk-based payments designed to give health centers access to more of the Medicaid dollar $$ Build clout with managed care plans and hospitals while maintaining health center independence $$ Centralize expertise in data analytics, care management, and coordination of care outside of primary care (in select cases) $$ Enhance specialty access and management of high-cost hospital services through relationship-building with hospitals Health Plans $$ Provide contracts for value-based pay — for care management payments, performance payments, and proposed APM payments $$ Leverage plan capabilities with data infrastructure and analytics to stratify member data by risk, measure quality outcomes, and manage utilization outside of primary care $$ Build capacity in care managing high-need members through either directly funding health center staff (e.g., care managers, behaviorists) or covering these responsibilities through additional payment Mergers and $$ Leverage economies of scale to do the following: Acquisitions $$ Recruit and retain leadership expertise $$ Spread administrative costs over a larger patient population $$ Expand the care team to include new roles that are more efficiently shared among multiple patient panels (e.g., pharmacist, behavioral health) $$ Preserve and/or expand access to, and range of, services California Health Care Foundation 36 Recommendations for 3.Leverage regional relationships with health plans and hospitals to help small health centers Organizations That access data. Support Small Health 4.Identify opportunities for adding new central- ized services, such as data analytics, contracting, Centers credentialing, and evaluation. The MAHP presented in this paper is intended to help 5.Assist small health centers in assessing and small health centers identify and actualize partnerships brokering new partnerships. that will enable them to deliver excellent patient care and thrive in the transition to value-based payment. In California, many different organizations have a role to Opportunities for Policymakers, play in supporting the development and/or expansion Health Plans, State and/or Regional of partnerships that can meet the needs of small health centers. These include consortia, IPAs, MSOs and CINs; Associations, and Funders health plans; regional and state associations; and foun- Other types of organizations can help build capacity dations. Although some of these organizations already within existing partnerships or cultivate the develop- excel at addressing the needs of small health centers, ment of new partnerships. For example, they can do the there is variation across the state. The research gath- following: ered for this paper identified several opportunities for 1.Support the development of regional IPAs in improvement, as listed below. markets where they do not exist. This may start with identifying regions where health plans (local initiatives, in particular) have interest in contract- Opportunities for Consortia, ing with health centers collectively but where no IPAs, MSOs, and CINs Led by health-center-led IPA or CIN exists. It would also Health Centers include assessing interest of local health centers Compared with their larger counterparts, small health in forming an IPA or clinically integrated network centers are less likely to participate in consortia, IPAs, to contract collectively with the plan(s) and pro- MSOs, and CINs (see Figure 5 on page 9). To enable vide health centers with support in improving small health centers to participate in existing networks quality outcomes. and partnerships, supporting organizations should do as 2.Form a statewide MSO for health centers that follows: do not have access to centralized, nonmedical 1.Conduct outreach, needs assessment, and functions. One key area of focus would be data intentional welcoming for small members. analytics and, in particular, risk stratification and understanding total cost of care. 2.Create governance that provides small health centers with an equal vote for strategic direction 3.Expand high-functioning consortia through setting, even if financial rewards are prorated targeted investments. based on the number of patient lives. 4.Help small health centers build tighter 3.Adjust membership fees for small health centers. relationships with county health systems and local initiative health plans. A natural Supporting organizations should also consider what starting place could be around advancing services they can offer to help small health centers excel. care management of high-risk populations, For example, they can do the following: including potential collaborations related to the recently launched Whole Person Care 1.Ensure that small health centers are optimizing pilots and the Health Homes initiative. group purchasing from vendors. 2.Tailor support and coaching for small health centers. Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 37 Conclusion Creating high-quality, comprehensive primary care is core to the mission of community health centers that aim to improve the health and well-being of low-income and vulnerable persons. Doing this work well, and in a finan- cially sustainable way, increasingly means understanding and participating in value-based payment arrangements. Improving care and succeeding in value-based payment requires considerable, shared infrastructure. All health centers struggle to put this infrastructure in place, but small health centers face unique challenges in securing access to capital, building expensive data capabilities, and negotiating favorable rates with vendors and con- tracts with health plans. Health centers have a history of working well together on advocacy and policy, but the recent infrastructure requirements for value-based pay and care redesign invite new kinds of partnerships. Sharing infrastructure, clinical approaches, and data openly with partners rep- resents a new way of thinking for many health centers. The following case studies demonstrate some partner- ing strategies that have opened up new doors for small health centers and effectively stretched their limited resources. In this health care environment, finding part- ners to share resources and infrastructure will be crucial to success. California Health Care Foundation 38 Case Studies The following four case studies — from diverse geographic regions across California — show how small health centers have taken advantage of partnerships to enhance their ability to sustain high-quality, comprehensive care for their patients and/or better position themselves for participation in value-based payment. They represent the wide range of partnership options discussed in this paper. The sites were recommended as compelling examples of relationships that can support small health centers. CASE STUDY 1 Partnering to Support Physical, Mental, and Hill Country Community Clinic Social Wellness Leveraging a county partnership to bring behavioral HCCC developed its unique approach to providing holis- health and community resources to a rural setting tic care in response to patients’ behavioral and social needs through several innovative partnerships and fund- This small, rural health center used a variety of partner- ing streams. Its most significant partnership is with the ships to provide more comprehensive, whole-person care Shasta County Mental Health Department (SCMHD), to their community. Hill Country Community Clinic’s story a department under Shasta County Health and Human demonstrates how partnerships involve serendipitous Services. In 2006, SCMHD stopped direct provision of timing, relationship building, and the ability to mold a mental health services and closed several outpatient cohesive program from work supported by different part- and inpatient mental health facilities. In response, com- ner organizations. munity providers convened a coalition to decide how to Interviewees best address mental health service needs. This coalition Lynn Dorroh, CEO work allowed HCCC to respond the following year when Nick Cutler, CFO the county received funds through the Mental Health Bridget Schafer, CIO/COO Services Act (MHSA, also known as California Proposition Susan Foster, Medical Director 63). As a result, HCCC was able to offer a variety of men- tal health services to a larger population and work more Organizational Profile intensively with the severely mentally ill. Located in Round Mountain, a small town about an hour east of Redding in Northern California, Hill Country HCCC also opened the Circle of Friends Wellness and Community Clinic (HCCC) has been working toward the Recovery Center, a wellness and peer-support program integration of behavioral health, dental care, and primary for families experiencing mental illness. Circle of Friends care since 1982. Responding to unmet needs for primary offers classes and activities such as knitting, quilting, and care, HCCC opened a satellite clinic in Redding in 2015, painting; workshops on topics such as boundary-setting and it also runs a number of community-based wellness and dealing with loneliness; and group social activities programs. The health center provides a wide array of such as movie days and volunteering at local parks. HCCC services including dental care, behavioral/mental health simultaneously expanded its intensive case management care, substance abuse treatment, complementary and program to serve teens with serious mental illness and to alternative treatments, supportive services, and commu- implement an after-school wellness program. nity linkages. Recent funding from SCMHD helped initiate the CARE HCCC has grown from serving about 3,700 people in (Counselling and Recovery Engagement) Center in 2013 to more than 6,000 in 2016. The payer mix changed March 2017. Open 24 hours a day, seven days a week, dramatically during that period, from 35% uninsured in the CARE Center’s goal is to reduce inappropriate emer- 2010 to 8.5% uninsured in 2016, a change largely attrib- gency department use for mental health crises and utable to Medicaid expansion. Of HCCC’s patients, 66% provide intensive case management to those with serious are age 18 to 64, and 20% are under 18. HCCC has had mental illness. The CARE Center also supports foster chil- very stable leadership; the current CEO has served for dren and families and has space for community members over 13 years and is well known and respected in the to connect with each other. A mental health counselor is community. on call to deal with crises. Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 39 HCCC participates in Shasta County Health and Human Close-knit communities where many people have long- Services Agency’s Whole-Person Care pilot, a Medi-Cal standing relationships helped the CEO and her team program to coordinate care for Medi-Cal beneficiaries develop important partnerships and gain a well-deserved who are high utilizers of services. Through this pilot, HCCC reputation; some of these components would not be fea- provides intensive case management for qualified home- sible in large, urban centers. less individuals and is exploring the creation of a mobile crisis unit. To support whole-person care, HCCC inte- Key Takeaways grated a comprehensive panel of mental and behavioral health screening tools (e.g., PHQ-9, Generalized Anxiety HCCC, while a relatively small health center, has built a Disorder-7 [GAD-7], Adverse Childhood Experiences comprehensive set of services for their clients by look- [ACEs], SBIRT, and opioid risk assessment) and documen- ing outside standard clinic funding mechanisms and tation and referrals to related services. These activities engaging with partners. The following are some of the have put HCCC in the top quartile of all community strategies HCCC has used to maximize the overall effec- health centers in the country for tobacco use screening tiveness of their partnerships and build a comprehensive and providing a cessation intervention, as well as screen- set of services around multiple partnership activities: ing for depression and providing a follow-up plan. $$ Relationships are critical. HCCC is known as a good partner that is friendly, flexible, and easy to work with In addition to the partnership with SCMHD and Shasta and has demonstrated several times throughout its County Health and Human Services, HCCC has many history the importance of relationships. other alliances that expand its capacity to address the social determinants of health and serve high-needs and $$ Develop a clear mission. HCCC chose early on at-risk populations. These include participation with to focus on behavioral health integration and the the Special Education Local Planning Agency (SELPA), mental health needs of at-risk populations. This move Partnership Health Plan, Alliance Chicago, Shasta Health positioned it to respond to recent funding and part- Assessment and Redesign Collaborative (SHARC), and nership opportunities targeted at whole-person care Health Alliance of Northern California (HANC). and the social determinants of health. $$ Listen to the needs of the community and com- These partnerships, especially the funding partnership munity partners. Listening and planning around the through SCMHD, enable the health center to target spe- needs of the people served allows a clinic to focus cific populations that need specialized support. Other efforts on areas of high need and the potential for partnerships allow access to QI and IT technical assis- high impact. tance. HCCC benefits from their ability to knit resources into a cohesive whole of sustainable programs. $$ Develop a reputation for being good collaborators and partners. By garnering respect in the local and HCCC works with their partners to plan for the future. regional community, HCCC’s CEO leveraged many One example is the City of Hope, an ambitious collab- important partnerships and funding opportunities. orative project aimed at providing holistic care including $$ Demonstrate the organization’s mission statement primary care, dental care, behavioral health, support on a regular basis. This underscores commitment to services including wellness recovery action plans and core goals and values. résumé building, and housing for homeless and tran- sitional youth. The City of Hope will engage numerous $$ Base actions and decisions on a clear mission. This community partners. attracts similarly mission-driven employees who see the long-term sustainability of the organization as a Caveats joint effort that they are willing to commit to for the HCCC initiated a relationship with the county based on long term. a large gap in care and a real need to find services for a vulnerable population. This ready-made partnership opportunity might not exist in other regions. California Health Care Foundation 40 CASE STUDY 2 Health Center Partners of Southern as the umbrella organization for a family of the following three companies. California and Community Health Systems, Inc. Health Quality Partners (HQP) develops and imple- Partnering to improve administrative efficiencies and ments innovative, collaborative programs that focus on build an infrastructure for value-based payment and care access to care, patient engagement, and quality and per- formance improvement support for members. It serves For Community Health Systems, Inc., a midsize health as an innovation hub and incubator to improve primary center in Southern California, joining Health Center care. Historically, HQP has provided managed care con- Partners of Southern California was a game changer. tracting and other services that are available for purchase This case study describes the experience of participating by all members. in a consortium that includes a QI-focused nonprofit, a clinically integrated network of health centers operating Integrated Health Partners (IHP) is HCP’s clinically inte- under a master contract with health plans, and a nation- grated network. Eleven of 17 HCP members currently wide purchasing organization. operate under a group contracting model, where mem- Interviewees bers maintain their discrete organizational identities but HCP Henry Tuttle, CEO work together to achieve clinical integration; the goal is Nicole Howard, EVP, CAO to implement the same clinical protocols and provide the Sabra Matovsky, former EVP same level of care across all sites. IHP is governed by CHSI Lori Holeman, CEO an independent board of directors that includes up to five of the 11-member health centers’ CEOs and HCP Organizational Profile leadership. Additionally, IHP members are eligible for Community Health Systems, Inc. (CHSI), with five sites performance incentives if they reach quality and access in Riverside, San Bernardino, and North San Diego metrics negotiated with the plan (most are HEDIS counties, serves about 25,000 unduplicated patients measures). annually with a budget of just over $20 million. CHSI joined Health Center Partners of Southern California CNECT is a nationwide group purchasing organization (HCP), a consortium of 17 community clinic and health (GPO) that optimizes member operations through a center organizations. HCP members operate 133 medi- robust 2,200+ GPO contract portfolio and consultative cal and dental practices in San Diego, Riverside, and supply chain support. Membership in this organization is Imperial counties, collectively serving 868,000 patients. broader than the consortium membership at more than HCP fulfills many of the same functions as other consor- 6,500 members to date. CNECT is a source of innovative tia in respect to policy, advocacy, and training. It serves external revenue streams for the consortium. Health Center Partners of Southern California Health Quality Partners Integrated Health Partners CNECT Quality improvement-focused Clinically integrated network under Nationwide support in purchasing nonprofit subsidiary a master contract with health plans supplies and select services Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 41 Consortium Meets Multiple Needs of an Improving Quality Through Culture Change and Data Unaffiliated Health Center Changes in staffing for QI were implemented prior to With the Affordable Care Act, many health centers joining HCP, but improving data systems and analytics invested in EHRs. CHSI chose instead to use a capital was an infrastructure challenge that HCP helped CHSI to investment grant to expand its sites. But with the expan- overcome — ultimately improving care and outcomes. sion accomplished, CHSI worried that they were four years behind their peers in EHR adoption and optimiza- CHSI viewed HCP as a key facilitator in providing techni- tion. As a midsize health center, CHSI also struggled with cal assistance to the QI team as they made the changes being deprioritized by vendors for optimization, training, necessary to become PCMH recognized. CHSI was able and technical assistance. to draw on other health centers in the network to help solve problems — through a one-on-one call between These factors led CHSI to join the HCP family of com- medical directors or by having an expert from another panies, which offered access to training, consultants to health center come and give an in-service training to provide technical assistance, and opportunities to learn staff. CHSI staff also regularly participate in HCP peer from other health centers that had already been through learning committees. About peer learning, Lori Holeman this transition. For CHSI, the dues and fees associated observed, “Information is shared freely — you can eas- with joining were a significant investment. However, ily find someone who has had a similar problem.” Such CHSI CEO Lori Holeman described this decision as “a interactions with other health centers have helped CHSI game changer.” to feel less isolated. Prior to joining HCP, CHSI leaders described feeling like it was just “swimming upstream The benefits of the partnership — including improved the whole time” and that it was much easier to be a part care quality and increased revenues — have outweighed of “a whole pool of fish.” the costs. CHSI improved its ability to collect and analyze data through its EHR, enhanced its performance across Changing its care model and enabling the additional several quality measures, and was able to achieve Level data collection and analysis associated with being part 3 PCMH recognition for all of its sites in 12 months. HCP of HCP required CHSI to make significant staff changes. described being able to “fast track” CHSI’s progress in This included expanding its QI group and training all staff a number of areas. Benefits to joining have positively to be accountable for data quality. impacted CHSI’s quality of care as well as its financial stability. Participation in IHP and HCP’s technical assistance in EHR optimization (in its role as a health-center-controlled net- work) gave CHSI access to new data and analytics for QI. An important piece of data that CHSI was newly able to “When we began with this, we would see our access was the assigned member population that hadn’t HEDIS scores — . . . the different measures previously been a point of focus for staff or providers. Using the new QI team, CHSI is now actively managing colored red, yellow, and green — I just these patients, including those who are assigned but have stared at two pages of red [lower than a not yet been seen, leading to notable improvements in quality outcomes. Because many of these “assigned but desired performance level]. In a little over a not seen” members are included in HEDIS denomina- tors, reaching out to ensure that they receive preventive year and a half . . . we went from mostly red screenings and to engage them in primary care is key to to all yellow and green on every measure! improved care. CHSI leaders believe the technical assis- tance, transparency in committee members, and effective With the improvement in the data, we have communication around data verification processes have improvement in the incentive monies greatly bolstered performance on quality metrics. CHSI described this as one of many ways that its decision to that come in.” engage with HCP helped the health center to deliver — Lori Holeman, CEO value-based care and improve performance under value- Community Health Systems, Inc. based payment arrangements with payers. California Health Care Foundation 42 Financial Benefits Rooted in Negotiating Power Investment in IHP and other services from the family of As part of larger entity, CHSI sees increased clout with companies in terms of dues and investment in technol- payers, hospitals, and local decision-makers. Negotiating ogy licensing fees is substantial for a health center the size with payers as a group with IHP has led to higher pay- of CHSI. However, leaders estimate that the increased for-performance and incentive payments than CHSI performance payments financially balance these costs. achieved alone. In addition, hospitals in the community When taking improved patient and staff experience into have been more willing to talk about emergency depart- account, CHSI leadership believes these are worthwhile ment diversion programs and other initiatives. investments for maximizing revenue under current and future value-based pay arrangements. As a result of having data on all assigned members from IHP, CHSI has also been able to increase revenue by Implications for the Field actively engaging all assigned members in primary care. FOR HEALTH CENTERS: It has done this by inviting patients to a face-to-face visit and making sure that they are using the full range of $$ It is worth being deliberate about the objec- CHSI’s services in addition to primary care. tives sought in joining a consortium or network. Consider questions such as the following: What is the main focus (e.g., is it more politically focused or more QI driven)? Who are the other members and are they “We increased the staffing in our QI team. like-minded? CHSI did this research and found that Before we could run on one or two people, convincing clinic leadership to make the initial invest- ment in joining the consortium was bolstered by a QI nurse and the CMO. Now we have HCP’s strong reputation and like-minded leadership. 10 different people looking at data, IT $$ The transition from the status quo to more data- driven care is a pain point for some health centers. structure, provider care, watching all Cleaning and validating data is a painful but nec- the measures. We’ve invested in trainers essary step toward improved care and successful participation in value-based contracting. and train full time at all clinics. With FOR CONSORTIA: staff turnover and continued systems $$ Consortia may have an opportunity to build on improvement, there is a need for continued their experience in providing training, best training to ensure that data is as clean and practices sharing, and technical assistance with QI to explore group contracting opportunities accurate as possible.” with payers. — Lori Holeman, CEO $$ Consortia can fulfill their mission of supporting a Community Health Systems, Inc. thriving safety net by expanding their membership to include motivated small and medium health Improving quality and the IHP-negotiated group contract centers that can benefit from such supports. CHSI are enabling CHSI to receive significant and consistent noted several potential ways to facilitate this expan- performance payments for the first time. Prior to joining sion, including lowering dues and fees to be more IHP, any performance payments were earned “by acci- affordable for small health centers and expanding dent” because the health center had such limited data geographic membership. to understand their practice model and outcomes. CHSI leadership sees this new consistency in care, and the financial rewards received for high-quality outcomes, as contributing to the health center’s financial stability. Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 43 “We do see more patients now. In the past, Key Takeaways we had outreach events, but we didn’t have $$ Consortia, consider expanding your role. HCP has expanded its role to include a wide range of services an organized fashion to use the data from and support that help members improve care and the plans to see what patients we are seeing succeed under payment arrangements with health plans. These offerings include a clinically integrated and what patients are not coming in.” network, group purchasing discounts, training and — Lori Holeman, CEO technical assistance, managed care contracting sup- Community Health Systems, Inc. port, and other services. $$ Recognize the related effects of improving data Caveats systems and QI, and of participating in value- HCP was careful to note that several factors helped facili- based payment. As a midsized health center, CHSI tate its success. These include: was able to benefit from this partnership and the $$ A history of more than 40 years of partnership multiple services offered by a high-functioning among health centers in San Diego County that consortium. The partnership as a whole facilitated formed a critical foundation of trust. Member a chain of events starting with EHR optimization, health centers have long-tenured CEOs who through QI, and ending with dollars attached to already knew each other well. improvements in quality performance. $$ A high-level of pre-existing capacity among health $$ Take advantage of benefits consortia can offer. centers and supporting organizations. CHSI accelerated its transformation to PCMH by joining the consortium and taking advantage of staff The availability of significant internal and external finan- training, data and analytics, new QI infrastructure, cial resources to fund planning and readiness activities. and more favorable value-based payment contract- The founding members of IHP each contributed $10,000 ing. CHSI went through a change process that it had to cover initial legal and planning costs, and $200,000 taken other health centers a decade to achieve. each in loans to cover IHP start-up costs. These loans will be repaid when IHP builds sufficient reserves to meet its reserve policy. In addition to these resources from mem- bers, HCP administers over $6 million of grant funding annually, including a federal HCCN grant from HRSA. Every member in a collective contracting arrangement — large or small — needs to bring a benefit to the col- lective and must be ready for a high level of transparency about individual health center results. For health centers without a significant number of patients or those lack- ing strong baseline outcomes, this benefit may be in the form of a specialized skill, such as care managing a spe- cial population, or in demonstrating the ability to rapidly improve outcomes. California Health Care Foundation 44 CASE STUDY 3 “I would highly recommend this model. Community Health Center Network A partnership for analytical support and participation in The administrative structure is key. . . . It’s value-based payment through managed care important that everybody, regardless of This case study profiles the Community Health Center size, has a fairly equal say in whatever the Network (CHCN), a health-center-led managed care organization (MCO), through the perspective of two of decisions may be.” the smaller health centers in the group (Axis Community — Sue Compton, CEO, Axis Community Health Health and Tiburcio Vasquez Health Center). This partnership model centralizes managed care func- Tiburcio Vasquez Health Center is described as a “clas- tions and has proven successful in improving care and sic-model” health center by CEO David B. Vliet. It was accessing additional funding from payers. founded in 1971 to serve migrant workers and other mar- ginalized groups in southern Alameda County. Tiburcio Note: CHCN refers to itself as a managed care organi- Vazquez is a midsized organization with a budget of about zation (MCO) to best reflect its core functions, and this $35 million serving approximately 25,000 unduplicated term is used throughout this case study. However, other patients. Patients are largely Spanish-speaking families organizations that serve similar functions use the term in Union City, Hayward, and San Leandro. In addition to “health-center-led IPA”; this term is used in this paper medical services, Tiburcio Vasquez has a robust promo- to refer to these types of organizations overall, including tora program as well as state and county contracts with CHCN, in its typology of partnerships.  CalWorks and CalFresh. Tiburcio Vasquez is also one of the larger WIC providers in the area. Interviewees CHCN Ralph Silber, CEO The Community Health Center Network was estab- Laura Miller, CMO lished in 1996 in response to the advent of managed care Tiburcio Vasquez David B. Vliet, CEO in Alameda County. CHCN currently has eight member Axis Sue Compton, CEO health centers, and takes full professional risk for 141,000 Medi-Cal members. It contracts for primary care services Organizational Profile with all eight health centers and contracts and pays claims Axis Community Health was founded in 1972 to pro- for specialty care and lab services. If there is a surplus vide health care in Eastern Alameda County. It has five after paying out these claims, CHCN shares it prorated sites serving about 14,000 unduplicated patients with to patient population size and contingent on achieving a budget of $18 million. In contrast to other clinics in defined performance outcomes. CHCN also fulfills a host the network, Axis Community Health is in a suburban/ of community leadership, administrative, and analytic rural location that is somewhat geographically isolated tasks for member health centers paid for through a man- — some patients travel 10 miles to the nearest health agement services organization fee. CHCN evolved from center, and many make the trip into Oakland, 25 miles the Alameda Health Consortium, through which these away, for specialty or hospital care. same eight health centers had already been collaborat- ing on advocacy and policy work for many years. “There’s always little fear of getting run The CHCN governance structure, a board comprised over, but in general we have a good of the CEOs of each of the member health centers, understanding amongst ourselves of was replicated from the consortium structure. The eight health centers differ in terms of patient demograph- equality in decision making — we just ics and geographic distribution, and they are intent on have to be sure to speak up about remaining independent. They nevertheless see the ben- efit of working together and have overcome barriers to what it means to be small.” collaboration through a sense of shared mission and a — Sue Compton, CEO, Axis Community Health board structure where all members have a voice. The Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 45 interviewees emphasized the importance of making sure In terms of exploring future value-based payment, CHCN the perspective and the unique needs of small organiza- has been at the forefront of state negotiations to shape tions are heard. health-center-specific APMs. Indeed, health center lead- ers cited continued reliance on the PPS rate as a barrier Axis and Tiburcio Vasquez CEOs see CHCN as serving to truly transforming clinical practice. CHCN has helped multiple functions including providing financial returns, its interested member health centers to evaluate their both in terms of current and future contracts; operating capacity to participate in the APM, including data-driven as a mechanism for improving care, including building exploration of the financial risks and opportunities associ- understanding and capacity to manage utilization out- ated with a shift away from volume-based pay. side primary care and managing social complexity; and providing economies of scale in centralized administra- Axis and Tiburcio Vasquez CEOs see CHCN’s capacity to tive functions. analyze data across health centers, as well as the incor- poration of data from other parts of the health system, as a key benefit of participation. Health centers receive detailed clinical reports on quality measures in addition “Sweet spots — where you just have to to financial reporting. CHCN has also leveraged its cen- know a lot of detail and sometimes very tralized data analytic capacity to demonstrate the impact to health plans on metrics they value. For example, health specialized information that you have to plans are motivated by opportunities to improve HEDIS keep up with. . . . Increasingly, there’s a lot measures, and CHCN is partnering with their member health centers to help them meet this health plan goal. of complexity on the business end that isn’t When HEDIS scores improve, the health centers ben- efit under pay-for-performance contracts held with the very different by clinic and the population/ plans. CHCN’s analytic capacity has also been essential in community they serve.” ongoing professional risk-contracting negotiations and in — Ralph Silber, CEO securing supplemental funding for innovative programs Community Health Center Network such as its intensive outpatient care management pro- gram, Care Neighborhood. Centralizing Managed Care Expertise and Though members are not currently sharing medical pro- Data Analytics Capacity tocols, data is shared for risk management and quality Centralized managed care expertise, administrative func- purposes. This includes transparently looking at indi- tions, and analytic capacity are integral to the success of vidual health center results on a host of quality process value-based payment arrangements. Axis and Tiburcio and outcome metrics. Comparison of health centers was Vasquez CEOs see CHCN as an efficient way of centraliz- described as a positive process that prompts the unveil- ing managed care contracting expertise (and headaches) ing of best practices and areas for growth. and meeting health plan needs. Over the years, CHCN has realized that there are many areas of specialized Health center leaders saw clear financial benefits rooted knowledge involved in taking risk in California’s managed in negotiating clout and in the upside of bearing risk. care regulatory environment, and that it makes sense to CHCN represents 141,000 lives, and has been able to have one central expert rather than having each health wield the corresponding clout with both payers and part- center house this expertise. For CHCN leadership, the ners. For example, CHCN successfully negotiated with network has a clear function of centralizing administra- plans for supplemental payment for the social determi- tive functions so that health centers can focus on patient nants of health-focused Care Neighborhood intervention. care. CHCN provides particular support in data analytics, In another example, CHCN is a contracted partner under compliance, and credentialing, but it is always looking Alameda County’s Whole Person Care Pilot as the county for ways to shift functions that can be lifted from member strives to better coordinate behavioral health, social, and health centers and streamlined. health care services for some of the county’s most vulner- able residents. California Health Care Foundation 46 During 20 years of operating in a capitated risk environ- of Care Neighborhood in reducing utilization and costs; ment, CHCN has been able to effectively manage the this has prompted health plan investment, which in turn financial risk it has taken for the benefit of its members. allows CHCN to continue to do this work. For a small health center, participation in CHCN was seen as essential for negotiating contracts and data analytic Health centers, particularly small members like Axis, capacity. CHCN provides the data for health centers to have benefited from the increased gravitas afforded by actively manage assigned members, both in terms of the CHCN partnership. Being well known in the com- making sure all assigned members have had at least munity, and having the credibility to collaborate with one visit at the health center (to establish a relationship others, has facilitated the member health centers’ par- between members and their PCMH) and making sure ticipation in a range of community initiatives, including that established patients are receiving timely and appro- improving care coordination and transitions of care. For priate care. In terms of risk sharing, small health centers example, CHCN leaders negotiated with a local private noted advantages in sharing risk with other larger health hospital to fund health center nurses to manage hospi- centers in the network. tal transitions. Using CHCN data analytics, this program has demonstrated reduced readmissions and emergency Health center leaders anticipate an increasingly value- department use, which has helped the hospital to sustain based payment and care going forward, and they cite the program. many of the functions of CHCN (data sharing, QI support) as critically important for this future. CHCN has also supported innovation in specialty care through building relationships with hospitals and imple- menting an e-consult platform. Because the expansion of Medi-Cal has taxed existing specialty connections, “If you’re small and you’re taking risk on CHCN is seeking to build trust between its 500 primary your own, and you have a couple of really care physicians and public hospital specialists by host- ing dinners and facilitating specialist shadowing. CHCN high need patients, it stings. Risk sharing is partnered closely with the county health system to offer always a good thing.” a number of county health system specialists as first responders to e-consults sent out by CHCN primary care — Sue Compton, CEO Axis Community Health providers to a national network. Going forward, CHCN plans to continue to build on its experience with care management with a social determinants focus through a Building Care Management Capacity and number of initiatives. CHCN leaders see their MCO future Focusing on Social Needs as increasingly including HEDIS QI work, improved care CHCN supports building care management capacity with transitions, and potential expansion into confronting the a social determinants focus and expanding access to spe- opioid epidemic in primary care. CHCN is also exploring cialty and primary care. It takes an active role in improving taking risk for mild to moderate behavioral health and care quality and supporting care transformation. CHCN continues to be at the forefront of coordinated health has developed innovative pilot programs such as Care and behavioral health care through its participation in Neighborhood, an intensive outpatient care manage- Alameda’s Whole Person Care pilot (Alameda County ment effort. Care Neighborhood is a hybrid program with Care Connect). centralized program development and administration through CHCN and implementation through health cen- For small and medium health centers interested in taking ter-employed community health workers. The program professional risk and building capacity for care manage- is focused on addressing the social determinants and ment and coordination, a health-center-led MCO model behavioral health issues that contribute to repeated hos- can help to improve care and gain access to additional pitalizations and episodes of post-acute care — including funding from payers. In many ways, health-center-led housing; food insecurity; transportation and mobility MCOs are taking on the role that Medicaid ACOs are issues; access to health care; loneliness and social isola- playing in other parts of the country in terms of help- tion; and the intersection of trauma, behavioral health, ing providers transform care, and they benefit financially and poverty. CHCN used data to demonstrate the value from those transformations. Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 47 Caveats Plan and managed care structure may preclude the for- mation of health-center-led MCOs. In some counties, health plans will only contract directly with health cen- ters. In other counties, contracting has evolved in such a way that it would be difficult for health centers to start an entity like CHCN. The formation of an MCO may require third-party assis- tance from experts in multiple parts of the arrangement on both the clinical and legal aspects. Key Takeaways $$ Be sensitive to issues of equality. A board structure where each member has an equal vote was seen as a key element in the success of CHCN. Health centers that vary across a number of factors, including size and patient demographics, have been able to work collaboratively under this governance structure. $$ Use shared commitment and strong leadership to build trust. A collaboration of this nature relies on trusting relationships and leadership. At times, health centers may need to compromise when there is a benefit to the group that might not be an individual health center’s first choice. For this kind of arrange- ment to be successful and sustainable, members must share a commitment to the overall benefits of collaboration and draw on talented leadership to foster trust and collegiality. $$ Look for ways to centralize. There are infrastruc- ture components and administrative functions that can be successfully centralized. As the business side becomes increasingly complex for health centers, having a dedicated and trusted central entity for some functions can help them take advantage of revenue opportunities that require a certain level of infrastructure (e.g., data analytics or managed care contracting expertise). California Health Care Foundation 48 CASE STUDY 4 In the mid-1990s, the hospital found itself treating Parktree Community Health Center patients in the emergency department for primary care An acquisition to preserve and expand services needs. Recognizing the potential to deliver better primary care in more appropriate settings, they began exploring This successful “merger of missions” between a small, public and private partnerships. The hospital partnered independent community clinic and a community health with a local pediatrician to fund a school-based clinic to center was technically an acquisition. The case study provide care for uninsured children where there were few highlights how thoughtful leadership and dedication to pediatricians willing to see children covered by Medi-Cal. the same mission can lead to the formation of a com- This practice grew to become KCF. bined organization that preserves the mission and vision of the original, separate entities. During this timeframe, a PVHMC family medicine resi- dent Dr. Jamie Garcia and PVHMC CEO Rich Yochum Interviewees implemented their vision to combine LA County fund- Parktree Ellen Silver, CEO ing and PVHMC funding to create an outpatient primary Cynthia Prendiz, Chief Engagement Officer care clinic in Pomona. Under the hospital’s guidance, the PVHMC Rich Yochum, President/CEO clinic eventually became the Pomona Community Health Chris Aldworth, VP of Planning Center (PCHC). PCHC incorporated with the assistance of PVHMC capital dollars and LA County funding and Organizational Profile became an FQHC in 2013. Originally, PCHC staff were Parktree Community Health Center (CHC) consists of four hospital staff, but gradually they transitioned to become Southern California clinics in Pomona and Ontario. It is PCHC employees. In 2012, PVHMC, along with LA the combined vision of Kids Come First (KCF), a non- County and LA Care Health Plan, provided capital dollars profit, state-licensed independent community clinic led for expansion to a 13-exam room clinic in a second PCHC by Cynthia Prendiz, and the Pomona Community Health Pomona site. Center (PCHC) led by Ellen Silver. Though the merger is just over a year old, Parktree CHC has already realized significant advantages. Increased Financial Strain PVHMC remained an active participant in the solvency of both KCF and PCHC through various community ben- The original KCF dental program served as the starting efit activities and with key leadership from the hospital place for a new dental expansion grant awarded in 2016; serving on the governance boards of each clinic. In 2015, 800 patients have now received oral health services as KCF was facing increased financial strain and unforeseen part of their primary health care. In 2017, Parktree CHC key staffing turnover that led their CEO, Cynthia Prendiz, received one of only 75 federal New Access Point expan- to the decision that KCF needed to consider joining sion grants and has opened a second site in Ontario. another organization. She connected with Ellen Silver, These expansions, which resulted in increased access for the CEO of PCHC, and they identified potential ways to the Ontario community, were facilitated by the successful partner in the management of operations and recruit- transition of PCHC and KCF to a unified Parktree CHC.  ment challenges at KCF and PCHC. They found synergy in their leadership vision and values that set the stage A Partnership in the Making for the personal and organizational evolution that came This story began at Pomona Valley Hospital Medical next. Center (PVHMC) a nonprofit, 437-bed acute care commu- nity hospital at the far eastern edge of Los Angeles (LA) County. It served eastern LA and western San Bernardino counties for more than a century. According to the CEO “My biggest role was to make a way for the of PVHMC, the hospital has always had a mission to serve the community and has been a longtime provider of care clinic to survive and thrive. It was important for patients in these two communities who are uninsured for the community that we were still there.” or covered by Medi-Cal or Medicare.  PVHMC’s leader- ship understood the importance of providing health care — Cynthia Prendiz, Chief Engagement Officer Parktree Community Health Center to the entire community and recognized that primary care clinics were vital to the PVHMC population health goals. Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 49 A Merger of Missions KCF brought a passionate culture of “finding the yes” Though legally an acquisition, the message to staff and when serving patients regardless of the job description. patients was that the move was a “merger of missions.” This commitment to teamwork to meet the patients’ To make this real, both organizations’ boards worked needs is a treasured asset now modeled by all staff at with a facilitator to establish the mutual benefit of the Parktree CHC. To this patient-centered approach, PCHC arrangement and to align governance. One KCF board added competencies in risk management and patient member joined the 10-member PCHC board. In addition, safety as well as finance expertise and financial stability an Ontario Advisory Committee, which includes leader- to the culture of KCF. ship from both KCF and PCHC and reports to the board, was formed to ensure organizational focus on their com- Kids Come First / Parktree Community Health Center munity. Though required for one year by the acquisition Merger Transformation agreement, Parktree CHC leadership has continued this KCF PCHC PARKTREE committee to stay in touch with the Ontario community   2014 2014 2016 originally served by KCF. A significant part of the strat- Patients 2,910 2,511 7,610 egy was to merge the cultures on an equal footing, and so the combined clinic was renamed and marketed as Visits 7,433 10,271 22,535 Parktree Community Health Center. Clinic Sites 1 2 4 Throughout the acquisition there was a strong focus Employees 10 14 76 on staff and patient engagement and communication Annual Budget (in millions) >$1 $2.4 $7.6 throughout the merger process. Most KCF staff received upward adjustments of their salaries and benefits and Source: Kids Come First. new access to the PCHC retirement plan. Significant effort was put into training staff in the EHR, work flows, and clinical competencies. Patients were notified of the Caveats merger of missions through staff talking points, flyers, The success of this acquisition that looks like a merger and posters. Information stressed the advantages of the depended on a strong shared vision, an already estab- acquisition, which included expanded services, loca- lished relationship, and a willingness to bring leadership tions, and hours. In the transition period, the call center from the acquired organization to the table in a continued answered the phones with both clinic names to reassure prominent role. Silver credited Prendiz’s selfless commit- patients that they had reached the correct number.  ment to put the community first as a key facilitator in the successful merger.  Leadership was intentional about noting and assimilat- ing the best parts of both organizational cultures. PCHC Financial solvency was buoyed by the involvement of CEO Silver continued in the role of CEO at Parktree CHC, PVHMC both before and after the acquisition. but she recognized KCF’s long engagement in Ontario and wanted to maintain the “voice and vision” KCF had It is common that small and medium community clinics for that community. The role of chief engagement officer serve a defined segment of their community. There is was created for KCF CEO Prendiz, in part to demon- often strong staff, leadership, and governance commit- strate continued commitment to staff and the Ontario ment to the founding mission to serve this key group of community and to emphasize the centrality of Prendiz’ patients. Losing connection to this mission and control leadership. Prendiz is currently in charge of patient out- over the business are significant barriers for clinics con- reach and in-reach efforts, managing the call center, and sidering partnerships, mergers, and acquisitions to grow responsible for both patient and staff satisfaction. their organization and patient panel. California Health Care Foundation 50 Key Takeaways $$ Find the “wins” for the organizations and the community. This merger was a win-win-win for the three partners. PVHMC, with continuing capital and in-kind support, has realized increased stability in its primary care safety-net partners, bringing bet- ter access and more comprehensive services for the community. KCF, with improved financial and opera- tional stability, is able to spread its patient-centered passion to adult family members of the pediatric population it has always served. PCHC has increased access to care for children, more sites, dental services for patients, and highly committed patient-centered staff. $$ Find synergy in mission. KCF and PCHC, the two primary care organizations, shared an overall mission of providing excellent care to their community. This allowed both organizations to be flexible in nego- tiating financial modeling strategies, organizational structure, and workflow tactics. $$ Leverage existing community partners, especially hospitals and health plans. The shared history of working alongside a third partner, PVHMC, with its extraordinary community focus, represented a financial and leadership asset for this acquisition. The hospital’s vision to ensure stable access to primary care for the community was crucial in developing the clinics and supporting the culture for the partnership.  $$ Build on a foundation of trust. KCF had a history of referring adult family members to PCHC and had already developed trust in the alignment of its mis- sion to serve patients and the community. Further, the CEOs developed trust, which enabled them to share and resolve fears and concerns as the process developed.  $$ Lean on your leaders. The vision, commitment, and continuity of leadership present in these three organizations created the foundation for the success- ful merger. With its team in place, the organization anticipates forming other new partnerships in the near future. Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 51 Appendix A. Expert Advisors and Key Informants Expert Advisors Ellen Silver Veenu Aulakh, MSPH Chief Executive Officer Executive Director Parktree Community Health Center Center for Care Innovations Judith Steinberg, MD, MPH Robert Beaudry, MS Chief Medical Officer, Bureau of Primary Health Care Chief Operating Officer and Executive Vice President Health Resources and Services Administration California Primary Care Association Winston Wong, MD, MS Doreen Bradshaw Director, Disparities Improvement and Quality Initiatives Executive Director Kaiser Permanente Health Alliance of Northern California Ron Yee, MD, MBA, FAAFP Bridget Hogan Cole, MPH Chief Medical Officer Executive Director National Association of Community Health Centers Institute for High Quality Care Key Informants Naomi Fuchs, MBA ALEXANDER VALLEY HEALTHCARE Chief Executive Officer Deborah Howell, Chief Executive Officer Santa Rosa Community Health Centers Leah Sanchez, FNP Jenine Saunders, Chief Finance Officer Alan Glaseroff, MD Co-Director ONE COMMUNITY HEALTH Stanford Coordinated Care Bob Styron, Chief Finance Officer Paolo Troia-Cancio, MD, Chief Medical Officer Laura Gottlieb, MD, MPH Christy Ward, Chief Executive Officer Director, Social Interventions Research and Evaluation Network (SIREN) COMMUNITY CLINIC ASSOCIATION OF LOS ANGELES University of California, San Francisco COUNTY Louise McCarthy, MPP Megan Haase, FNP President and Chief Executive Officer Chief Executive Officer Mosaic Medical COMMUNITY HEALTH CENTER NETWORK Ralph Silber, MPH, Chief Executive Officer Bob Harrington, MSW Laura Miller, MD, Chief Medical Officer Principal La Piana Consulting COMMUNITY HEALTH PARTNERS MONTANA Lander Cooney, MS, Chief Executive Officer Louise McCarthy, MPP Hannah Pulaski, MSN, RN, Nursing Director President and Chief Executive Officer Amber Traxinger, Human Resources Manager Community Clinic Association of Los Angeles County ESPERANZA HEALTH CENTERS Bob Moore, MD, MPH Daniel Fulwiler, MPH, Chief Executive Officer Chief Medical Officer Wayne Sottile, Chief Finance Officer Partnership HealthPlan of California Andrew Jacob Van Wieren, MD, Medical Director Erica Murray, MPA Carmen Vergara, MPH, Director, Quality and President and Chief Executive Officer, California Practice Transformation Association of Public Hospitals and Health Systems HEALTH ALLIANCE OF NORTHERN CALIFORNIA Jennifer Sayles, MD, MPH Doreen Bradshaw, Executive Director Chief Medical Officer Inland Empire Health Plan California Health Care Foundation 52 HEALTH CARE LOS ANGELES INDEPENDENT PRACTICE SAN DIEGO FAMILY CARE ASSOCIATION Roberta Feinberg, Chief Executive Officer MedPOINT Management Manuel Quintanar, Chief Executive Officer Linda Deaktor, Vice President, Quality Management Liliana Uribe Herrera, Operations Director Sandy Hazel, RN, Vice President, Medical Affairs Aaron Zaheer, MD, Chief Medical Officer Derek Schneider, Chief Financial Officer SAN FRANCISCO COMMUNITY CLINIC CONSORTIUM Iris Weil, MHA, Executive Director John Gressman, former Chief Executive Officer HEALTH CENTER PARTNERS OF SOUTHERN CALIFORNIA David Ofman, MD, Chief Medical Officer Nicole Howard, MPH, Executive Vice President and SHARE OUR SELVES Chief Advancement Officer Eric Huang, MD, Chief Medical Officer Sabra Matovsky, MBA, former Executive Vice President Karen L. McGlinn, Chief Executive Officer Henry N. Tuttle, Chief Executive Officer Sergey Sergeyev, MPA, Chief Finance Officer HEALTHRIGHT 360 Philip Velasco, MBA, Chief Information Officer Vitka Eisen, MSW, EdD, Chief Executive Officer SONOMA VALLEY COMMUNITY HEALTH CENTER Ana Valdés, MD, Chief Executive Officer Carol Ahern, MD, Medical Director HILL COUNTRY HEALTH AND WELLNESS CENTER Cheryl Johnson, Chief Executive Officer Nick Cutler, Chief Finance Officer Susan Torres, Controller Lynn Dorroh, MS, Chief Executive Officer Julie Vlasis, CQI/Compliance Consultant Susie Foster, FNP, Medical Director ST. JOHN’S WELL CHILD & FAMILY CENTER Bridget Schafer, Chief Information Officer and Helen DuPlessis, MD, MPH, former Chief Medical Officer Chief Operations Officer Jim Mangia, Chief Executive Officer LA MAESTRA COMMUNITY HEALTH CENTERS Elizabeth Meisler, Chief Finance Officer Alejandrina Areizaga, Chief Operations Officer WESTSIDE FAMILY HEALTH CENTER Zara Marselian, MA, FACHE, Chief Executive Officer Debra A. Farmer, President and Chief Executive Officer Michael Pendarvis, Chief Finance Officer Marie McKinney, Chief Operations Officer Sal Saldivar, Chief Information Officer Rebecca Rodriguez, MD, Medical Director Sonia Tucker, QI Director YAKIMA VALLEY FARM WORKER’S CLINIC LIFELONG MEDICAL CARE Glen Davis, MHA, Chief Operations Officer Eric Henley, MD, MPH, Chief Medical Officer Kevin Heidrick, PA-C, Chief Medical Officer Marty Lynch, PhD, Chief Executive Officer and Carlos Olivares, Chief Executive Officer Executive Director Kanwar Singh, Chief Finance Officer LOS ANGELES CHRISTIAN HEALTH CENTERS Lisa Abdishoo, MD, President and Chief Executive Officer Albert Ocampo, CPA, Chief Finance Officer Katy White, MD, MPH, Chief Medical Officer PETALUMA HEALTH CENTER Daymon Doss, Chief Operations Officer Nurit Licht, MD, Chief Medical Officer Kathie Powell, MSHA, MA, Chief Executive Officer Pedro Toledo, JD, Chief Administrative Officer Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 53 Endnotes 1.“Health Center Program: Impact and Growth,” Health 16.Jonathan R. Sugarman et al., “The Safety Net Medical Home Resources and Services Administration, 2017, bphc.hrsa.gov. Initiative: Transforming Care for Vulnerable Populations,” Med Care 52, no. 11 Suppl. 4 (November 2014): S1-S10, 2.B. F. Miller et al., “Payment Reform in the Patient-Centered doi:10.1097/mlr.0000000000000207. Medical Home: Enabling and Sustaining Integrated Behavioral Health Care,” American Psychology 72, no. 1 (2017): 55-68, 17.Shi, “Impact of Primary Care,” 2012. doi:10.1037/a0040448. 18.Barbara Starfield, Leiyu Shi, and James Macinko, 3.B. D. Sommers et al., “Changes in Self-Reported Insurance “Contribution of Primary Care to Health Systems and Coverage, Access to Care, and Health Under the Affordable Health,” Milbank Quarterly 83, no. 3 (2005): 457-502, Care Act,” JAMA 314, no. 4 (July 28, 2015): 366-74, doi:10.1111/j.1468-0009.2005.00409.x. doi:10.1001/jama.2015.8421. 19. Barbara Starfield, Primary Care: Concept, Evaluation, and 4.Haleigh Mager-Mardeusz, Cosima Lenz, and Gerald F. Policy (New York: Oxford University Press, 1992). Kominski, A “Cap” on Medicaid: How Block Grants, Per 20.Edward W. Gregg et al., “Changes in Diabetes-Related Capita Caps, and Capped Allotments Might Fundamentally Complications in the United States, 1990-2010,” New England Change the Safety Net, UCLA Center for Health Policy Journal of Medicine 370, no. 16 (2014): 1514-23, doi:10.1056/ Research, April 26, 2017, healthpolicy.ucla.edu. NEJMoa1310799. 5.Leiyu Shi, “The Impact of Primary Care: A Focused Review,” 21.Katie Coleman et al., “Evidence on the Chronic Care Model Scientifica 2012: 432892, doi:10.6064/2012/432892. in the New Millennium,” Health Affairs 28, no. 1 (January/ 6.Dana B. Mukamel et al., “Comparing the Cost of Caring for February 2009): 75-85, doi:10.1377/hlthaff.28.1.75. Medicare Beneficiaries in Federally Funded Health Centers to 22.George L. Jackson et al., “The Patient-Centered Other Care Settings,” Health Services Research 51, no. 2 Medical Home: A Systematic Review,” Annals of (April 2016): 625-44, doi:10.1111/1475-6773.12339. Internal Medicine 158, no. 3 (February 5, 2013): 169-78, 7.Sarah Lally and Jill Yegian, California’s Medi-Cal Managed doi:10.7326/0003-4819-158-3-201302050-00579. Care Pay for Performance Landscape, Integrated Healthcare 23.Susan Dorr Goold and Mack Lipkin Jr., “The Doctor-Patient Association, July 2015, www.iha.org (PDF). Relationship: Challenges, Opportunities, and Strategies,” 8.More information about California’s Health Homes Program is Journal of General Internal Medicine 14, Suppl. 1 (January available at: www.dhcs.ca.gov (PDF). 1999): S26-S33, doi:10.1046/j.1525-1497.1999.00267.x. 9.Nonaudited financial data obtained from the Health Resources 24.Kimberly S. Yarnall et al., “Family Physicians as Team Leaders: and Services Administration’s Bureau of Health Professions, ‘Time’ to Share the Care,” Preventing Chronic Disease 6, no. 2 the Office of State Health and Planning Department, and/or (April 2009): A59, PMC2687865. other sources, 2015 and 2016. Publication forthcoming. 25.Coleman et al., “Evidence on Chronic Care Model,” 75-85. 10.Thomas Bodenheimer and Christine Sinsky, “From Triple to 26.Edward H. Wagner et al., “The Changes Involved in Patient- Quadruple Aim: Care of the Patient Requires Care of the Centered Medical Home Transformation,” Primary Care 39, Provider,” Annals of Family Medicine 12, no. 6 (November/ no. 2 (June 2012): 241-59, doi:10.1016/j.pop.2012.03.002. December 2014): 573-76, doi:10.1370/afm.1713. 27.Kevin Grumbach and J. Nwando Olayiwola, “Patient 11.Based on non-audited financial data obtained from the Empanelment: The Importance of Understanding Who Is at Health Resources and Services Administration’s Bureau of Home in the Medical Home,” Journal of the American Board Health Professions, the Office of State Health and Planning of Family Medicine 28, no. 2 (2015): 170-2, doi:10.3122/ Department, and/or other sources, 2015 and 2016. jabfm.2015.02.150011. 12. Hallmarks of High Performance: Exploring the Relationship 28.Paul A. Nutting et al., “Transforming Physician Practices to Between Clinical, Financial, and Operational Excellence at Patient-Centered Medical Homes: Lessons from the National America’s Health Centers, Health Resources and Services Demonstration Project,” Health Affairs 30, no. 3 (March 2011): Administration, January 2016, caplink.org. 439-45, doi:10.1377/hlthaff.2010.0159. 13. California Community Clinics: A Financial & Operational 29.Robert J. Reid et al., “The Group Health Medical Home at Performance Profile, 2008-2011, Blue Shield of California Year Two: Cost Savings, Higher Patient Satisfaction, and Less Foundation, 2013, caplink.org. Burnout for Providers,” Health Affairs 29, no. 5 (2010): 835-43, 14.Thomas Bodenheimer et al., “The 10 Building Blocks of High- doi:10.1377/hlthaff.2010.0158. Performing Primary Care,” Annals of Family Medicine 12, no. 2 30.Anna D. Sinaiko et al., “Synthesis of Research on Patient- (March/April 2014): 166-71, doi:10.1370/afm.1616. Centered Medical Homes Brings Systematic Differences 15.Melora Simon et al., “Exploring Attributes of High-Value into Relief,” Health Affairs 36, no. 3 (March 2017): 500-8, Primary Care,” Annals of Family Medicine 15, no. 6 doi:10.1377/hlthaff.2016.1235. (November/December 2017): 529-34, doi:10.1370/afm.2153. California Health Care Foundation 54 31.Patricia Bromley and Walter W. Powell, “From Smoke and 49.Gloria D. Coronado et al., “Using an Automated Data-Driven, Mirrors to Walking the Talk: Decoupling in the Contemporary EHR-Embedded Program for Mailing FIT Kits: Lessons from World,” Academy of Management Annals 6, no. 1 (June the STOP CRC Pilot Study,” Journal of General Practice 2 2012): 483-530, doi:10.1080/19416520.2012.684462. (2014), doi:10.4172/2329-9126.1000141. 32.Jay Bhatia, Rachel Tobey, and Michael Hochman, “Value- 50.Jessica S. Ancker et al., “Associations Between Healthcare Based Payment Models for Community Health Centers: Time Quality and Use of Electronic Health Record Functions to (Cautiously) Take the Plunge?,” JAMA 317, no. 22 (June 13, in Ambulatory Care,” Journal of the American Medical 2017): 2275-76, doi:10.1001/jama.2017.5174. Informatics Association 22, no. 4 (July 2015): 864-71, doi:10.1093/jamia/ocv030. 33. AHRQ New Models of Primary Care Workforce and Financing, Agency for Healthcare Research and Quality, 2016, 51.Jason C. Goldwater et al., “Open Source Electronic Health www.ahrq.gov. Records and Chronic Disease Management,” Journal of the American Medical Informatics Association 21, no. e1 34. Using Data to Manage Population Health Under Risk-Based (February 2014): e50-e54, doi:10.1136/amiajnl-2013-001672. Contracts, Health Information Technology, Evaluation, and Quality Center, July 2017, hiteqcenter.org. 52.Christina Miller and Mary Takach, A Medical Home Framework for Increasing Cervical Cancer Screening Rates: Best Practices 35. Health Centers and Payment Reform: A Primer, National for FQHCs, National Academy for State Health Policy, Association of Community Health Centers, 2013, August 2013, nashp.org (PDF). www.nachc.org (PDF). 53.Mark Earnest and Barbara Brandt, “Aligning Practice 36. Comprehensive Primary Care Plus (CPC+): Practice Frequently Redesign and Interprofessional Education to Advance Asked Questions, Centers for Medicare & Medicaid Services, Triple Aim Outcomes,” Journal of Interprofessional Care 28, August 1, 2016, innovation.cms.gov (PDF). no. 6 (November 2014): 497-500, doi:10.3109/13561820. 37. Accelerating and Aligning Population-Based Payment Models: 2014.933650. Patient Attribution, The MITRE Corporation, 2016, 54.Erica A. Smith et al., “Using Health Information Technology www.mitre.org (PDF). and Data to Improve Chronic Disease Outcomes in Federally 38. Response to the Request for Information Regarding Qualified Health Centers in Maryland,” Preventing Chronic Implementation of the Merit-Based Incentive Payment Disease 13 (December 29, 2016): E178, doi:10.5888/ System, Promotion of Alternative Payment Models, and pcd13.160445. Incentive Payments for Participation in Eligible Alternative 55. Accelerating and Aligning Population-Based Payment Models, Payment Models, American Academy of Family Physicians, 2016. November 9, 2015, www.aafp.org (PDF). 56. Hallmarks of High Performance, 2016. 39. Health Centers and Payment Reform, 2013. 57.“The Collaborative Map: Making Sense of Nonprofit 40.Lally and Yegian, California’s Medi-Cal, 2015. Partnerships,” La Piana Consulting, December 7, 2015, 41.Personal communication between Sarah Lally (project lapiana.org/blog. manager, Integrated Healthcare Association) and Rachel Tobey 58.James Maxwell, Rachel Tobey, and Christine Barron, (director, John Snow Inc.), August 2017. “Community Health Center Strategies for Pursuing 42. Medicare Program; Revisions to Payment Policies Under the Accountable Care,” Health Affairs Blog, 2015, doi:10.1377/ Physician Fee Schedule and Other Revisions to Part B for CY hblog20150902.050307. 2016, National Archives and Records Administration, July 15, 59.Laura M. Gottlieb et al., “Effects of Social Needs 2015, www.federalregister.gov. Screening and In-Person Service Navigation on Child 43.Bodenheimer et al., “10 Building Blocks,” 166-71. Health: A Randomized Clinical Trial,” JAMA Pediatrics 44.“Health Policy Brief: Patient Engagement,” Health Affairs, 170, no. 11 (November 7, 2016): e162521, doi:10.1001/ February 14, 2013, doi:10.1377/hpb20130214.898775. jamapediatrics.2016.2521. 45.Nadereh Pourat et al., “In California, Primary Care Continuity 60. Laurie Felland, Stepping Up to the Plate: Federally Qualified Was Associated with Reduced Emergency Department Health Centers Address Growing Demand for Care, California Use and Fewer Hospitalizations,” Health Affairs 34, no. 7 Health Care Foundation, 2016, www.chcf.org. (July 2015): 1113-20, doi:10.1377/hlthaff.2014.1165. 61. Felland, Stepping Up to the Plate, 2016. 46.Bodenheimer et al., “10 Building Blocks,” 166-71. 62.Rachel Tobey et al., Health Centers in the Era of Accountable 47.Wagner et al., “ Changes Involved in Patient-Centered,” 241-59. Care, John Snow Inc., July 2015, www.jsi.com. 48.Katie Coleman et al., Redefining Primary Care for the 21st 63. Accelerating and Aligning Population-Based Payment Models, Century, Agency for Healthcare Research and Quality, October 2016. 2016, www.ahrq.gov (PDF). 64.Lally and Yegian, California’s Medi-Cal, 2015. 65.“The Collaborative Map,” 2015. Partnering to Succeed: How Small Health Centers Can Improve Care and Thrive Under Value-Based Payment 55