FQHC Payment Reform Demonstration Q & A The following Q&A describes the FQHC Payment Reform Demonstration, also commonly referred to as the Wrap Cap. A visual of the payment flow can be found at the end. As the demonstration is still being shaped, this should be considered a working document created by CPCA/CAPH for the purpose of educating members. It will be updated as legislation is finalized and collaborative pilot workgroups comprised of DHCS, health plan and FQHC representatives shape the details of the pilot. The Q&A is organized into categories: Basics Clinic Payment Plan Payment Rate Adjustment Effect on Membership Effect on HRSA Compliance Participation Relationship to other payment reforms Readiness Basics 1. Why are CPCA and CAPH working with DHCS to advance an FQHC Payment Reform pilot? We are responding to member feedback reflecting a desire for more flexibility in providing high-quality care for an increasing number of Medi-Cal beneficiaries. Patients want to be able to access primary care without necessarily seeing a clinician face-to-face in the clinic. FQHC providers have felt limited in implementing care teams when their finances still depend on visits with a billable provider. We are also taking a proactive role in designing an FQHC payment reform that improves access and quality outcomes for Medi-Cal beneficiaries and that ensures FQHC sustainability as essential community providers as the field of healthcare shifts from volume-based to value-based payment. 2. What is the best document to read to get an overview of the demonstration? The April 2015 DHCS FQHC Reimbursement Pilot is the most succinct and recent paper. CPCA and CAPH have produced numerous proposals over the last three years, and much of what was included in these proposals are included in the DHCS April 2015 document. You can find this DHCS paper in the DropBox folder entitled FQHC Payment Reform/APM Model. 3. What s an APM? APM stands for Alternative Payment Methodology. APM has a specific definition in Section 1902(bb) of the Social Security Act [42 USC 1396a(bb)(6)], which states: Congress allows use of an APM as long as: It results in payment to the center or clinic of an amount which is at least equal to the amounts otherwise required to be paid to the center or clinic under PPS 1
It is agreed to by the State and the individual FQHC or RHC The APM should be described in the approved State plan 4. Is APM synonymous with PPS as the floor? Yes. The APM also allows FQHCs to receive at least the equivalent of PPS in a different manner. The APM will not affect any of the performance-based incentives that a pilot clinic receives. The APM says FQHCs and RHCs must be paid at least what they would have been paid under PPS. An APM does not say anything about payments under an APM having to be tied to volume of visits. It does require that a state could prove that FQHCs received at least what they would have received under volume-based PPS. While this is typically done through a reconciliation process, it does not say FQHCs have to be reconciled back to their volume of face-to-face visits. In fact, a DHCS legal analysis concluded, Based on available CMS guidance, there does not appear to be specific substantive requirements attaching to approval of FQHC alternative payment methodologies (APM) which would mandate a minimum scope or amount of required reconciliations in a capitated environment or otherwise dictate fixed parameters for an APM. Rather, State compliance with the statutory requirements accompanying the approval of an APM is demonstrated using a more process-based standard whereby participating clinics attest to the sufficiency of the reimbursement received under the APM. 5. Is the FQHC Payment Reform Demonstration an APM? Yes. The California Primary Care Association (CPCA) and California Association of Public Hospitals and Health Systems (CAPH) are partners in developing a FQHC payment reform demonstration in California that is built on the federal protection of the APM. The payment reform methodology is often referred to as the Wrap Cap because essentially what would occur is the FQHC s code 18 wrap around payment from the State would be built into a capitation payment paid to the pilot FQHCs by the health plans (potentially through IPAs). The result is a pilot site will receive a single PPS-equivalent permember-per-month (PMPM) payment for assigned members in APM categories of aid from the plan or IPA. This PMPM payment would be in lieu of being paid fee-for-service (FFS) and/or market-based primary care capitation for services included in the site s PPS rate for assigned members. For care for assigned members, the APM would also eliminate billing the State wrap around and waiting for reconciliation at the end of the year. 6. Is the FQHC Payment Reform Demonstration happening now? No. At the time of this Q&A drafting, CPCA and CAPH, in partnership with LA Care health plan, are working on passing legislation (SB147 Hernandez) to authorize the demonstration of the Wrap Cap APM. The legislation is drafted such that the demonstration, once the bill is signed by the Governor, will begin no sooner than July 2016. It will be implemented by county and run for three years. 7. Is legislation required to implement an APM? Yes. In order to ensure the federal protection of the APM, legislation is necessary to authorize an APM in California. Post legislation passing, federal approval of a State Plan Amendment in the Medi-Cal Program is also necessary to ensure the protections of the APM. 8. How can an FQHC participate in the demonstration? As per the legislation, once the demonstration is signed into law, the state will issue an invitation for participation to all FQHCs in the state. FQHCs will be invited to apply and will have to meet a set of 2
participation criteria. The state, with consultation from the health plans, will determine whether or not the FQHC meets the pre-established criteria. Once the state has approved the sites to participate, the state will begin working on developing the capitation rates for the FQHCs and plans in that county and the demonstration will be piloted for up to three years in each county. How many FQHCs are in the demonstration depends on how many apply, how many pass the participation criteria, and the resources available to DHCS to develop rates. In advance of the demonstration legislation passing, CPCA and CAPH recommend interested FQHCs engage their respective state association and their respective health plans. It is unlikely that every interested FQHC will be deemed eligible to participate, and talking to the state associations and health plans is an important first step. CPCA and CAPH have already provided DHCS and the health plans an initial list of approximately 60 interested sites. Interested members of CPCA should contact Andie Patterson at apatterson@cpca.org and members of CAPH should contact Allison Homewood at ahomewood@caph.org 9. What are the participation criteria? Participation criteria are still evolving. However, the current CPCA/CAPH proposed list, based on member and plan feedback, includes: Criteria as outlined in SB 147: o The FQHC has the demonstrated ability to collect and submit encounter data in a form and manner that satisfies the department requirements. 3 o o The FQHC is in good standing with the relevant State and federal regulators. The FQHC has the financial and administrative capacity to undertake payment reform. Note: In practice, this criterion could be evidenced by the FQHC s most recent clean audit or attestation from County Auditor for county-run FQHC participants that do not undergo a stand-alone audit process. Additional Criteria for Consideration: o Organizational Commitment to Transforming Primary Care Practices: As evidenced by a letter signed by leadership and participation in the CPCA/CAPH led Capitation Payment Preparedness Program (CP3). o Experience with Strategic Practice Transformation: As evidenced by one or more of the following: Patient Centered Medical Home Accreditation, participation in program(s) facilitated by the Center for Care Innovations, having received grant funding for work related to transformation, having engaged with performance improvement consultants/coaches. o Quality Improvement Infrastructure: As evidenced by an active quality improvement plan or strategic plan inclusive of quality improvement initiatives, and documentation of the staff/resources dedicated to improvement efforts. o Staffing Capacity: As evidenced by documentation of the FQHC s care team model, including numbers of staff by type/function. o Adequate pilot membership to drive FQHC s transformation: As evidenced by the number of assigned Medi-Cal members compared to the overall patient population served by the FQHC site.
Clinic Rate Setting and Payment 10. How does the clinic get paid under the Wrap Cap APM? The health plan or IPA that assigns Medi-Cal members to a clinic would pay the clinic pilot site a PPS equivalent per-member-per-month (PMPM) amount at the beginning of the month for all assigned members in APM categories of aid. Rates will be developed per category of aid. The categories of aid agreed to by the state, plans, and FQHCs for inclusion are: children, adults, and seniors and persons with disabilities. There is also agreement that we will include the Medi-Cal expansion (MCE) population. However the MCE population may not be part of the initial roll out of a site s APM demonstration because there is concern that the data for this population will not yet be robust enough to develop actuarially sound rates. For members in categories of aid that are not included in the APM (ex. Dual-eligible individuals) and for Medi-Cal beneficiaries who are not assigned to the clinic site, the pilot site will continue to be paid exactly as they are today (e.g., bill the plan or IPA and bill the State for Code 18). 11. How will the PMPM rate calculated? For a given aid category, a PPS-equivalent PMPM rate will be calculated in advance of the demonstration and will be based upon a historical reference period for each participating FQHC site. The State s actuary (Mercer) will use the historical number of billable visits for assigned members in a given aid category at that clinic, and multiply by the clinic s site-specific PPS rate. This total would then be divided by the total member months for those same assigned members for the same time period in order to arrive at a PMPM rate. The actuary will also take into account trend and utilization adjustments, as appropriate, in order to reflect the level of reimbursement that would have been received by the participating FQHC in the absence of the APM pilot. For example, it may be reasonable to assume that mental health utilization at an FQHC site will be greater in the future than during a baseline period prior to the incorporation of mild-to-moderate mental health services into Medi-Cal managed care. For example: Assume the aid category of Adult members, a clinic site PPS rate of $200, a reference period of July 2012-June 2013, and an average number of member months in the reference period as 12 months per member. If the average number of visits per adult assigned member at Pilot Site A was 3 visits per year, then the PPS-equivalent PMPM would be: 3 visits X $200/12 member months, or $50PMPM. 12. What is the historical reference period that will be used to set the rates? At this point we do not know which exact period of time will be used. It will depend on when the rate setting process begins. At that point, the DHCS actuaries will use the most recent audited data -- ideally two years worth. In each year of the pilot, the rates will be updated to reflect annual increases in MEI and based on updated clinic utilization data. For example, if the 2016 rates were based on 2012-2013 data, the 2017 dates would be updated to be based on 2013-2014 data. 13. What is the math to calculate the clinic payments in the pilot? For each Category of Aid (COA) at one clinic site, 4
Clinic-Specific PPS-equivalent Capitation Payment PMPM = [(visits x PPS)/assigned member months] In the DropBox folder FQHC Payment Reform/Site Financial Modeling Tools, the Excel file Modeling Wrap Cap Rate and Reconciliation allows you to enter in your clinic s data to model how rates would be set (not accounting for any assumed changes in utilization). 14. Why is the PPS-equivalent PMPM aid-category specific? The average number of visits for adult assigned members, pediatric members, SPD members and Medi- Cal expansion members is likely to be different. For example, if SPDs utilization were 5 visits per member per 12 member months and a pediatric members utilization were 2.5 visits per member per 12 member months at your pilot site, the SPD PMPM would be twice as much as the pediatric PMPM. By calculating a separate PMPM for each aid category, the clinic is protected from financial risk if the mix of assigned members changes. Aid-category-specific payment also aligns with the way that DHCS pays plans, so aid-category-specific payment creates alignment throughout the managed care system. 15. What if my clinic is in a county with more than one Medi-Cal managed care plan? Would I have different PPS-equivalent PMPM rates with each of my plans? Yes. Because utilization likely differs for categories of aid between plans; in 2-plan counties, each pilot site would have a set of PPS-equivalent PMPMs for each plan based on historical utilization of that plan s assigned members to the clinic. 16. So, what happens if the clinic is assigned more members during the pilot? Because it is a per-member-per-month payment, the clinic would receive more dollars in the month if they are assigned more members by the health plan or IPA. For example: In January, Clinic A has 1500 assigned adult members and a $50PMPM rate from Health Plan X. By an agreed upon date in the beginning of the month, the Health Plan would pay the clinic 1500 X $50PMPM, or $75,000. If Clinic A is assigned 1750 members in February, the February payment would be 1750 X $50PMPM, or $87,500. 17. For which aid categories will there be PPS-equivalent PMPMs? DHCS and CPCA/CAPH have agreed that there will be distinct PMPM rates per clinic pilot site for 3 aid categories: Adult, Child and SPD. It has also been agreed that duals will be excluded and will continue to be paid the way they are today. CPCA/CAPH and health plans have indicated that in order to maximize the incentive for transformation of care, the Medi-Cal expansion (MCE) population should also be included as a 4th aid category. However, the timing of when the MCE population is incorporated into the pilot will depend on when there is sufficient historical MCE data to develop initial rates. 18. How will the clinic site be paid for out of network patients? What about emergency only Medi-Cal patients and non-assigned patients that come to the clinic? The APM will only apply to the pilot site s assigned Medi-Cal members. The pilot site will continue to be paid as they are today for all duals, unassigned members (i.e. assigned to someone else) and nonassigned members (i.e. members who are not assigned to a PCP), including out-of-network patients and non-managed care Medi-Cal patients. 5
19. So, does this mean I will have two payment systems going on concurrently within Medi-Cal? Technically, yes. The APM will hopefully be for the majority of your patients, but you will continue to bill and be paid as you are today for duals, non-assigned and unassigned Medi-Cal beneficiaries. 20. Will PMPM rates in years 2 and 3 of the pilot include MEI increases? Yes. DHCS has agreed that PMPMs will incorporate MEI increases. 21. What happens if my clinic wants to file for scope change in the midst of the pilot? Clinics would retain the ability to do scope change during the pilot. CPCA/CAPH have suggested that under a scope change, the 4200 [traditional] visit requirement either be waived or take into account alternative encounters as well as traditional encounters. CPCA/CAPH have also proposed that in a scope change, a site will need to calculate a new per-visit PPS rate and then convert it back into a PMPM equivalent. 22. Does the health plan or IPA have to pay the FQHC one single capitation rate? One single capitation rate is being formulated, accounting for the existing FFS or capitation paid as well as the code 18 wrap and reconciliation. However, the state is leaving it up to the plans how the rate is actually paid to the pilot FQHCs. 23. Under the APM, what will happen to FFS payments I receive from my plan for services that are not part of my PPS rate? Just as these payments are not accounted for in reconciliation today, they will not be accounted for during APM rate setting. You would continue to receive these payments as you do today under the pilot. Plan Payment 24. What is a wrap cap from a plan perspective? The supplemental wrap cap PMPM that the plan will receive is the actuarial equivalent of the traditional wrap-around component of FQHC payments. This wrap cap PMPM would be the difference between the base capitation (the amount that the plan already pays the clinics under a capitated arrangement comparable to reimbursement for non-fqhc providers) and the clinics PPS-equivalent PMPM. DHCS has noted that if a plan is paying a pilot clinic a per-visit rate, then the plan will need to convert this payment to a base capitation amount. DHCS would include a new rate component for the supplemental wrap cap paid to the plan based on number of assigned members. The supplemental wrap cap PMPM for each aid-category will be an aggregate across the participating clinics associated with the plan. DHCS has stated that the aggregation would be a weighted average of pilot clinics site-specific wrap caps in each aid-category. The weighting factor would be the likely percentage of members in an aid category that are assigned to each pilot site in a county. 25. If a plan is paying a pilot clinic Fee-for-Service (FFS) for some or all services for assigned members, does this change under the pilot? DHCS has stated that in this demonstration plans would be required to transform payment for all PPSeligible services into a PMPM payment for each category of aid. If the plan pays the pilot site FFS for services not included in the site s PPS rate, those payments would continue as they do today. 26. How will wrap cap rates be set? 6
DHCS has agreed that the rate setting process will include input from the plans and FQHCs. Ultimately, it is the state and their actuaries that will set both the FQHC PMPM rates and the health plan supplemental wrap cap PMPM rates. For each category of aid, the DHCS payment to each plan will be: Health plan supplemental Wrap Cap PMPM = weighted average of [Clinic site-specific PPSequivalent PMPM base capitation (amount health plan/ipa pays to clinics for PPS-eligible services today)] Weighting by likely distribution of assigned membership across pilot sites. 27. Will rates be locked for the 3 year demonstration? As per normal course of action in Medi-Cal managed care, rates are established per year, and then updated annually as newer claims and utilization data is audited. 28. How frequently does the plan receive the wrap cap PMPM from DHCS? On a monthly basis. The Department will include a new supplemental wrap cap paid to the plan based on number of members assigned to pilot sites. To receive the supplemental wrap cap PMPM, the plan would report to DHCS on a monthly basis the number of members assigned to each pilot clinic. 29. Will the wrap cap supplemental be paid in addition to the plans current capitation rates? Yes. 30. Is the wrap cap considered supplemental to the plans current rate for each category of aid and thus not influence the portion of the health plan auto-assignment algorithm related to total cost in 2-plan counties? Yes. 31. If a clinic s rate changes based on annual MEI increases, will the State pay the health plan and the health plan will pay the clinic retroactively to the date of the approved MEI increase? Yes. 32. If a clinic files for scope change and gets a scope change, will the State will pay the health plan and the health plan will pay the clinic retroactively to the date of the approved scope change? Yes. 33. Can the plan or IPA use a portion of the wrap cap PMPM DHCS pays to the plan for administrative fees? No. In order to meet APM requirements, plans must pay the entire PPS-equivalent PMPM to the pilot clinics. 34. Will plans be paid additional resources, or an admin load, to administer the supplemental wrap cap payments? Yes. DHCS will pay actuarially sound rates, and in order to have an actuarially sound rates, health plan administrative costs are factored in. 7
35. Will IPAs be paid additional resources, or an admin load, to administer the supplemental wrap cap payments? DHCS has said it would be up to the plan contracting with the IPA or delegated plan to determine any administrative fees paid to the IPA for wrap cap administration. 36. Is there a risk corridor? Yes, there will be a risk corridor arrangement between the health plan and DHCS. The DHCS proposed risk corridor is 0.5% of the supplemental PMPM wrap cap payments to the plans, plus a small band that would be shared 50/50 by the State and the plans. The small band is proposed as 0.5% of the PMPM wrap cap payments, pending CMS approval. Thus, total financial risk to the plans is equal to a maximum of 0.75% of the health plan wrap cap payments. On the flip side, the most a plan could keep of the wrap cap--if fewer members were assigned to pilot sites than anticipated or if members were assigned to lower cost pilot sites--would be 0.75% of the wrap cap payments. 37. Why are we counting alternative encounters? DHCS has agreed that alternative encounters will be factored in and valued for the purposes of out year health plan and FQHC rate setting. The state has committed that they will form a workgroup of FQHCs and Health Plans to help inform what this process looks like. Alternative encounter data will also be critical for the demonstration s evaluation. Rate Adjustment 38. Is rate adjustment the same thing as reconciliation? Effectively yes, but CPCA/CAPH are consciously not using the same term as the processes are very different. However the intention is essentially the same. Just like reconciliation, rate adjustment would be done annually, and is intended to ensure the APM requirements are met. It is the process to ensure FQHCs receive at least what they would have otherwise received. 39. What happens if a clinic s actual visits are greater than the utilization assumption used to develop rates? There will be graduated risk over the course of the three year demonstration. In year one, FQHC pilot sites will be at risk for 5% of visits, in year two 7.5%, and in year three 10%. This means that should a site s visits be more than the PMPM utilization used to build their PPS-equivalent, the site will only be paid a rate adjustment for visits that exceed 105% of anticipated utilization in year 1, 107.5% of anticipated utilization in year 2 and 110% of anticipated utilization in year 3. The health plan will be ultimately responsible for paying rate adjustment to the clinic (and would include these extra payments in the risk corridor calculation with the Department). 40. What happens if a clinic s visits are less than the utilization assumption used to develop rates? FQHCs will have 30% flexibility to transform their care. If a site s actual visits are more than 30% less than assumed in the rate setting process, the state and the health plan will perform an audit to determine what the cause of the drop in visits was related to and determine if the site will be required to refund the health plan. The language in SB 147 reads: To incentivize care delivery in ways that may vary from traditional delivery of care, participating FQHCs shall have the flexibility to experience a lower than expected visit utilization of up to 30 percent of projected utilization. If an FQHC site s actual utilization 8
is at a level that is more than 30 percent lower than the projected utilization, the department shall review, in consultation with the principal health plan, or subcontracting payer, as applicable, the FQHC site s relevant data to identify the cause or causes of the difference, including, but not limited to, its volume of alternative encounters. If the department is able to determine that all or part of the lower than expected utilization was due to objective factors developed by the department in consultation with the principal health plans and FQHCs that are related to delivery system transformation and enhancements, such as alternative encounters, the department shall allow the participating FQHC site to retain all or a portion of the payments attributable to the utilization decrease that exceeds 30 percent lower than the projected utilization. If the department is unable to determine that all or a portion of the utilization decrease in excess of 30 percent was related to delivery system transformation and enhancements according to the objective criteria developed, the participating FQHC site shall be required to refund the applicable payment amount to the participating health plan or subcontracting payer as described below:. (B) The total amount refunded by the participating FQHC s site to the principal health plan or subcontracting payer shall be limited to an amount calculated as follows: (i) The actual total utilization, expressed as traditional encounters, for the applicable year shall be determined. (ii) The projected total utilization contained in the clinic-specific PMPMs for the actual APM enrollees for the applicable year shall be determined and multiplied by 70 percent. (iii) The amount in clause (i) shall be subtracted from the amount in clause (ii). (iv) The amount in clause (i) (iii) shall be multiplied by the participating FQHC site s per visit rate that was determined pursuant to Section 14132.100, yielding the maximum amount of the refund to be made by the participating FQHC site. The refund shall be paid in one aggregate payment. 41. Does the proposed pilot mean there would be a potential for 2 separate and independent reconciliation processes for pilot clinics? Yes, there would be one guaranteed PPS reconciliation between FQHCs and DHCS related to duals, unassigned members and MCE (should it be excluded) and potentially a second APM rate adjustment process related to assigned members in pilot categories of aid with the plan. 42. Does the clinic bear any financial risk under the APM? It is the clinics responsibility to manage the PMPM they receive to deliver the appropriate mix of faceto-face and alternative care to patients. Thus, the clinic site is at financial risk for the alternative encounters rendered to patients. Additionally, clinics would be at risk for the costs of increased visits in the first year up to 5%, second year 7.5%, and third year 10%.Clinics may also be at risk of needing to pay money back to their plan if their visits drop by more than 30% of the expected utilization upon which their rate was developed. 9
43. If rate adjustment were triggered, would the plan pay or receive payment associated with the rate adjustment? If the clinic was determined to have been overpaid, the plan would be on the receiving end of the adjustment funds. If the clinic was determined to have been underpaid, the plan would be paying the clinic. Payments would flow between the plan and the clinic. These dollars would be accounted for when determining if a risk corridor payment was needed between the plan and DHCS. DHCS has also confirmed that the DHCS infrastructure for doing PPS reconciliation would be maintained to support the health plan in the process should they desire it. 44. Will DHCS support plans--not accustomed to rate adjustment in this process should it occur? Yes, DHCS has committed to supporting the health plans in performing necessary calculations for rate adjustment and telling the FQHC or health plan the amount that one needs to pay the other in the form of a rate adjustment, should it be necessary. Effect on Membership 45. Could a health plan decide to steer patients away from pilot FQHCs and use the wrap cap $ received to pay other non-fqhc providers more? While a health plan could conceivably engage in steerage, it would be extremely minimal because the plan would be required to pay money back to DHCS. The risk corridor is designed to be two-way and very narrow, in part to prevent this type of adverse outcome. If the plan receives more money than it passes on to FQHC pilot clinics for assigned members, it would have to pay back to DHCS any money beyond 0.75% of the original wrap cap payments received not paid to pilot clinics. 46. What if a plan pays out more money to pilot clinics than the plan received from DHCS? DHCS would pay the plan. The narrow risk corridor, as designed, would have DHCS pay the plan for additional dollars paid to clinics except for the first 0.75% more than the wrap cap PMPM received. The plan is at risk for less than 1% of the wrap cap payments. 47. Is participating in the APM pilot a way to gain more members? This remains to be seen. Some speculate that by having more flexibility to address members needs via alternative encounters (email/phone/group visits/home visits) or with non-billable providers (MFTs, clinical pharmacists, community health workers), clinics will be able to increase their capacity to take on more members and/or attract patients who appreciate these alternative modalities. Effect on HRSA compliance 48. Will HRSA ding our clinic if visits go down? CPCA and CAPH are maintaining communication with NACHC and HRSA regarding this pilot to ensure that there is an understanding of the transformation in care that would be expected under changed financial incentives and ensure that there would be no detrimental impact to pilot sites. Participation 49. Do all clinic sites of a clinic organization have to be in the pilot? No. It is up to the FQHC organization to decide how many of their sites they want to include in the demonstration. 10
50. Is FQHC participation voluntary? Yes. As per federal APM rules, FQHC participation is voluntary. 51. Do all plans in a county have to participate? Yes, DHCS will require all plans in a county to participate in the demonstration should DHCS approve FQHCs in that county to participate in the demo. 52. How does an IPA or delegated plan fit in to the demonstration? There is general agreement by the State, FQHCs, and plans that if an IPA or delegated plan is the entity that currently assigns members and pays a clinic site, the IPA or delegated plan would continue to assign membership and pay the clinic the PPS-equivalent PMPM for all assigned members. The parent plan would be required to pass the wrap cap supplemental payment received from DHCS to the delegated plan and/or IPA. Any administrative fees would need to be negotiated without decrementing the PMPM paid to the clinic. Relationship to other payment reforms 53. Will my P4P payments from my plan or IPA change under this pilot? Not unless you negotiate that with your plan or IPA. P4P, as it is today, will remain a separate payment stream that is not accounted for in PPS or the reconciliation process. In fact, most participating clinics are hopeful that the additional flexibility of the pilot might help them to better achieve their P4P benchmarks. Some plans may try to align P4P measures with APM evaluation measures in order to create incentive alignment through the managed care system. Preliminary APM evaluation measures were also selected based on being highly aligned with measures on which plans are evaluated in Medi-Cal. 54. What happens if the State pursues a Health Home Supplemental Payment for Complex Members with funding from Section 2703 or through the waiver? A Health Home demonstration in California would complement but not supplant the APM demonstration. The APM aims to transform currently provided care for all assigned Medi-Cal members. A Health Home demonstration would only target a more narrow population of high-risk Medi-Cal beneficiaries. The APM is designed to allow flexibility to deliver current services differently. Conversely, a health home supplemental payment would be designed to fund new care management and coordination services that are not provided or are underprovided under PPS or an APM. The two demonstrations would complement each other. For instance, some of the same team members that might be hired to perform transformed services might also perform new care coordination services for health home-eligible beneficiaries. FQHCs should be able to do participate in both demonstrations. Readiness 55. What can my FQHC do to prepare for a PMPM rate? In general, here are some key things for pilot leaders to be doing now to prepare: Foster a culture of quality improvement and change Be accountable for all assigned members o Get never been to the clinic members in for a visit 11
o Ensure you know who your members are Data analytics: o Measure quality at a site level o Enabling services: How do you track these now? Begin transformation to a Patient Centered Health Home o Empanel your patients o Expand capacity to provide integrated behavioral health services o Foster communication with health plans and hospitals to better understand and manage your patient population o Consider your role in high-utilizer programs o Anticipate operational changes under more flexible payment Think about how you will implement alternative modalities of care, i.e.: o Patient portal, including implementation of email visits o Telephone access o Group visits Think about how you would reconfigure your care team if not restricted by visits with billable providers (ex. Use of clinical pharmacists, MFTs, CHWs, etc.) 56. What is CPCA/CAPH doing to prepare members for the demonstration? CPCA and SNI (CAPH s performance improvement affiliate) are developing a Capitation Payment Preparedness Program (CP3) that will support the sites in the demonstration to transform their practices so they can be successful in the demonstration. For more information contact Christina Hicks at cmhicks@cpca.org or Nancy Oswald at noswald@caph.org. VISUAL 12
13 Updated August 24, 2015