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Health and Medicine Hosts Community Health Centers and Managed Care Organizations Forum

Wesley Epplin
October 29, 2013
The following post provides a brief summary of the proceedings and notes from a recent HMPRG forum focused on community health centers (CHCs) working with managed care organizations (MCOs).

Health and Medicine Policy Research Group hosted a forum on October 1, 2013 focused on providing tools to help community health centers (CHCs) contract with managed care organizations (MCOs).  Navigating Relationships in an Evolving Healthcare Environment: Community Health Centers and Managed Care Organizations Forum brought together people from CHCs, health departments, hospitals, and other health professionals who work with or are planning to work with MCOs.  The following provides a snapshot of the three main forum sessions.  Some of the notes are taken verbatim from the presenters’ slides and others are in an abbreviated form.  The information and ideas that follow are those of the different forum presenters.

Session 1: Dr. Art Jones, Principal, Health Management Associates: Provided overview of the managed care environment.

After providing some of his background in working both at a CHC and with managed care, Dr. Art Jones reminded the audience of the triple aim of: improving population health, controlling costs, and improving individual care experience.   Jones also pointed out that with the ACA being implemented, two inter-dependent objectives are being attempted: 1) make adequate health insurance coverage more available and affordable; and 2) reform delivery and payment systems to provide better care in a more cost-efficient manner.  Managed care attempts to address this second objective.

So, how do FQHCs work to improve outcomes and change the payment system in tandem?  They can use a progression with true partnership to transition from FFS to managed care payment.  With managed care, FQHCs move slowly to take on more financial risk and with it, greater accountability.  Negotiating with MCOs, they receive money for care coordination.  They may take on total financial risk for some services.  For example, being responsible for emergency department (ED) visits, an FQHC might move to being open at night, having shorter wait times for appointments, and having nurse triage.  This may lead to increasing revenue and savings, because of reductions in ED visits.

Dr. Jones listed some contract pitfalls and advice:
  • Non-solicitation clauses: These say that you can’t contact your members if you stop working with their insurer.  Don’t sign this.
  • Termination without cause clauses: Don’t sign this.
  • Transfer of members before cure period expires for breach of contract: Usually 60 days to cure problems, after which insurer can break contract and transfer members.  Don’t sign the clause that says they can transfer before cure period.
  • Indemnification, defending, and hold harmless clauses: Don’t sign contract saying you’ll indemnify them; take that clause out.
  • Unilateral contract amendments: Don’t sign this.  The MCO should have to check in with the health center to make any amendments.
  • Failure to review the provider manual: Look at this ahead of the contract and make sure it is something you can live with.
  • Ability to terminate contract immediately for MCO insolvency or non-payment: Need clause saying that you can terminate contract, or else in some circumstances the CHC may have to provide services for 90 days without getting paid.
  • Review all of these with an expert.
Session 2: The forum also included two leaders from CHCs: Bob Urso, MS, MHA, BSN, President and CEO, PCC Community Wellness Center, and Lee Francis, MD, MPH, President and CEO, Erie Family Health Center.

Here are contracting recommendations and considerations from the CHC representatives:
  • If new to managed care, consider attempting to form one model contract with one MCO, test it out, work out kinks, and then be able to judge future contracts against the initial contract
  • Consider different payment models, including: FFS; PCP vs. Full/Partial risk; P4P; SSF; wrap payment; and care management fee
  • Importance of addressing the triple aim of improving patient care, improving the health of patient populations and communities, and lowering the per capita cost of providing healthcare
  • Need integrated delivery system, in which we work toward becoming accountable care entities, involving hospitals, specialists, PCPs, behavioral health, and other providers.
  • Research any given MCO in preparation for contracting, including: assessing market share, service area, stability, solvency, and reputation.  Also, investigate who owns the MCO, is it for-profit or non-profit?
Session 3:  Two representatives from MCOs provided their perspective on navigating these relationships: Sanjoy Musunuri, CEO, AETNA Better Health and Matthew Collins, COO, Cigna-HealthSpring.

Here are considerations and recommendations from the MCOs’ perspective:
  • Requirements include: access and availability, including ADA compliance; licensure and credentialing; meeting of administrative obligations; hospital/NH privileges; and rates
  • CHC partner attributes: willingness to serve the populations; cultural competence; capability to be a medical home; focus on quality; delivery system innovations
  • Contracting needs include having engaged providers with a strong presence in the community
  • Also, looking for quality provider partners: government is working on definition of quality, holding MCOs accountable for quality results; MCOs are then holding providers accountable
  • MCOs want to work with CHCs who know the basic premises of managed care; important for providers to understand how managed care works
Each session ended with Q and A with the audience.  For more extensive notes and to review the slides from each presenter, click here.