Earlier this year, CEP America began partnering with the urgent care centers of two clinics of a Federally Qualified Health Center (FHQC) in Southern California. These clinics, Desert Hot Springs Community Health Center and Centro Medico Cathedral City, had a combined 7,400 visits last year in their urgent cares. Both clinics are owned by Borrego Community Health Foundation, which operates 23 clinics in California’s San Diego and Riverside counties.
These are CEP America’s first partnership with an FQHCs with more planned, as we see how an integrated team
of emergency physicians, hospitalists, intensivists, and FQHC primary care and specialty providers creates an excellent opportunity for controlling costs and improving quality of care
. Matthew Keane, PA-C, is the lead physician assistant at Desert Hot Springs and Cathedral City, and Glen Grayman, MD, is chief population health officer and regional medical director for Borrego Community Health Foundation.
Perspectives recently sat down with these leaders to get an overview of FQHCs, and talk about how these clinics fit into the Acute Care Continuum.
Perspectives: FQHCs play an important role in serving the healthcare needs of a specific population. Can you give us an overview of an FQHC?
Dr. Grayman: Federally Qualified Health Centers
own and operate non-profit multi-specialty clinics whose purpose is to care for the underserved safety net population. FQHCs have either clinics that have been around and have been functioning as nonprofit primary care clinics, or, in some cases, clinics can start from the ground up, applying for grant dollars from the federal government to ultimately follow a set of guidelines and best practices in order to ensure that those who can’t afford healthcare, don’t have access to healthcare and/or live in a medically underserved area have access to primary, specialty, and preventive care.
How is an FQHC funded?
There are two types of FQHC statuses. There’s a full FQHC that qualifies for specific enhanced reimbursement from Medicaid and also may receive grants from the U.S. Health Services and Resources Administration (HRSA) authorized under Section 330 of the Public Health Service Act. These grants represent significant funding for most FQHCs. The other status is an FQHC Look-Alike health center, which operates exactly like an FQHC with the same enhanced Medicaid reimbursement and similar patient services. The only difference is that Look-Alikes do not qualify to receive the HRSA grants.
In a nutshell, when an FQHC first begins operations, all the costs are added up and submitted to the federal government. From that information the government calculates a prospective payment system (PPS) rate, a per-visit reimbursement rate that is significantly higher than what a for-profit clinic receives.
What are the advantages of being an FQHC?
As Dr. Grayman mentioned, on the for-profit side, clinics may be getting $25, $40 or $50 per patient, per visit from the insurance company, while FQHCs are getting $100 - $300 per patient, per visit. This enhanced reimbursement rate ensures the centers can continue to provide comprehensive services to every patient who comes in, regardless of their ability to pay.
The enhanced reimbursement is the biggest advantage, as it allows us to operate, hire staff, build new clinics and care for all-comers. Some of the other benefits include the ability to provide medications and vaccines at incredibly low prices. In addition, the providers that FQHCs hire qualify to have a significant portion of their student loan debt relieved because it is often difficult for public clinics to attract providers to these medically underserved areas.
Because FQHCs are federally funded, there is some uncertainty around what future funding will look like. What can you tell us about proposed funding changes?
We expect that somewhere between three and five years from now reimbursement will change to value-based reimbursement
, rather than cost-based. We’ll be put at-risk in some sort of fixed fee or capitated arrangement. It’s not clear what that will look like and I don’t think HRSA has figured it out yet, but that is going to change our operations dramatically.
To a certain extent, that’s why Borrego created my position of chief population health
officer. Clearly, we want our communities to be healthy for all the right ethical reasons. But the imperative becomes even greater when you no longer want lots of visits. You want to keep people healthy in the community, such that their visits are limited because they don’t need to come in
As Dr. Grayman said, one of the proposed payment reform methods would be for FQHCs to operate under a capitated payment system like most other clinic systems operate. The benefits would be that these FQHCs would be allowed to decide how they want to provide services that 1) fit their clinic and staffing pattern and 2) fit their geographic area. For example, a big emerging trend is telephone visits
. Currently, HRSA doesn’t reimburse for telephone visits. But in a rural area or with a patient population that doesn’t have transportation, being able to cover a telephone visit may be very beneficial to that clinic. I think that flexibility in allowing sites to provide services in a way that’s best for their patient population is a positive thing.
How is urgent care practice at an FQHC different than in a private clinic?
We see an urgent care patient as an entrée into becoming a full primary care/preventive care patient of Borrego Health. At Centro Medico Cathedral City, we see 250 to 300 patients a day, most of whom are primary care. We have immediate in-house consultation for a number of specialties available for those patients. For example, similar to the way an emergency department (ED) might need the pediatrician to come in and look at a patient, we have access to a pediatrician in real-time.
: I think the FQHC urgent care as a medical home model
is going to become more and more important as the main access point for people to be seen, get care and then receive care coordination after the visit. With most FQHCs on electronic health records, providers and staff can see when the patient had labs done, when they had medications filled, and when or where their last visit took place. So, the medical home and care coordination aspects are truly where FQHC urgent care centers excel above most private urgent care centers.
How do FQHCs fit into the Acute Care Continuum?
As we see with the ED patient population and volume, there are a lot of underserved patients who need access to primary care
. If a hospital can partner with an FQHC, which has all the primary care, dentistry, psychiatry, pediatrics, and women’s health services, now you can see someone in urgent care and get them plugged into the appropriate follow-up appointment the next day, preventing an ED visit. You start looking at population health and really making sure patients are getting the right care at the right time in the right place.
: Absolutely. We take the idea of a patient-centered medical home (PCMH) very seriously. Through an FQHC’s primary care providers, network of in-house specialists and specialty referral network, we’re able to care for the whole patient in a tightly coordinated manner.
What is the future strategy for delivering care to the medically underserved?
There is still a lot of opportunity to make transformational and system changes in communications between the ED and FQHC as far as follow up and care coordination. With CEP staffing Desert Hot Springs and Cathedral City urgent care centers, I’m excited about some of the things that we can do between the ED and urgent care centers as far as follow up.
As CEP America and Borrego increase the depth of our relationship, there’s a lot we can potentially teach each other. CEP is facing issues around population health and figuring out very effective ways of meeting the same or very similar metrics that we have to meet. And so I think Borrego can learn from you what has been successful. And hopefully we can return the favor in other areas. So, I think that our relationship is more than one where CEP staffs our urgent cares and then the shift is over and your provider goes home.