Business Case Guide

To peer at the horizon in business planning and strategy for population health, you can simply look to categories three and four in the HCP-LAN framework and move into value-based payment arrangements, which are organized around upside and downside risk and shared savings. This extends all the way to accepting global risk for managing the total health and total healthcare costs for a population of patients.

Since the formation of the Center for Medicaid and Medicare Innovation (CMMI), which was created at the Center for Medicaid and Medicare Services (CMS) by the Affordable Care Act, many different programs have been launched to trial the effects of category three and four payment reforms at both the federal and state levels.^[1] The primary care transformation efforts facilitated by CMMI in this first decade have shown mixed results, with “few programs demonstrating meaningful increases in the availability of primary care, reductions in costly forms of utilization or improvements in quality.”^[2]

Although there are mixed results overall, there are examples from around the country of community health centers successfully entering into category three and four value-based payment arrangements with varying approaches to population and global payment and a range of downside risk agreements. Some of the critical strategies for success include taking a stepped approach to adopting alternative approaches to payment, and making strategic investments in care delivery and data management. This includes adding clinical pharmacists, community health workers, and diabetes educators to teams, and new technology supports, such as tools for telehealth, timely health information exchange, and population data management.^[3]

For community health centers considering value-based payment arrangements as a lever to promote health equity, consider designing and implementing a linked set of strategies that provide mutual reinforcement between new approaches to care delivery, including a focus on person-centered, culturally and linguistically responsive, integrated care, as well as equity-focused and intentional payment model and measurement design. You may also want to consider integrating a social risk adjustment approach to your payment arrangements, in addition to adjusting for medical complexity. If you are going to be paid for improving engagement and outcomes, social risk adjustment will help to account for the additional effort required to successfully engage and improve health for people living with complex and challenging circumstances.

In the first decade since CMMI was created by the Affordable Care Act, a great deal of experimentation and learning has been achieved. CMMI recently announced a new 10-year initiative, Making Care Primary (MCP), which will build on the results of the past decade. Making Care Primary will be tested in eight states and will provide opportunities for provider organizations to take a gradual approach to population-based and value-based payment adoption, with a focus on building infrastructure for behavioral health, social services, and specialty care coordination and integration. While only eight states are participating in Making Care Primary, this latest investment from CMMI points to national trends in primary care payment reform and care delivery transformation nationally.