FQHC: Is Now the Time?
Minnesota Rural Health Conference
June 27-28, 2011
Duluth, Minnesota
WHO?
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Tribal health care programs
Free clinics
Primary care in underserved areas
Providers
Community Mental Health Centers
Boards of directors, administrators
and fiscal personnel
WHO?
• Private practices converting from fee for
service to cost-based reimbursement
• Critical Access Hospitals (CAHs)
• RHCs converting to FQHC status
• Migrant health programs
• Health care for the homeless programs
• Health care for public housing programs
Funding
• Increases tied to costs and
number of patients served
• Biggest jump in funding ever
• Continuous appropriation funding
• Can apply to expand
National Health Expenditures, 2008
Flipping the Resource Triangle
Current Resource Allocation
Needed Resource Allocation
Acute
Care
Acute
Care
Specialty
Care
Specialty
Care
Primary
Care
Primary Care
CHC Cost Savings per Person
• Studies show that in 2009 there were $1,262 in medical
savings per person for low income individuals accessing
care at CHCs compared to costs for those cared for
elsewhere in the health care system. Greater increases
are projected in coming years.*
– 2009
– 2015
– 2019
$1,262
$1,520
$1,756
* Shi, L et al. (2004). ―America’s Health Centers: Reducing Racial and Ethnic
Disparities in Prenatal and Birth Outcomes‖ Health Services Research, 39(6),
Part I, 1881-1901.
Reduce Emergency Room Use
• Educate patients
• Focus on prevention
• Make services accessible
• Evenings and weekends
• Same-day and walk-ins
Emergency Room Use
• Overuse will worsen in the
short-term
• Demand for care to increase
40 percent
FQHC Challenges
• Reimbursing care managers
who coordinate care
• Changing patient behavior
• Recruiting providers
Emergency Room Use
• Emergency room use
increased 11% in 2007
• Of the 117 million visits in
2007, about 8% were nonurgent.
Medicaid Expansion
Medicaid will include people with
incomes at or below 133 percent
of the federal poverty level
Distribution of 45.7 Million Uninsured Adults and Children by Federal
Poverty Level and Provisions of the Affordable Care Act
Uninsured Adults and Children ages 0–64
Percent
Number
Uninsured
Premium-Subsidy Cap
as a Share of Income
Cost-Sharing
Cap as Share of
Medical Costs
<133% FPL
46%
20,783,010
Medicaid
Medicaid
133%–149% FPL
6%
2,736,669
3.0%–4.0%
6%
150%–199% FPL
13%
5,981,582
4.0%–6.3%
13%
200%–249% FPL
10%
4,496,475
6.3%–8.05%
27%
250%–299% FPL
7%
3,041,499
8.05%–9.5%
30%
300%–399% FPL
8%
3,620,349
9.5%
30%
Subtotal
(133%-399%FPL)
44%
19,876,574
3.0%–9.5%
6%–30%
>400% FPL
11%
5,019,092
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--
100%
45,678,676
--
--
Federal Poverty
Level
Total
Source: Analysis of the March 2009 Current Population Survey by N. Tilipman and B. Sampat of Columbia University for The
Commonwealth Fund; Commonwealth Fund analysis of Affordable Care Act (Public Law 111-148 and 111-152).
Health Insurance Exchanges
• FQHCs guaranteed reimbursement
at their Medicaid Prospective
Payment System (PPS) rate
• Plans must contract with essential
community service providers
• Plans must include at least
essential benefits, including
preventive care
Self-Pay and Sliding-Fee Scale
• FQHCs see more Medicaid and
Medicaid managed care
populations
• This will change
• Health insurance exchanges must
contract with ―essential
community providers.‖
Health Reform Changes
• Medicare payments changing
• New PPS similar to existing
Healthcare Common Procedure
Coding System for-profit uses
• January 1, 2011 health centers began
reporting using HCPCS codes to
establish payment rates
• Coding of FQHC clinician encounters
important now — and in the future.
QUESTIONS?
• Contact Craig Baarson,
Reimbursement Specialist,
Minnesota Department of Health Office of Rural Health and Primary Care
• [email protected]
• 651-201-3840