Health Care Homes Sustainability Roadmap
Finance
Despite current high levels of health care spending in the United States, the proportion spent on primary care is insufficient. A shift in resources to support greater access to comprehensive, coordinated primary care is imperative to achieving a stronger, higher-performing health care system.
Reimbursement, incentives, alternative payment arrangements, value-based contracting, and optimizing revenue streams are critical to financial stability. As a certified Health Care Homes (HCH) organization in Minnesota, there are opportunities to obtain reimbursement for care coordination and to maximize the benefits of participation in programs such as the Centers for Medicare & Medicaid Services (CMS) Quality Payment Program (QPP). HCH certification also prepares organizations for participation and success in value-based payment arrangements.
Strategies
- Pursue alternative payments and value-based arrangements with state and national programs, accountable care organizations, and contractual agreements which recognize the value of and provide reimbursement for high-quality, team-based primary care.
- Participate in Integrated Health Partnerships (IHP) - DHS: Certification as an HCH serves as a gateway to participation in IHP, the Minnesota Department of Human Services (DHS) Medicaid accountable care organization (ACO). The current iteration of IHP began in 2018, building on the original model and allowing DHS to continue contracting with innovative health care delivery systems to provide high-quality, efficient care to Minnesota's Medicaid (MA) population. To participate in an IHP, an organization must be HCH certified or meet a set of care delivery standards that match those of HCH.
- Optimize reimbursement for care coordination services: Some commercial and public payers reimburse for care coordination services using the Minnesota Health Care Programs (MHCP) process and codes. Others reimburse through population-based payments or per member per month alternative payment arrangements. Examples of direct billing sources include: Physician and Professional Services - Health Care Homes; MHCP Other Billing Resources; and CMS Medicare Billing Resources.
- Review Health Care Homes - Incentives & Payments - CMS MIPS: Health Care Homes that participate in the Centers for Medicare & Medicaid Services (CMS) Merit Based Incentive Payment System (MIPS) program are eligible to receive added benefits.
- Pursue advanced certification levels: Clinics that progress to HCH Level 2 or Level 3 certification demonstrate an increased capacity to address social determinants of health and health equity. Payers are increasingly interested in finding ways to meet these challenges, opening potential new avenues for reimbursement.
- Evaluate workflows for opportunities to create efficiencies that allow staff to maximize productivity and patient flow while reducing burdensome administrative tasks. Even incremental improvements can provide financial benefits.
- Seek grants: Foundations, health plans, and other entities can be a source of funding for initiatives that advance health equity, address critical community health needs, or improve health and well-being of patients and community members. This can be a means for clinics and their partners to fund pilot efforts while testing their impact.
Resources
- CMS.gov What are the Value-Based Programs
- Making Care Primary (MCP) Model | CMS
- Advanced Primary Care: A Key Contributor to Successful ACOs (PDF)
- Financial Sustainability for Complex Care Models Serving Low-Income Patients: a New Role for Philanthropy - PMC (nih.gov)
- The Impact of Primary Care Practice Transformation on Cost, Quality, and Utilization - PCC (the pcc.org)
- Health Care Payment Learning and Action Network
- Understanding Billing for CHW Services in Minnesota - Medicare and Medicaid (YouTube video)
- Part II: Understanding Billing for CHW Services in MN 2024 (PDF)
Stories
The Health Care Homes (HCH) Sustainability Workgroup and leadership of the State Employee Group Insurance Program (SEGIP) began a collaborative project to educate SEGIP members about the benefits of HCH certification in 2019. The HCH Sustainability Workgroup’s primary objectives are to improve the health of all Minnesotans by ensuring the sustainability of certified HCH clinics and promoting population health and health equity. These goals complement SEGIP’s mission, which is to help members achieve and maintain health in every aspect of their lives by providing high-quality and cost-effective insurance and benefits.
SEGIP administers the MN Advantage Health Plan, the medical insurance program offered to state employees. It encourages members to choose cost-efficient, high-quality clinics. The Advantage Plan covers more than 130,000 members, including employees of state agencies and quasi-state units, their dependents, pre-65 retirees, and other separated employees. Members choose a primary care clinic that manages their care, and each clinic is assigned a cost level between one and four, with one being the most cost-efficient and four the least. Members are encouraged to select lower cost level clinics through reduced cost-sharing.
To help members choose the clinic that best meets their needs, SEGIP maintains a comprehensive online clinic directory that provides information on clinic location, cost level, quality, and HCH certification status. SEGIP incorporated HCH status prominently on the clinic directory starting with Open Enrollment 2022. This shows if a clinic is HCH certified, provides an informational pop-up that explains what HCH certification means for their care, and links to the HCH website for more information.
While analyzing 2022 enrollment results, SEGIP found that HCH certification was widespread in clinic networks, and the majority of members chose to receive care at a HCH certified clinic. In addition, those members enrolled at HCH certified clinics had lower average cost levels.
Nearly 55% of SEGIP primary care clinics in Minnesota had HCH status in 2022.
About 85% of SEGIP members in Minnesota chose an HCH as their primary care clinic for 2022.
Members enrolled at HCH clinics had lower average cost levels for 2022.
“Adding Health Care Homes certification to our clinic directory has been a great way to show our members when a clinic emphasizes effective care coordination,” said Zach Holmquist, a Senior Health Care Analyst at SEGIP.
To further this collaboration, HCH and SEGIP will continue to look at new ways to improve awareness and promote the benefits of the HCH model of care.