Value-Based Care for FQHCs in Ohio: Comprehensive Primary Care (CPC) & Episodes of Care

In our downloadable guide for FQHCs in Ohio, we share how FQHCs can capitalize on the opportunities that value-based-care presents. Here's a sneak peek of that guide, outlining the value-based care landscape for FQHCs in Ohio.

Ohio’s unique SIM grant in 2013 laid the foundation for a new approach to value-driven healthcare in an attempt to shift its position as 17th in the nation spending but bottom 25 percent in outcomes.

The transformation plan is divided into two major programs: The Comprehensive Primary Care (CPC) program and Episodes of Care (Episodes) initiative. Together, they aim to prioritize the delivery of preventive primary care and reduce spending on emergency department visits, hospitalizations, and other high-cost services.

In the years since the SIM grant expired, Ohio has kept the basic structure of the program and continues to offer both the CPC and Episodes of Care options to state providers.

Comprehensive Primary Care (CPC)

To participate in CPC, primary care providers, including FQHCs, could voluntarily apply to become approved patient centered medical homes (PCMHs). CPC practices adopt a population health management approach to primary care, offering team-based care, same-day access, transitional care services, and other patient-centered care.

To become an approved PCMH entity, providers must have at least 500 claims-attributed Medicaid patients, attest to participation in relevant learning activities, and be able and willing to share data with the Ohio Department of Medicaid and contracted managed care providers.

If these requirements are met, CPC PCMHs become eligible for two additional payment streams: per-member-per-month (PMP) Medicaid payments to support program activities and shared savings payments if the practices hit specific spending benchmarks, clinical quality metrics, and program efficiency metrics.

If certain requirements are met, CPC PCMHs become eligible for 2 more payment streams: 

1. Pay-member-per-month (PMP) Medicaid payments to support program activities

2. Shared savings payments if the practices hit specific spending benchmarks, clinical quality metrics, and program efficiency metrics.

The PMPM payments are tiered by patient risk status. In 2022, the payments range from $1.80 for low-risk individuals to $22.00 for extremely complex patients. The risk tiers are updated quarterly to ensure that providers are being appropriately compensated for managing their patient panels.

To earn payments, CPC practices must meet thresholds for ten activity requirements, four efficiency metrics and 19 clinical quality measures.

To support success, practices receive data and reporting from Medicaid containing information on quality performance, patient attribution details, and spending rates.

Ohio also offers a CPC program enhancement for providers who serve at least 150 claims-attributed Medicaid beneficiaries under the age of 21. “CPC for Kids” requires additional quality improvement activities but opens the opportunity for more shared savings payments.

Episodes of Care

TEMPORARILY SUSPENDED - Episodes of Care is suspended through 2022 due to the COVID-19 pandemic’s impact on healthcare providers.

The Episodes of Care program has taken a slightly different course. While still an important piece of the value-based care transition, the program has been temporarily suspended through 2022 due to the COVID-19 pandemic’s impact on healthcare providers.

Pre-pandemic participants are still encouraged to report on quality and performance data but will not receive any incentives or be held financially accountable for less-than-optimal performance during the nation’s recovery period.

When the suspension is lifted, participants will once again be able to engage in this pathway, which provides bundled payments for defined sets of services related to specific diagnoses. Episodes focus more on specialty and hospital care, but primary care providers still have some opportunities to participate.

Since 2015, the state has defined 43 episodes. Eighteen of these episodes are currently linked to value-based payment opportunities, including care for asthma, congestive heart failure, COPD, low back pain, and common infections such as upper respiratory infections and UTIs.

Download our guide to learn what actions your FQHC can take to capitalize on value-based care in Ohio.