New York State's Proposed Medicaid Redesign Creates New Opportunities for FQHCs

In April, New York State released its draft 1115 waiver amendment seeking $13.25 billion in federal funding over five years to improve health equity and address systemic disparities for underserved populations.

The new plan, called the “Strategic Health Equity Reform Payment Arrangements: Making Targeted, Evidence-Based Investments to Address the Health Disparities Exacerbated by the COVID-19 Pandemic” (SHERPA), builds on previous successes while incorporating lessons learned from the COVID-19 pandemic and innovative, flexible approaches to enhance value for patients and providers.

The legal and policy teams at Yuvo have carefully reviewed the draft - and overall, we are very pleased and encouraged by the attention to quality, health equity, and administrative design outlined in the document.

FQHCs stand to gain many opportunities to deliver more comprehensive and coordinated services aimed at the social determinants of health (SDOH) while fully participating in emerging alternative payment models (APMs) designed for their success.

(Related: Download our guide to learn more about the value-based care landscape for FQHCs in NY)

However, as staunch advocates for our FQHC partners, we know that there’s always room for improvement.  

When invited to share our comments with state Medicaid authorities, we pushed for even greater attention to issues that specifically affect FQHCs, including equitable APM design, more integration with community-based organizations (CBOs), and enhanced oversight of arrangements that involve managed care organizations (MCOs).

Here are some of the key points from our comment letter.

Architecting inclusive FQHC-focused alternative payment models

SHERPA includes an FQHC-specific capitated APM that involves “a per member per month wrap payment for members to allow for flexibility in pursuing integrated care.”  We applaud the inclusion of this APM, and believe that a capitated, value-based environment is necessary for FQHCs to provide the best support and even better outcomes for the vulnerable populations they serve.

However, we also urged the state to be inclusive of all clinic types when building out these models.  APMs should not solely favor larger, more established FQHCs which have an opportunity to earn significantly more per visit dollars due to their size.  Smaller FQHCs are just as essential to our health system and should be treated as such.

Creating Health Equity Regional Organizations (HEROs) to reduce disparities

The draft plan proposes $325 million to invest in Health Equity Regional Organizations (HEROs) that would serve as coordinating entities for formalized partnerships between MCOs, hospitals, community-based providers, Qualified Entities (QEs), and other stakeholders.

We strongly support the establishment of these regional planning organizations, as well as the collaboration, coordination, and facilitation of activities they will provide.  However, these HEROs will need to be led by entities that can remain objective and neutral while truly addressing the needs of the communities they serve.

We also encouraged the state to include FQHC-sponsored School-Based Health Centers as potential HERO leaders and recommended that HERO boards include actual Medicaid beneficiaries to provide meaningful, direct representation for their communities.

Actively addressing the social determinants of health

The waiver would establish Social Determinants of Health Networks (SDHNs) that would “organize coordinated networks of CBOs to provide evidence-based interventions that address a range of social care needs, such as housing, food insecurity, transportation, and interpersonal safety.”  

These networks would be a step forward for infusing holistic care into vulnerable communities. It is critical to extend the capabilities of clinicians beyond the four walls of their health care setting to understand all of the factors impacting patient health outcomes.

To further enhance this approach, we recommended earmarking funding to administratively and operationally support CBOs with upfront investment dollars to ensure SDHN success. And we also believe that VBP contracting agents, such as IPAs, should be given the option to engage with one or more SDHNs as part of their VBP arrangement with the state or an MCO.

Yuvo also supports allowing providers to continue using preferred SDoH tools rather than mandate uniform social needs assessments - as long as the SDoH tool addresses the minimum areas of assessment to be captured by the equivalent statewide tool.

Providing additional guardrails for value-based payment arrangements

Value-based payment arrangements should include a wide variety of stakeholders, but they should also offer strong oversight to prevent any one entity from taking advantage of another.  When MCOs are involved, we believe that additional guardrails are called for, including:

• MCOs should be required to incorporate gaps-to-goal quality improvement measures to calculate shared savings
• MCO should be required to contract with IPA/ACOs that meet their minimum attributable lives
• MCOs should be prohibited from setting member attribution thresholds for any VBP arrangements
• MCOs should be required to provide upfront investments in primary care and behavioral health
• MCO should be required to submit claims data in a timely and ongoing manner to all providers in a VBP arrangement and provide shared savings in a more timely manner

Encouraging patient-centered care, care coordination, and care navigation

In our comments, Yuvo encouraged the State to continue the flexibilities afforded during the COVID-19 pandemic. To provide truly patient-centered care, we must allow for care in many different locations, including virtually.

Enhancing the ability to provide telehealth, offering reimbursement regardless of  audio-only or audio/video telehealth, and offering reimbursement for home or community based delivery of care will create improved outcomes and experience for Medicaid members. Care coordination and navigation that is agnostic to the delivery system allows beneficiaries a more seamless experience while also improving the interface of CBO and provider organizations.

Additionally, Yuvo supports a pipeline for race and ethnicity concordant care. We recommended further investment in education and training for community members to work locally, as well as the development of metrics that measure workforce diversity.

Preparing for a bright future for FQHCs in New York State

The SHERPA draft is a promising framework for improving health equity across a large and highly variable state healthcare environment.  We applaud state officials for recognizing the vital role that FQHCs, community-based organizations, and other partners play in improving outcomes for Medicaid beneficiaries.

While there are still many ways to make the Medicaid ecosystem even more efficient and effective for individuals and their communities, we strongly believe that the future is bright for FQHCs.  We are eager to continue sharing our commentary and experiences with state officials to inform the future of Medicaid in New York State and ensure that emerging policies are optimized for FQHC success to create a sustainable, resilient, equitable health system for all individuals.