The National Academy for State Health Policy (NASHP) designed this toolkit to support states interested in developing a value-based alternative payment methodology (APM) for federally qualified health centers (FQHCs). The following section on stakeholder engagement discusses key considerations and promising strategies based on lessons learned from states during NASHP’s Value-Based Payment Reform Academy.
Key considerations for engaging stakeholders include:
- Identify core stakeholders.
- Identify a vision and shared goals.
- Employ varied communication strategies to ensure FQHC support.
- Develop collaborative processes to help foster trust and transparency.
- Assess and adapt stakeholder engagement as the project evolves.
FQHCs typically serve a high volume of Medicaid patients and provide a wide array of services including primary and preventive care, behavioral health and oral health care. FQHCs that participate in the Health Center Program, authorized under Section 330 of the Public Health Service Act,[i] must meet specific programmatic requirements, such as reporting on Uniform Data System[ii] measures and quality improvement initiatives.[iii] For these reasons, FQHCs may be uniquely well positioned to participate in state value-based purchasing initiatives.
However, FQHCs may also face resource constraints that could make transitioning to a value-based APM challenging. FQHCs that participate in the Health Center Program are required to offer care to underserved populations regardless of insurance or ability to pay,[iv] creating potentially unstable revenue. For these reasons, stakeholder engagement is a particularly important component when developing a value-based APM that is mutually beneficial for the state Medicaid agency and for FQHCs.
Identify core stakeholders.
State agencies: Developing a value-based APM can require engagement across numerous state agencies and offices. States may want to include staff who are knowledgeable about FQHCs and the Prospective Payment System (PPS) from the outset to identify potential policy barriers and challenges early on. Early contact with state staff who can speak to measurement, data analytics, managed care contracting, and other policy and operations issues will also help facilitate development. States may also want to include a representative from the state’s Department of Health, to advise on how APM components could impact workforce issues, prevention strategies, and efforts that target social determinants of health.
The Primary Care Association (PCA): State teams participating in the NASHP Academy all included their states’ PCAs on their core planning team. PCAs are state or regional non-profit organizations that provide training and technical assistance to safety net providers. PCAs can be critical partners to Medicaid agencies as they have significant expertise in FQHC financial and clinical operations and serve as a convener of the FQHC community. As APM development progresses, PCAs can help FQHCs understand value-based purchasing and their capacity for participating in alternative reimbursement models.[v]
FQHC executive and clinical leaders: Executive-level staff can offer perspectives on how to overcome FQHC fiscal and operational challenges in the transition to a value-based APM. Clinical champions can be important ambassadors in outreach with their professional peers, and can also provide insight into how clinical practice and workflows may need to change to effectively implement the value-based APM.
Consumers and patients: Most FQHCs are required to have at least 50 percent patient participation on their boards, and will likely have patient/consumer leaders with an understanding of their practices’ patient priorities who can bring a consumer focus to planning.
Identify a vision and shared goals.
Identifying a vision and shared goals allows stakeholders to work from a common foundation and can help overcome barriers. States may want to formalize the shared vision and goals through a charter or work plan. Colorado stakeholders formalized their goals through a statement of shared intent,[vi] which listed key design decisions and included a timeline for additional decision-making.
Employ varied communication strategies to ensure FQHC support.
States can use a variety of communication mechanisms to engage FQHCs and encourage buy-in from practices.
- Early identification and outreach to health centers that are interested in payment reform can provide the foundation for ongoing engagement. In Hawaii, for example, the state’s PCA convenes a subcommittee on value-based purchasing that offers a forum for these FQHCs to provide feedback on the development of the state’s value-based APM development.
- Targeted educational materials and activities about value-based purchasing and practice transformation can prepare stakeholders for more meaningful participation. Both Michigan and Oklahoma have provided FQHCs with ongoing training and education on value-based purchasing at PCA meetings.
- Letters of interest (LOI) or requests for information that document the state’s thinking and direction can be helpful tools to educate target audiences, gauge level of interest, and identify interested FQHCs and leaders. FQHCs that responded to Colorado’s LOI[vii] now actively provide feedback on the state’s proposed APM and receive additional resources and support to ready them for implementation.
Develop collaborative processes to help foster trust and transparency.
Several states that participated in the NASHP Academy reported that developing relationships with their state PCA and FQHC community has been a key factor in successful planning. The District of Columbia’s Medicaid agency, for example, created a continuous feedback loop to provide information to and receive comments from PCA leaders, FQHCs, and managed care plans through regular meetings with each stakeholder group. Nevada created subcommittees, which included leadership from each Medicaid bureau and the PCA, that each focused on a core element of APM design (e.g., attribution of patients to providers). Subcommittees were responsible for researching potential options and presenting their recommendations to the team of core stakeholders.
Assess and adapt stakeholder engagement as the project evolves.
As APM development gains momentum, states may need to engage additional stakeholder groups, such as state legislators, managed care organizations (if applicable), and the state’s Medicaid Advisory Committee to educate a broader audience and build support for the model. States can also convene public hearings and conduct focus groups to gather feedback from broader audiences, or to get more granular feedback from specific perspectives. States are also required to provide a public notice and comment period for any changes to payment methodologies that require a State Plan Amendment (SPA).
For more resources about stakeholder engagement, see the resources tab. To view additional information about developing a value-based APMs for FQHCs, return to the toolkit home.
[i] Public Health Service Act, 42 U.S.C. §254b. https://uscode.house.gov/view.xhtml?edition=prelim&req=42+usc+254b&f=treesort&fq=true&num=20&hl=true.
[ii] Health Resources & Services Administration, “Uniform Data System (UDS) Resources,” accessed September 29, 2017, https://bphc.hrsa.gov/datareporting/reporting/index.html.
[iii] Health Resources and Services Administration. “Health Center Program Site Visit Guide.” November 2014. https://bphc.hrsa.gov/archive/administration/visitguidepdf.pdf.
[iv] Public Health Service Act, 42 U.S.C. §254b. https://uscode.house.gov/view.xhtml?edition=prelim&req=42+usc+254b&f=treesort&fq=true&num=20&hl=true.
[v] PCAs are state or regional non-profit organizations that provide training and technical assistance to safety net providers. Funding from government or foundation grants, membership dues, and charges to members to participate may be used to provide support, education, and technical assistance on the health center or provider level for those interested in participating in a value-based APM. For more information please visit: https://bphc.hrsa.gov/qualityimprovement/strategicpartnerships/ncapca/associations.html.
[vi] Colorado Department of Health Care Policy and Financing and Colorado Community Health Network. “HCPF/CCHN Shared Intent for FQHC APM.” December 7, 2016. **NASHP Communications – please insert link to this from the toolkit once available.**
[vii] Colorado Department of Health Care Policy and Financing and Colorado Community Health Network. “CCHN CHC Alternative Payment and Care Model (APCM) Pilot: Request for Letters of Interest.” November 2017. **NASHP Communications – please insert link to this from the toolkit once available.**