October 29, 2021

We are excited that the Center for Medicare and Medicaid Innovation (CMMI) supports OCHIN’s recommendations for driving health equity by expanding access to specialty care and other services through value-based pay. We look forward to the opportunity to continue providing CMMI with the data, insights, and experience of our national network of providers, as the agency hones new models for improving the health of Medicare and Medicaid beneficiaries across the country.

For years, OCHIN has advocated for the Centers for Medicare and Medicaid Services (CMS) to update the payment models used to reimburse health care providers for the valuable services they provide to underserved communities. While significant CMS work has been done to develop models for patients covered by Medicare, the models have not focused on advancing equity, nor have they addressed the growing cost and demand for specialty care. This issue is particularly important for community-based providers, like local health centers, who serve a much higher volume of patients covered under Medicaid or without any health insurance. Sustainable payment models are needed for these community care providers to support the high standard of care their patients receive.

With the release of CMS’ CMMI’s new white paper “Driving Health System Transformation – A Strategy for the CMS Innovation Center’s Second Decade,” it is clear that CMMI has heard OCHIN’s feedback and incorporated our practical policy suggestions to finally close this payment disparity by moving toward a new model of value-based care focused on increasing equity and sustainable models among underserved providers.

New Payment Models to Enhance Specialty Care Access

Under the new 10-year innovation plan, CMMI intends to examine and simplify the more than 50 payment models currently in operation. Complex and confusing payment models have posed consistent barriers to entry for many community health care organizations in America, which are often too overburdened and under-resourced to use them. These barriers are particularly striking when examining specialty care referrals. OCHIN has long advocated for the advancement and modernization of payment models to reflect the needs and capabilities of providers who typically cannot participate in the current payment structure. Creating payment structures that focus specifically on specialty care is a critical step in the right direction for CMS.

Patients in underserved communities experience significantly longer wait times to see specialists, often never receiving specialty care because of geographic mismatch, shortages, and inadequate reimbursement. To put this into perspective: a March 2019 analysis of OCHIN Epic referrals made by 39 community health care organizations in multiple states found significant unmet demand for specialists. Among 84,600 cumulative referrals made in March 2019, just 22% were successfully fulfilled (in-person or virtually) within one month. Of those referrals, 16% took more than 27 weeks to be successfully fulfilled, 40% took between nine and 26 weeks, and 23% took between four and eight weeks.

Of the close to 1 million referrals OCHIN Epic clinics made in 2019, it is estimated that no more than 35% were completed and transitioned back to primary care. Delays for those who did see a specialist ranged between 3-10 weeks, with an average wait time of more than a month across specialists. The foregoing wait times were comparable to national data for specialists accepting Medicaid and Medicare and generally longer than Veterans Affairs (VA) wait times and Kaiser Health Plan service level agreements.  In the OCHIN network, many patients wait longer for referrals or don’t have access to specialists at all compared to patients with commercial health insurance coverage. For example, in the OCHIN network:

•   Time to appointment is 44 days on average across patients served.
•   Black and Hispanic/Latinx patients experience 10% delay in scheduling.
•   Rates of referral are 32% less for uninsured patients in OCHIN network.
•   75% of OCHIN members’ referrals are outgoing and have a 60% longer wait time on average.
•   Referrals that take longer than two months to schedule are more than 40% less likely to be completed than those scheduled earlier.

These findings underscore an important growing trend where patients can access specialists virtually. Allowing patients to access a specialist from their home, saving lengthy drives, expenses, and reducing the spread of COVID-19 are all boons which come from the implementation of new technology and payment models. Adopting new payment models would allow uninsured and underinsured patients to receive the care they need and deserve.

Equitable Value-based Rather than Volume-based Care

For most in the health care industry, payment is a result of volume of care, not quality of care. This is not a sustainable model for the U.S. health care system. Misaligned incentives create situations in which quantity over quality is emphasized, which can be detrimental to patient outcomes and experiences of care. OCHIN has long been a proponent of equitable value-based care, a methodology of payment that relies not on the quantity of treatment delivered, rather, how the treatment benefits the patient and the outcome of care received while advancing health equity. Successful equitable value-based models would result in more efficient care, better outcomes, and cost savings for the provider, insurer, and patients who have been systemically underserved.

Value-based care is already being used by some in the health care field. For example, Humana reported that its move from fee-for-service (FFS) to value-based care reduced medical costs by 18.9% for older adults enrolled in their Medicare Advantage plans in 2019 when compared to costs for those in traditional FFS Medicare. Additionally, the quality of care received by patients is improved when a value-based care model is used. In a survey of 120 payers, 77% of respondents reported improvements in care quality.

Of course, good data are essential to any health care quality improvement effort, and we cannot hope to optimize these new equitable value-based care models without reliable and representative data. To that end, national standards for data quality and interoperability are essential. Providers must have a full picture of a patient’s health—including their physical, mental, and social determinants of health (SDOH)—to provide their highest value and quality of care equitably.

OCHIN has been a national leader in collecting standardized SDOH data and a long-time advocate of responsible data sharing practices to improve whole-patient care coordination, advance health disparities research, and support public health. CMMI’s commitment to enhancing data availability and completeness will go a long way toward improving patient health outcomes and building a value-based care system that helps drive health equity on a national scale.

Learn more about OCHIN’s research exploring the benefits of value-based pay:

• Adoption of Social Determinants of Health EHR Tools by Community Health Centers
• Full Citation: Gold R, Bunce A, Cowburn S, Dambrun K, Dearing M, Middendorf M, Mossman N, Hollombe C, Mahr P, Melgar G, Davis J, Gottlieb L, Cottrell E. Adoption of Social Determinants of Health EHR Tools by Community Health Centers. Ann Fam Med. 2018 Sep;16(5):399-407. doi: 10.1370/afm.2275. PMID: 30201636; PMCID: PMC6131002.
• Using Health Information Technology to Bring Social Determinants of Health into Primary Care: A Conceptual Framework to Guide Research
• Full Citation: Cottrell EK, Gold R, Likumahuwa S, Angier H, Huguet N, Cohen DJ, Clark KD, Gottlieb LM, DeVoe JE. Using Health Information Technology to Bring Social Determinants of Health into Primary Care: A Conceptual Framework to Guide Research. J Health Care Poor Underserved. 2018;29(3):949-963. doi: 10.1353/hpu.2018.0071. PMID: 30122675; PMCID: PMC6779030.
• Advancing Social Prescribing with Implementation Science
• Full Citation: Gottlieb L, Cottrell EK, Park B, Clark KD, Gold R, Fichtenberg C. Advancing Social Prescribing with Implementation Science. J Am Board Fam Med. 2018 May-Jun;31(3):315-321. doi: 10.3122/jabfm.2018.03.170249. PMID: 29743213.
• Impact of Alternative Payment Methodology on Primary Care Visits and Scheduling
• Full Citation: Heintzman J, Cottrell E, Angier H, O’Malley J, Bailey S, Jacob L, DeVoe J, Ukhanova M, Thayer E, Marino M. Impact of Alternative Payment Methodology on Primary Care Visits and Scheduling. J Am Board Fam Med. 2019 Jul-Aug;32(4):539-549. doi: 10.3122/jabfm.2019.04.180368. PMID: 31300574.
• Documenting New Ways of Delivering Care Under Oregon’s Alternative Payment and Advanced Care Model
• Full Citation: Cottrell EK, Dambrun K, O’Malley J, Jacob RL, Mossman N, Ashou C, Heintzman J. Documenting New Ways of Delivering Care Under Oregon’s Alternative Payment and Advanced Care Model. J Am Board Fam Med. 2021 Jan-Feb;34(1):78-88. doi: 10.3122/jabfm.2021.01.200027. PMID: 33452085.
• Comparison of Community-Level and Patient-Level Social Risk Data in a Network of Community Health Centers
• Full Citation: Cottrell EK, Hendricks M, Dambrun K, Cowburn S, Pantell M, Gold R, Gottlieb LM. Comparison of Community-Level and Patient-Level Social Risk Data in a Network of Community Health Centers. JAMA Netw Open. 2020 Oct 1;3(10):e2016852. doi: 10.1001/jamanetworkopen.2020.16852. PMID: 33119102; PMCID: PMC7596576.