APM, alternative payment model, social determinants of health, health equity
Photo credit: Katharine Kimball

Go big or go home: transforming primary care to achieve health equity for all

By Ariel Singer, MPH, Innovations Director at the Oregon Primary Care Association.

The Oregon Primary Care Association (OPCA) has been garnering a lot of attention for our Alternative Payment and Advanced Care Model program (APCM). We’ve been leading its development since 2010, and our first APCM group went live in Oregon in 2013. For years, we’ve experienced strong demand nationwide to share our experience in payment and care transformation, and we have been on a multi-year journey of figuring out how to effectively respond as a state Primary Care Association.

In 2016, with the support of the Wagner Endowment of the MacColl Center for Health Care Innovation at Kaiser Permanente Washington, we launched the APCM Learning Exchange, which now includes our peers from ten state Primary Care Associations (PCAs) and staff from the National Association of Community Health Centers. Our vision for this partnership between PCAs is to create an opportunity for the exchange of ideas and experiences between all of the participating states to promote Alternative Payment Methodologies and Advanced Care practices that support community health center readiness to improve health outcomes and thrive in an environment of value-based pay. Our goal for the Learning Exchange is to build on Oregon's APCM experiences, to disseminate and improve upon lessons learned in Oregon and in states across the country. The Learning Exchange is focused on APCM approaches that are similar to Oregon's, rather than the full range of advanced care and alternative payment approaches available in the rapidly changing health care environment.

Achieving health equity for all

Oregon has made a great deal of progress in changing primary care delivery via participation in the Safety Net Medical Home Initiative and other state-level patient-centered medical home (PCMH) efforts. Together, our member health centers provide access to high quality, patient-centered primary care to 1 in 10 Oregonians.

Yet, OPCA’s work with health centers and the vulnerable populations they serve has led us to become keenly aware that even perfect medical care only constitutes a small portion of what affects health. Social circumstances have a tremendous effect on the health of individuals and communities, and we can’t truly improve health and well-being across our state solely by building great medical homes. 

We push for transformation so that health centers can partner with patients authentically and learn more deeply about their lives, preferences, and priorities. Our goal is to help health centers respond to patients and communities in a holistic way that both responds to their immediate needs and also addresses the upstream drivers of health. We believe that community health centers can provide the best value to patients, payers, and the staff who work there, by focusing on strong human relationships and the root causes of health.

The PCMH has limits

We started to move towards this vision for payment and care model transformation while supporting our health centers to adopt the PCMH model. At that time, we received a strong message from the medical leadership in our state: “We can’t do this within the fee-for-service payment structure we have. We can’t provide the proactive, whole-person care that we know is likely to produce better outcomes without having more flexibility in the way we conduct our business.”

Health centers in Oregon have become successful medical homes and 100% of Oregon health centers are recognized through the state PCMH-recognition program. But the world has kept turning, and we knew that to keep pushing towards our vision of health equity for all, we couldn’t rest on those PCMH laurels! We are never going to achieve the kind of health and wellness we want for our communities by providing better medical care. 

Genesis of the Alternative Payment Model

Because the traditional model of health center payment was not aligned with the transformational change expected of primary care, we developed the Alternative Payment and Advanced Care Model in partnership with member health centers and our colleagues at the Oregon Health Authority. Oregon’s approach is the first Medicaid Alternative Payment Methodology (APM) for Federally Qualified Health Centers and Rural Health Clinics that creates a per-member per-month approach to payment, removing the incentive to produce face-to-face visits with a billable provider, over a multi-year timeframe. 

Although the genesis of our APCM approach was changing payment, our experience is that changing payment doesn’t actually change care. It is very easy for conversations to get magnetized by the complexities of changing payment models, and we’ve learned that to move towards our north star of health equity, we have to maintain the focus on care transformation, with payment to support it - not the other way around.

Go big or go home

We’re still learning, but in each opportunity that we have to share our process with others, we say that you have to go big or go home with this work. As a PCA, you have to be ready to build capacity and fully commit to shepherding payment and care transformation in partnership with the community health centers in your state. APCM takes a lot of resources, skills and commitment from PCA staff. It’s exciting to see momentum building around the country to push the boundaries of the existing system.

Sharing our learnings

We’ve received many requests from our partners across the nation to share what we’re learning about APCM here in Oregon. Prior to the creation of our Learning Exchange, we shared our APCM experience with over 18 state Primary Care Associations via on-site visits, webinars, phone calls and email. The APCM Learning Exchange is our first effort to move from sharing resources in an ad hoc and marginal way, to proactively and systematically disseminating our lessons learned.

We don’t know exactly what the future of the APCM Learning Exchange looks like, but an early indicator of success is that our PCA peers tell us they’re coming away from the meetings with a renewed sense of the importance of leading the conversation from the perspective of changing care. Our commitment to changing the community health model to promote health equity provides us with that signal beacon we can keep coming back to, no matter what obstacles, competing priorities or barriers arise in our path.

OPCA is a non-profit membership association, founded in 1984, guided by its mission to achieve health equity for all. The OPCA 2016 Learning Exchange was funded by the Ed Wagner Endowment for Health Care Transformation at Kaiser Permanente Washington Health Research Institute.

Ariel Singer, MPH, organizes a new body of work for community health centers around emergent practices and innovative ideas to improve population health in collaboration with the Oregon Primary Care Association teams working on care model transformation and social determinants of health interventions.

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