Policy and Advocacy -

Testimony

 

Council of the District of Columbia

Hearing on

The Oversight and Performance of the DC Department of Health Care Finance

February 23, 2018

Committee on Health

The Honorable Vincent Gray, Chairman

By

Patricia Quinn

Director of Policy and External Affairs

District of Columbia Primary Care Association

 

Good morning Chairman Gray and distinguished members of the Committee. My name is Patricia Quinn, Director of Policy and External Affairs for the DC Primary Care Association (DCPCA). DCPCA works toward a health system that helps everyone in the District get and stay well, no matter the color of their skin, the language they speak, where they live, how much money they have, or who they love.  Our partners in this work are community health centers who serve nearly 1 in 4 District residents in every ward. I am here today to offer testimony on the performance and oversight of the DC Department of Health Care Finance.

 

DCPCA applauds DHCF’s commitment to health information exchange, as well as its focus on behavioral health integration, including increased access to substance use disorder treatment. We appreciate the Department’s partnership in a solutions-focused dialogue regarding FQHC payment, and we are encouraged by DHCF’s engagement in DC PACT, a multi-sector coalition of clinical care providers, community support organizations, and government partners focused on building a health system that identifies and addresses social drivers of health. In addition, we support DHCF investment in care management, and look forward to working closely with the Department as we build the FQHC Clinically Integrated Network, a new joint venture that represents an unprecedented collaboration on transitions of care and care management among seven of the District’s FQHCs. That said, we must highlight significant challenges in the FQHC billing system that result in excessive administrative burden for health centers and that divert resources away from critical efforts to improve patient health. We also urge a move to yearly recertification for Alliance beneficiaries and expansion of telehealth.

Health Information Exchange

DCPCA partners with DC Department of Health Care Finance to build provider capacity to utilize the full array of available HIE and HIT tools implemented by DHCF in the past year. Those tools include:

  • Dynamic Patient Care Snapshot: An ‘on-demand’ web based document, accessible by providers and members of their care teams, that provides an aggregated display of both clinical and non-clinical data for a selected patient, including demographic information, patient care relationships and clinical encounters.
  • Analytical Patient Population Dashboard:  A population-level dashboard that facilitates patient panel management.
  • Electronic Clinical Quality Measurement Tool and Dashboard: An electronic clinical quality measurement (eCQM) tool that aggregates and analyzes data captured through Continuity of Care Documents (CCDs) submitted to the HIE to assess provider performance against quality metrics standards for their empaneled patient population.
  • Obstetrics/Prenatal Specialized Registry: An electronic form that enables District providers to collect data associated with prenatal screenings and assessments for submission to the District’s OB/Prenatal Specialized Registry.
  • Ambulatory Connectivity and Support: Engage with District providers to support their connection to the DC HIE, including delivery of technical assistance aimed at the advanced use of HIE services.

DHCF’s aim in developing these tools is to provide technology solutions that will bolster clinical care, improve health-related service utilization throughout the continuum of care, and increase the exchange and integration of data associated with population health and social determinants of wellbeing.

In 2017, DCPCA expanded its relationship with DHCF through a multi-year contract award to deliver HIE-HIT technical assistance and outreach services to providers eligible for participation in the District’s Medicaid EHR Incentive Program (MEIP).  Under this contractual relationship, we have worked with health centers and small ambulatory practices throughout the District to enroll their eligible providers in MEIP so that they are able to fully benefit from DHCF’s HIE - HIT program investments.  As DHCF’s partner, DCPCA is able to offer on-going Meaningful Use technical assistance and attestation services to health center providers at no cost.  We are also able to offer technical support that is focused on helping health center staff effectively use the expanded HIE tools listed above that were launched at the end of 2017. 

As challenging as building a Health Information Exchange from disparate parts is, DHCF leadership in this endeavor is exemplary. The Department has successfully engaged partner capacity across the District to effectively coordinate an HIT/HIE approach to meet the needs of providers and patients for coordinated, effective information exchange. DHCF thinks creatively and innovatively, regularly seeking input and feedback at the implementation level to give the emerging District HIE the best chance to reach its potential to improve health outcomes.

Recommendation:

  1. DHCF should grow the District’s HIE capacity, increasing interoperability and continuing to balance innovation with investment in utilization training and analysis. Improved health outcomes and cost containment depend on this HIE capacity.
  2. DCPCA welcomes the opportunity to return to this committee in the coming months to share progress on the impact of new investments in HIE tools.

Behavioral Health Integration

DCPCA recognizes DHCF’s commitment to integrated and coordinated behavioral health in order to address the crushing inequity in health outcomes in the District. DHCF has kept the focus on behavioral health across multiple departmental initiatives, and has leveraged opportunities to partner cross-departmentally to meet behavioral health needs. Importantly, the FQHC Medicaid rule that allows for same-day payment of medical, behavioral, and dental visits became final in September 2017. DCPCA and our FQHC partners have identified some additional payment policy barriers related to behavioral health CPT billing codes and drafted a request and rationale to the District’s Medicaid agency that is currently under consideration.

SUD treatment requires some additional strategic thinking and planning. The aforementioned FQHC rule increased the list of billable behavioral health providers to include certified addictions counselors, among other additions. DHCF and DBH have agreed that FQHCs can bill DHCF directly for substance abuse treatment. This means that FQHCs that want to support patients with SUD treatment can do so without having to engage in an entirely separate billing and reporting system.  Still, FQHCs must be certified by DBH as substance abuse providers, and it is not clear how much of a barrier this may be. And health centers have yet to bill SUD for patients in the new system, particularly for those who are part of Medicaid Managed Care Organizations, so the implementation of the new policy has yet to be tested.

In addition, as health centers increase the number of primary care providers who are trained to treat SUD with Medication Assisted Treatment, we need to ensure that they can help their patients in need of immediate counseling support and connect patients to ongoing counseling, peer connection, and family education/intervention as necessary. DCPCA hopes to complete an analysis of SUD treatment capacity within FQHCs this year.

Recommendation: DHCF should maximize delivery of behavioral health services within FQHCs by all means at their disposal including:

  1. Approve use of behavioral health CPT billing codes recommended by DCPCA and our Behavioral Health Peer Group
  2. Seek to reduce any barriers to SUD treatment in the FQHC setting as they may emerge through implementation of certification and billing
  3. Expand behavioral telehealth opportunities that allow for flexibility in terms of patient and provider location
  4. Push for of the ability to access behavioral health data through the District’s HIE

FQHC Billing and Payment

             The recently approved FQHC payment rule precipitated a need to revamp DHCF’s FQHC billing process.  Beginning in the summer of 2016, the Department of Health Care Finance (DHCF,) the District of Columbia Primary Care Association (DCPCA,) the District’s Federally Qualified Health Centers (FQHCs,) and the Medicaid managed care organizations have worked in partnership to establish a payment system that would facilitate differential rates for medical, behavioral, and dental services, payment for same-day services, and timely and accurate wrap payments. We are most grateful for the Department’s spirit of collaboration and resolute problem-solving throughout the process.

                                                             

Implementation of the new system required significant, accurate, and timely re-configuration of health center billing, Medicaid MCO payment systems, and the DHCF wrap payment system. Without question, all parties substantially underestimated the scope of the necessary changes. Although all parties acted in good faith, we cannot avoid the hard truth of insufficient advance preparation, insufficient testing of the system prior to implementation, and insufficient contingency planning when problems inevitably arose.

At the heart of the new payment system is the institution of new NPI numbers and Taxonomy codes.  In particular, the new system requires each FQHC site to have a separate NPI, versus the old system which allowed health centers to bill MCOs and DHCF under a single organizational NPI. Another major change in the new system is that DHCF instituted a policy to pay wrap only on claims which could be matched to a specific MCO paid claim. FQHC finance offices have spent massive staff time to run down MCO payments, and then must also devote major resources to get wrap payments on those same claims—the perfect storm for a health center cash flow disaster.

Health centers and DHCF report light at the end of the tunnel. They see resolution of some of the most significant configuration and matching problems, and all remain hopeful that the system will cease to cause overwhelming administrative burdens to FQHCs.

Recommendations:  

  1. FQHCs should be compensated for the costs associated with that increased administrative burden. We had previously recommended a lifting of the payment rule’s administrative cap, and we are open to dialogue with DHCF on how recompense should be granted.
  2. DHCF, FQHCs, MCOs, and DCPCA may still need to consider whether a system that has such potential for double jeopardy for health centers for each and every MCO claim is sustainable or fair. If MCOs are reporting the claims and payments correctly to DHCF, we question the benefit to any party of having health centers file a secondary claim for the wrap, as opposed to paying it automatically based on MCO data. FQHCs would retain the option to appeal MCO denied claims to DHCF if necessary. DHCF has agreed to explore this option.
  3. As the work to mitigate challenges with the new FQHC billing system is ongoing and proceeding somewhat positively, DCPCA would welcome the opportunity to report further within the next two months to determine appropriate next steps.

Alliance Recertification

DCPCA believes that systemic issues that impact Alliance beneficiaries who must renew in person every 6 months result in loss of Alliance coverage for otherwise eligible residents. Even those who successfully complete the renewal process are likely to experience significant burden in terms of time and effort. Such churn regarding insurance coverage is associated with poor health outcomes, and may be part of the cause for increased cost per patient within the Alliance population.

Recommendation:  DHCF should allow yearly recertification for Alliance coverage. This change would benefit Alliance beneficiaries, as well as they many other beneficiaries of other District safety net programs. The current twice-yearly in-person recertification for Alliance beneficiaries impacts the functioning of Economic Services Administration, increasing wait times for all applicants for ESA programs.

My Health GPS

DCPCA supports DHCF’s investment in care management and care coordination, and its focus on value-based payment. Initiated in 2017, the MyHealth GPS program is an opportunity to identify what supports and interventions will best improve health outcomes and reduce utilization of high cost settings for Medicaid beneficiaries with multiple chronic conditions. It should also build knowledge about the most essential capacities and services in the provider community to achieve the best results. DCPCA and the FQHC Clinically Integrated Network welcome partnership with DHCF to engage further in value payment models. The seven DC FQHCs in the DCPCA Clinically Integrated Network (DCPCA-CIN) believe primary care should be at the center of health investment and improvement, and that their best chance to thrive as high quality safety net providers is together.

DCPCA has spent the better part of the last decade building the health information technology and analytics capacity that makes the CIN possible. That HIT, coupled with DCPCA and District investment in HIE will be leveraged to reach the following targets:

  1. Reduce LANE ER visits by 10% over 2 years
  2. Reduce hospital re-admissions by 25% over 2 years
  3. Reduce hospital admissions by 5% over 3 years

 

 

The primary interventions are:

  1. Expanded clinic access: 24/7 nurse triage, coordinated access to same day and next day appointments, and mass communications patient education campaign on primary care network services.
  2. Hospital-based transitions of care: Nurse-led transition of care program for priority group focused on discharge follow-up with PCP and specialists, transmission of discharge plan, home health coordination, and medication reconciliation.
  3. Standardized care management for complex health and social needs: Clinic-based teams that implement standardized assessment and care plan approach. This includes a Housing-to-Health pilot targeted to high utilizers with intervention-sensitive social determinants.

Recommendation:  DCPCA and the DCPCA CIN look forward to partnership with DHCF, particularly to address the needs of Medicaid Fee-for-Service patients, targeting those with evidence of poorly managed care. In addition, the CIN intends to engage with Medicaid MCO partners to achieve its stated goals.

TeleHealth

The District of Columbia Primary Care Association supports expansion of telehealth in the District because of its potential to:

• empower patients as key partners in their health care

• reduce disparities in access to care

• improve the timeliness and quality of care

In particular, we support asynchronous store and forward services and remote patient monitoring for their potential to provide care for patients when, where, and how they need it.

We also support payment for originating sites when telehealth services are facilitated directly from one provider location to another. Including a transaction fee for originating sites when appropriate could increase the use of telehealth to meet patient needs.

The DC Department of Health (DOH) notes in the 2017 Health Systems Plan (HSP)

“While gaps may exist in medical specialty care and possibly outpatient surgical services, the gaps are focused on low-income residents who are insured by Medicaid, the DC Healthcare Alliance, or are uninsured. Findings show that there are inequities in service distribution and barriers that prevent full engagement in appropriate care for some segments of DC’s population.”

The HSP identifies the need to increase availability of high-quality medical specialty services for low-income individuals and families. Telehealth can efficiently improve access and quality of care for underserved patients by providing consultations and specialty care.

Additionally, the HSP highlights that services in DC are often fragmented and uncoordinated, and that factors implicated include information flow, referral practices, barriers to access (including transportation, cost, and language/culture), and limited collaboration between providers. Telehealth is an important tool to address these systemic issues. This modality, in its many variants, should be leveraged to tackle persistent inequities that deepen along racial and socio-economic lines in the District.

Recommendations: DCPCA supports elimination of barriers to telehealth and promotion of flexible service models that increase patient access and engagement in care. We encourage expansion of telehealth to reduce health systems challenges, enhance patients’ experience of care, and improve health outcomes. We look forward to working with the Committee on Health, DHCF, DOH, and our FQHC members to build world-class telehealth services in the District of Columbia.

 

Social Determinants of Health

DCPCA supports the “health beyond health care” philosophy critical to impacting entrenched health inequity in the District. Providers across all systems of care acknowledge the need to align clinical and community supports to reach beyond the four walls of traditional clinical settings and focus on place-based care as close to home as possible. As with the need to resource provider capacity-building in HIT and care management, we must work together to identify resources and opportunities to align across multiple governmental and community entities to provide care.

Recommendations:

  1. DHCF should continue to work with DC PACT to standardize screening for social determinants of health.  
  2. DHCF should ensure that any HIE investments in community resource inventory be produced in an open, standard, interoperable format made publically accessible and adaptable by other resource inventories
  3. DHCF should consider investment in a bi-directional resource platform accessible to health and social support organizations with capacity for participating entities to communicate and track referrals   

In closing, DCPCA is focused on expanding capacity for all partners to function as a seamless accountable health community over time and across sites of care through increased cross-sector collaboration, clinical practice transformation, expanded HIT capacity and HIE connectivity, and responsive and supportive patient engagement.  In DHCF, we are fortunate and grateful to have a partner that shares that vision. We express our genuine appreciation to DHCF for the strong spirit of partnership and shared commitment to do our best for the people of the District who rely on all our work in order to get and stay well.

 

DCPCA thanks Chairman Gray and the Committee on Health for the opportunity to share our perspective on the District’s Health Services Plan. DCPCA works toward a health system that helps everyone in the District get and stay well, no matter the color of their skin, the language they speak, where they live, how much money they have, or who they love.  Our partners in this work are community health centers who serve nearly 1 in 4 District residents in every ward.

 

The Health Services Plan produced by the Department of Health is impressively rich in data analysis and information about health status, health care utilization, barriers to care, and recommendations for improving the District’s health system. The report raises questions about the impact of utilization patterns on individual and community health, and highlights some potential challenges that may result from getting primary care further from home. DCPCA looks forward to the deeper dive on some of these issues promised in the coming Primary Care Needs Assessment. We make the following recommendations regarding the challenges and opportunities presented in the HSP:

 

  1. The District should deepen investment in care management within primary care.

The launch of the Department of Health Care Finance My Health GPS program is an important beginning to investment in primary care provider capacity to coordinate across sites of care and effectively manage care for priority populations. Additionally, continued DHCF-DOH collaboration and investment in a robust District health information exchange is critical. The changes necessary in staffing, HIE, data analysis, community supports, and patient engagement to impact population health improvement should not be underestimated. But neither should we settle for anything less than a seamless, accountable health community that works to meet patient and caregiver needs, that supports patients in developing the skills and strengths to take charge of their health, and that fights for equity in health outcomes across every ward in the District.

 

  1. The District should expand policies that support and enhance behavioral health services in primary care.

In the recently approved FQHC payment rule, the Department of Health Care Finance expanded the range of behavioral health providers eligible for reimbursement in the FQHC setting. It can take the next step and allow billing for behavioral health codes that represent early intervention for patients with anxiety, stress, and depression symptoms. The Department of Health has played an important role in supporting access to Medication Assisted Treatment (MAT) for addiction in the context of primary care and should continue to expand opportunities for providers to offer addiction care. DCPCA plans a crosswalk of Department of Behavioral Health certification requirements for substance use treatment facilities with those necessary to become an FQHC. As appropriate, we will urge DBH to waive some or all requirements, with a goal to increase the number of FQHCs that offer substance use disorder treatment.  Lastly, DCPCA urges the District to invest in connecting behavioral health providers to the growing DC Health Information Exchange, including an education campaign regarding the legality of exchanging mental health information.

 

  1. The District should explore evidence-based interventions that educate beneficiaries on the best use of the health care system to achieve optimal health.

Evidence presented in the report confirms painfully high rates of hospital admissions and emergency department use to address ambulatory care sensitive conditions. While cost implications are clear, more importantly, use of these high cost settings has not and will not result in high quality health outcomes for patients. DCPCA is committed to addressing the role primary care providers can play in changing this utilization pattern so prevalent in the District. We are interested in exploring what role residents’ use of neighborhood vs out-of-neighborhood primary care may play in the use of hospital and emergency department care. We welcome the opportunity to work with our government and other health sector partners and community members for an aggressive, comprehensive approach to this challenge.

 

  1. The District should support access to appropriate specialty care within primary care.

The Department of Health Care Finance should apply the same payment rules for FQHC-based primary and specialty care to increase the number of health centers offering high-need specialty care such as podiatry and ophthalmology.

 

  1. The District should support cross-sector coalitions focused on addressing social determinants of health

DCPCA leads a multi-sector coalition focused on maximizing resources and collaboration between clinical services and community supports called DC PACT (Positive Accountable Community Transformation). DC PACT is committed to using a collective impact approach to address social determinants and increase health equity in the District. The stark health disparities in Ward 7 and 8 make this connection between direct health care and the resources to address social factors absolutely critical.

 

  1. The District should identify health workforce needs, particularly in the safety net.

Capacity to serve patients is as much a function of success hiring providers as it is a function of the policies, resources, passion and will to serve them. All of our health center partners compete to hire nurses, psychiatrists, physicians, frontline staff, administrative teams, quality improvement leaders, care managers, community health workers and more. We hope to continue to work with the Department of Health and our health partners at the DC Hospital Association, the DC Behavioral Health Association, and the DC Health Care Association to develop strategies that attract top level talent across all levels of our member organizations.

 

In closing, DCPCA is committed to staying engaged with the Council, with the government health and human services sector, and with all health system actors to use all means at our collective disposal to fight for health equity and ensure every resident in every ward has a fair shot at a long, full, healthy life. We appreciate the opportunity to testify, and I look forward to working with you to build a healthier DC.

Good morning Chairman Gray and distinguished members of the committee.  My name is Eric Vicks, Associate Director Advocacy and Public Policy for the DC Primary Care Association (DCPCA.) We work to build a healthier DC by strengthening safety net community-based primary care. Our partners in this work include community health centers and FQHCs who serve 1 in 4 District residents in every ward of the District.  Today I am here to provide testimony in support of B22-0231 - Department of Health Care Finance D.C. HealthCare Alliance Amendment Act of 2017.

 

Chairman Gray, for years now, DC HealthCare Alliance consumers, who have do not qualify for Medicaid due to not meeting the lawfully presence requirement have been engaging in a difficult recertification process which penalizes them for being immigrants.  The recertification process which Alliance members are required to complete is an in-person interview which must be completed every six months. Medicaid, which is considered a successful program, does not require either a six-month or in-person recertification. These hoops are not characteristic of a sanctuary city that strives to avoid excluding residents from services based on their immigration status. The result has been more members dropping off of the roles likely due to the burden of the process, as you know there has been a long list of complaints including long lines at ESA, a lack of language skills to engage consumers, and lost documents. Those who complete the process have proven to be more costly to insure as they are sicker and need more health care; leading some in the administration to believe that they only endured the recertification process in order to address pressing health care needs.

 

DCPCA applauds your leadership in filing B22-0231. It creates options for Alliance consumers to complete registration. Shifting requirements to once a year and making the interview available by phone or with a familiar face at the community health center where the consumer receives their care are the common sense approaches we need to address this barrier to all people being covered. The benefits to this arrangement are: consumers can expect to better communicate with the individuals helping them to recertify; consumers will not have to take a day off of work, and show up at an ESA office at 5:00AM in hopes that they might be seen. The goal is to get all District residents covered so that health care is not a barrier to wellness.

 

Community Health Centers already helps consumers enroll in Medicaid and Qualified Health Plans via DC HealthLink. They provide an invaluable role in the quest to get everyone covered. Community Health Centers have been applauded in this role for their dedication, their attention to detail, and for their professionalism. When we speak of DC HealthLink we applaud the quest to have all District residents covered. These are consumers in QHPs and Medicaid. When we speak of Alliance consumers we speak of costs or the specter of non-residents stealing healthcare. We should instead focus our energies on many DC residents who simply cannot recertify due to bureaucracy and a flawed process. 

DCPCA supports an Alliance recertification process which removes the six month recertification requirement and the in-person interview.


We thank you for the opportunity to testify, and for your work and partnership in building a healthier DC. I am happy to answer any questions now or going forward.