To: The Honorable Christina Henderson, Chair, Committee on Health

The Honorable Vincent Gray, Chair, Committee on Hospital and Health Equity

Members of the Committees on Health and Hospital and Health Equity

From: Ruth Pollard, President and CEO, DC Primary Care Association

Re: Performance Oversight Hearing for Department of Health Care Finance and Deputy Mayor for Health and Human Services

Date: February 8, 2024

The DC Primary Care Association (DCPCA) works to build a healthier DC by sustaining community health centers, transforming DC health care delivery, and advancing racial and health equity. Our collaborators in this work include community health centers, serving almost 1 in 4 District residents in every ward of the city, District government agencies including the Department of Health Care Finance (DHCF), and other providers in the DC health ecosystem. Thank you for the opportunity to provide testimony regardi ng the work of the District of Columbia Department of Health Care Finance (DHCF.)

DCPCA’s partnership with DHCF is robust and effective. DHCF leadership understands the role the District’s community health centers play in the effort to achieve health equity in our city. Health centers are dedicated to the delivery of high-quality person-centered care, and DHCF leadership is responsive to the ir needs and challenges. We enjoy a long-standing alliance to develop the DC health information exchange and advance its capabilities, and we share a commitment addressing social drivers of health as a key strategy for improving health outcomes and well-being. Our testimony will focus on DHCF’s oversight of the Medicaid Managed Care Organizations (MCOs) with particular attention to the need for investment in primary care, value-based contracting, and the behavioral health carve-in.

Investment in Primary Care

High quality, sustainable, accessible primary care must be at the heart of any effort to rewrite our city’s health story, and the survival and success of community health centers remains critical to a successful and thriving District of Columbia. Primary care should serve as the cornerstone of healthcare delivery, offering preventive services, early disease detection, and management of chronic conditions. By investing in primary care, we prioritize patient-centered approaches that emphasize continuity of care, patient education, and holistic well-being. Primary care interventions improve health outcomes and mitigate healthcare costs by reducing the need for expensive specialized treatments and avoidable hospitalizations. Ultimately, investing in primary care not only enhances individual health but also strengthens the resilience and sustainability of healthcare systems, laying the foundation for healthier communities and societies at large.

Despite its importance to overall health and well-being, primary care spending is in the single digits compared to spending on specialty and hospital care. DHCF has opportunities to increase investment in primary care including:

• An 1115 waiver for health-related social needs (HRSNs) that includes resources for primary care infrastructure,

• Several CMS primary-care focused initiatives,

• Alternative payment methodologies for federally qualified health centers, and

• A Managed Care quality strategy that requires reporting on and increases in primary care investment.

We appreciate the Department’s consideration of which vehicles best align with our shared goals to increase primary care capacity, improve access, and support health centers’ delivery of high-quality team-based care. We look forward to further progress and welcome the opportunity to brief this committee on defined strategies for improved primary care investment.

Value-Based Contracting

In pursuit of greater quality and lower cost for DC residents, 7 Federally Qualified Health Centers (FQHCs) DC-based community health centers and the DC Primary Care Association (DCPCA) have established the DC Connected Care Network (CCN). Participating health centers are:

• Bread for the City

• Community of Hope

• Family and Medical Counseling Services

• La Clínica del Pueblo

• Mary’s Center

• Unity Health

• Whitman-Walker Health

The CCN will support coordinated care to prevent avoidable hospitalizations and readmissions, minimize duplication of services, and address gaps in care. Combining the services, partnerships, and practice culture of the member FQHCs, the CCN will establish a continuum of care that addresses the diverse needs of each patient. Collectively, we provide comprehensive pediatric and adult primary care, specialty care services, chronic disease management, as well as various social support services, at over forty-five locations throughout the city.

To achieve its goals to create capacity for care management, coordination across sites of care, and capacity to address social needs at the point of primary care delivery, the CCN needs the support and engagement of DHCF and our MCO partners. Most importantly, we need DHCF to develop a standard MCO value-based care contract that includes guidelines for quality measures and requires a glide-path for total cost of care contracts. Alignment across payers is essential for the kind of systems transformation necessary to improve health outcomes and advance health equity.

The 2023 DHCF-commissioned report Medicaid Business Transformation DC: Recommendations for Technical Assistance indicates that states that succeed in moving their Medicaid systems to value-based care have key features including:

• Upfront investment in the primary care system,

• Support for formation of provider-led entities (such as the CCN described above), and

• Resources to address social domains.

Our member health centers upon which so many residents impacted by inequity rely, need DHCF and its MCO payers to engage in proven strategies for value-based care and improved health equity.

MCO Accountability and Behavioral Health Carve-In

As the District further invests in the managed care approach, and as the carve -in of behavioral health services brings new providers into MCO systems, the need for DHCF oversight of MCOs grows. DHCF has the power to hold MCOs accountable to improve the functioning and sustainability of a comprehensive, coordinated system prepared to meet the needs of high- priority District residents. We encourage DHCF to support standardization of processes such as credentialing and prior authorization to reduce provider burden and delays in patient care. We can work together to improve payment and credentialing systems so we can all fully focus on ending the persistent, pervasive inequities that drive disparate health and well -being in the District.

Issues regarding behavioral health:

• We need DHCF and the MCOs to establish a process for FQHCs to bill for basic behavioral health services provided to Alliance beneficiaries.

• We need a mechanism for unlicensed providers who provide the bulk of Community Support services to be credentialed by MCOs, or we need MCOs to establish another process for unlicensed providers to bill claims.

• We need aggressive testing of MCO payment systems for these new (to the MCOs) services and a commitment not to move forward until billing readiness is assured

DCPCA knows how critical robust and effective behavioral health care is to a thriving health system. We urge DHCF to ensure operational readiness at the MCOs to avoid disruptions in care and delays in payment that will destabilize a vulnerable system.

Partnership for Health Information Technology and Exchange

DCPCA has worked closely with DHCF and the Department of Behavioral Health to support Mental Health Rehabilitation Services (MHRS) and Adult Substance Abuse Rehabilitative Services (ASARS) providers to connect to CRISP, the District’s Health Information Exchange (HIE). Forty-four MHRS organizations and twelve ASARS agencies have upgraded to a federally approved electronic health record (EHR), thereby qualifying for financial incentives totaling almost $2.7 million. Those fifty-six provider organizations are now connected to CRISP, the District’s Health Information Exchange, and can better coordinate and support whole-person care.

DCPCA recognizes a need for ongoing technical assistance for DBH providers to support quality data collection and effective use of available reports and analyses.

Maternal Health

Over the past several years, DHCF has taken important steps to support maternal health, including expansion of coverage to include doula care, adding the non-emergency transportation benefit to Alliance beneficiaries for prenatal and postpartum care, and ensuring health care coverage for 12 months postpartum. The recent release of recommendations from the DHCF-facilitated Perinatal Mental Health Taskforce offers additional opportunities for policy and practice changes that could help to address inequity in maternal health outcomes.

The Taskforce report includes multiple recommendations centered on resourcing care coordination and other “connector” roles such as community health workers (CHWs) that DCPCA endorses. Such personnel ensure that birthing people have navigation assistance across sites of care and support to make the best care decisions for themselves and their families. We also support the range of provisions seeking to expand the perinatal mental health workforce and extend it with more robust inclusion of paraprofessionals and making group care more viable.

Health-Related Social Needs and the 1115 Waiver

DHCF is a leader in leveraging Medicaid resources--particularly HIE resources--to better link clinical and community social care. As the agency considers incorporating social interventions that improve health and well-being, we know DHCF will be inclusive of evidenced-based approaches. In addition to our recommendations on the opportunities via the 1115 waiver to invest in primary care, DCPCA also urges DHCF to explore approaches that reorient the healthcare delivery system around people and communities.

States such as Illinois and New York have used their waivers to support community-driven entities that identify and assess root causes of health inequity. Healthcare Transformation Collaboratives (Illinois) and Health Equity Regional Organizations (New York) engage the community to drive health system accountability and investment. DHCF should not miss this opportunity to reorient toward integrated health and social care. Changes in Medicaid policy, in payment models, in community benefit requirements, and in accountability can be leveraged for action on social and structural determinants of health and health equity.

Cedar Hill Regional Medical Center

Cedar Hill Regional Medical Center (CHRMC) will provide access to a system of high quality acute and specialty care previously unavailable in the communities at the east end of the District. Through its partnership with Universal Health Services (UHS), the District makes significant investment in the health of the people of Ward 7 and 8 and commits to long-term improvement in their wellbeing.

DCPCA and our member health centers recognize the opportunity to re-envision partnership between primary care, acute care, and specialty care with the GW Cedar Hill team. We look forward to defining communication, continuity of care, and information transfer across settings and we seek expedited access to specialist care at Cedar Hill for health center patients. We look forward to clearly defining the roles we each play in developing a truly integrated health care delivery system for District of Columbia for residents East of the River.

DCPCA and our member health centers are grateful for the partnership of Deputy Mayor and DHCF Director Wayne Turnage, Senior Deputy Director and Medicaid Director Melisa Byrd, Senior Deputy Director of Finance Angelique Martin, Director of the Health Care Delivery Management Administration Lisa Truitt, and their dedicated teams. We believe in our collective capacity to build a health system that gives every District resident a fair shot at a full, healthy life, and we stand ready to support the DC Council Committee on Health to engage in that effort.