As the September 30th funding cliff looms for Community Health Centers it occurs to me that this may be an appropriate time to discuss an opportunity that could increase revenues and better prepare them for these stormy financial times.

Innovative Health Media, LLC has self funded 2 pilot projects.  One in community based senior living programs and the second in a Federally Qualified Health Center in Missouri.  Both pilot projects demonstrated that prevention and wellness begins with the patient and that Community Health Centers are the most likely to meet those patient’s needs.

In our quest to garner support from Community Health Centers we learned that these organizations often have a much lower Medicare population.  Even as their large Medicaid population transition into Medicare, these patients tend to leave their CHC’s provider.  In an interview with one FQHC we were told they “discourage” Medicare patients from staying in their system.  We feel this is a missed opportunity for health centers, patients and the national Medicare program.

Why Community Health Centers are important to the Medicare Population.

On October 1, 2014, FQHCs began transitioning to a prospective payment system (PPS) in which Medicare reimbursements are made based on a national rate.  Because of the PPS rate, FQHCs are able to offer services that wouldn’t otherwise be affordable to implement.

In addition certain preventive services  are adjusted up to encourage more widespread use. “The adjusted FQHC PPS rate is increased by 34.16 percent when a patient is new to the FQHC, or an Initial Preventive Physical Exam (IPPE) or Annual Wellness Visit (AWV) is furnished.”

The PPS includes the following additional codes specific to prevention and wellness among the Medicare populations:

HCPCS Qualifying Visits for G0466/7

97802 Medical nutrition indiv
994062 Behav chng smoking 3-10 min
994072 Behav chng smoking > 10 min
99495  Trans care mgmt 14 day disch
99496  Trans care mgmt 7 day disch
99497 Advncd care plan 30 min
G0442 Annual alcohol screen 15 min
G0443 Brief alcohol misuse counsel
G0444 Depression screen annual
G0445 High inten beh couns std 30 min
G0446 Intens behave ther cardio dx
G0447 Behavior counsel obesity 15 min

Why isn’t every Primary Care Provider offering these services?

Regular Fee for Service providers are reimbursed less than $30 for most preventive services listed above.  This means the cost of offering these services is often more than the reimbursement, which makes it impossible for the practice to offer them to their patients.

Because FQHCs are reimbursed at the PPS rate for all visits, they are able to offer these valuable programs where their contemporaries can not.  This means for prevention and long term wellness the FQHC may be a “better” place for Medicare patients to receive preventive services.  FQHC’s can become the Wellness Centers for the Medicare population.

For demonstration purposes, let’s focus on 2 visits in particular that are often not used in primary care but have been available since 2011.

  1. Intensive Behavioral Therapy for Cardiovascular Disease: The CDC estimates that a third of all heart attacks and strokes are preventable.  CPT Code G0446 is a perfect opportunity for providers to sit down with their patients and discuss preventive strategies to lower that risk.
  2. Intensive Behavioral Therapy for Obesity: One third of the total population in America are obese.  Studies have shown that even a minor loss in weight can significantly reduce the risk for a myriad of diseases.  CPT G0447 is the perfect opportunity for providers to see obese patients and support their ongoing lifestyle changes necessary to reduce their BMI.

As already stated, most primary care physicians do not use these two codes due to the low reimbursement rate.  FQHCs are different because of the PPS rate and are able to see patients and get reimbursed the same rate regardless of the visit.

Shared Support

Because regular Fee for Service providers are unlikely to offer these services to their patients, it is possible (where a competitive environment doesn’t exist) for FQHCs to offer these preventive services as a benefit to other primary care programs.  Regular fee for service can treat the FQHC as a prevention and wellness resource and  can make referrals for patients with obesity, need for health literacy around cardiac health, etc.  If the FQHC is already referring patients who become Medicare age to other providers this model may be rather beneficial for all the primary care communities surrounding the FQHC.

Importance for Medicare Research

There is bipartisan support in Congress to expand prevention and wellness services but without longitudinal data that demonstrates the value of these programs, Congress is unlikely to approve additional reimbursement amounts.  FQHCs offer a unique opportunity for research data to be collected regarding the value of these services.

Quality Measures Met

Medicare’s preventive services meet an abundance of quality measures that are essential to reaching milestones required for continued operational support.

The following table demonstrates quality measures supported by performing Medicare’s preventive services:

DM A1c Control X X X
BP Control (HTN and DM) X X X X X X
Colorectal Cancer Screening X X X X X
Depression Screening and Follow-up (All, DM) X X X X
DM A1c Testing X X X
Adult Weight Screening and Follow-up X X X X X
New HIV Cases and Follow-up X
Tobacco Assessment and Cessation Advice X X X X
Breast Cancer Screening X X X
Care Coordination
SBIRT (Screening & Follow-up: Alcohol/Drug)
Flu Immunization (All, Peds, Asthma) X X
Pneumococcal Immunization (All, Adults, DM) X X
Asthma Severity X
Disease Self-Management (DM, HTN, Asthma) X
Falls Screening for Future Fall Risks X X
HIV Medical Visit X


Choosing a Different Path

Coming to the realization that Health Centers are an appropriate place for Medicare patients is an important first step.  Following that, health centers who build their Medicare program around preventive services are poised to ensure their bottom lines are less vulnerable to the increasingly common political upheavals.

The greatest value health centers give to the Medicare population is the impact that these programs can have on the lives of their patient populations.  These positive impacts on patient outcomes translate into valuable research that could lead to a more efficient national Medicare program in the future.