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Ryan White and ACA: Agency Decides to Pursue FQHC Status

November 14, 2013


Catawba Care

Pursue FQHC status. That call to action—slightly snappy sounding in the lexicon of the health care bureaucracy—belies the exhaustive thinking, meeting and talking behind one Ryan White agency’s decision on how best to adjust to the Affordable Care Act (ACA).

The grantee is Catawba Care in South Carolina, just one of hundreds of Ryan White agencies around the nation that are deciding how best to adjust to changes in payers and services under health care reform. This blog series will track their progress and share their tools and insights.

“When we first began looking at change, the uncertainty of Ryan White funding going forward was the biggest factor".

In the first blog, we took a look at how Catawba’s board contemplated what direction to take. This blog examines the factors that propelled Catawba’s decision to go for designation as an FQHC, a Federally Qualified Health Center, and the initial steps they are taking to get ready to become an FQHC, which promises access to enhanced reimbursement rates under a mission broader than HIV alone.

What Drove the Decision?

Much has changed for Catawba in their years-long work to decide how to adjust to ACA, including the forces driving change. Said Catawba’s Executive Director, Anita Case: “When we first began looking at change, the uncertainty of Ryan White funding going forward” was the biggest factor.

The fear subsided, replaced by new factors like a needs assessment funded by a HRSA Bureau of Primary Health Care planning grant that Case learned about at a National Association of Community Health Centers training on developing an FQHC. HRSA’s planning grants are a potential stepping-stone to achieving some type of health center status. Yet another driver was encouragement from HRSA to keep focusing on restructuring.

That message come from both the HRSA/BPHC project officer, Babak Yaghmaei, who was overseeing the planning grant, and Catawba’s HRSA HIV/AIDS Bureau Part C project officer, Tracey Gantt. Catawba’s Case recalls Gantt expressing concern about Catawba’s long-term viability as they were an AIDS Service Organization, which limited their patient service delivery structure and funding opportunities.

A local funder also urged Catawba to keep at it and figure out how to deliver care to a larger section of the community. A cut in local United Way funding also created some, shall we say, refocusing time.

The Needs Assessment

Catawba’s needs assessment results, said Case, helped Catawba conclude that they “had a really strong program and unmet needs in the community and that we could deliver services to meet that need and serve the community.” To get the assessment done, Catawba issued a request for proposals, which was awarded to and carried out by the Duke Center for Health Policy & Inequalities Research. 

The targeted components included the following:

  • Review and Analysis of Existing Data (e.g., United Way needs assessment, county health indicator data)
  • Healthcare Environment Scan (review of policies and research, especially the potential impact of healthcare reform on access to care for lower income individuals and implications for FQHC operations)
  • Qualitative/Quantitative Data from the Community. The following audiences and methods examined availability of services, barriers to care, ideas for improvement, and other topics: Key Informant Interviews (10 sessions); Provider Surveys (20 surveys); Target Population Surveys (248 surveys); Target Population Focus Groups (5 groups)
  • Community Forums/Listening Sessions (2 sessions to get feedback on findings and solicit additional input from attendees via a brief survey)
  • Community Asset Mapping (geographic location of existing health care agencies as a measure of accessibility to populations in need) 

The planning grant and the assessment were guided by a Community Advisory Group, comprised of medical and service providers (not HIV-specific only). “At the end, they recommended we become a community health center,” said Case. The board delayed a decision for a time given uncertainty about ACA with the looming Supreme Court ruling and the 2012 elections but gave the go-ahead in 2013.

Decision in Hand, Time for FQHC Baby Steps

Catawba plans to apply for a HRSA New Access Point grant in the coming months. HRSA’s Health Center program has been undergoing significant expansion of health care services for underserved individuals, beginning with a big push that started in 2001, which has since broadened under the Affordable Care Act as part of efforts to expand third party payer coverage under Medicaid and Marketplace health insurance. Most recently, in November 2013, HHS awarded 236 new Health Center awards, with some grants going to Ryan White grantees.

There are many tasks to undertake in deciding how to become an FQHC, like determining which services are reimbursable and assessing the agency’s infrastructure capacity (e.g., third party billing). To set the stage for its FQHC application, one of Catawba’s first steps is identifying community partners, which is a key requirement for FQHC development.

Catawba’s outreach protocol is fairly straightforward:

  • Identify key health care agencies, medical providers, and hospitals
  • Arrange meetings with each
  • Meet face-to-face with broad questions like: What is your agency looking for? How can we help each other? Are their opportunities for us to partner together? 

Catawba has a back-up plan if additional health center funding doesn’t come out as they hope. They will apply to be an FQHC look-alike. That’s no easy task, either, said Case. “A look-alike has to be up and running for six months under FQHC rules, which means we would have to secure private funds to sustain the program for that time period.”

Where Should Your Agency Start?

What first steps should a Ryan White agency take to adjust to ACA? It depends on many variables. Is the agency a medical clinic or does it focus on providing supportive services that may not be readily reimbursed by Medicaid and private insurance? How many other agencies are in the area? What partners are nearby? What gaps in care are there to fill? What does the patient population look like in terms of income and payer sources? On this latter point, a clinic with mostly very low-income patients may not benefit from expanding its capacity to contract with private health plans.

Despite all these factors, Case’s first recommendation is to “get in touch with your state Primary Care Association to find out what resources they have. Can they come in to do a training about what it means to be health center?”

“Get in touch with your state Primary Care Association to find out what resources they have...."

In adjusting to ACA, “you need to understand what it is you are getting into,” said Case.” “If you are not a clinic, it’s a huge jump. If you are already a clinic, it’s still a jump but not as big. There are a lot of requirements and expectations to make the change.”

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