FQHC Industry Trends Thoughts from a Madman December

FQHC Industry Trends & Thoughts from a Madman December 2016

Some Health Care Facts… • United States: • 321 Million People in USA as of 2015 • • 165 Million covered by Private Insurance 55 Million covered by Medicare 73 Million covered by Medicaid 28 Million uninsured

More Health Care Facts… • Minnesota: • 5. 5 Million People in Minnesota as of 2015 • • 3, 232, 000 covered by Insurance 912, 000 covered by Medicare 1, 036, 000 covered by Medicaid 320, 000 uninsured

Big Picture • 1993 Healthcare Reform – Defeated • The Clinton health plan required each US citizen and permanent resident alien to become enrolled in a qualified health plan and forbade their disenrollment until covered by another plan. It listed minimum coverages and maximum annual out-of-pocket expenses for each plan. It proposed the establishment of corporate "regional alliances" of health providers to be subject to a fee-for-service schedule. People below a certain set income level were to pay nothing. The act listed funding to be sent to the states for the administration of this plan, beginning at $13. 5 billion in 1993 and reaching $38. 3 billion in 2003.

Went Underground 1993 – 2009 – Government support (dollars) for: • • Electronic Health Record Expand the number of CHCs Adopted Patient Centered Health Home Model Set minimum service requirements for CHCs § § § Medical Dental Behavioral Health

ACA - 2009 • Prohibiting health insurers from refusing coverage based on patients' medical histories • Prohibiting health insurers from charging different rates based on patients' medical histories or gender • • • Repeal of insurance companies' exemption from anti-trust laws • • A subsidy to low- and middle-income Americans to help buy insurance • Requiring most Americans to carry or obtain qualifying health insurance coverage • Reductions in projected spending on Medicare of $400 billion over a ten-year period Establishing minimum standards for qualified health benefit plans An expansion of Medicaid to include more low-income Americans by increasing Medicaid eligibility limits to 133% of the Federal Poverty Level A central health insurance exchange where the public can compare policies and rates

Single Payor – 2020? ۞A four letter word or …………. . ØPros include universal care for all patients and lower costs through efficiencies. ØTwo of the cons of a single payor health insurance system is concern over wait times for an appointment with a provider and loss of the decision making process by the provider.

HRSA Strategic Plan The Strategic Plan for FY 2016 - FY 2018 is a blueprint for HRSA

HRSA - Five Goals 1: Improve Access to Quality Health Care and Services 2: Strengthen the Health Workforce 3: Build Healthy Communities 4: Improve Health Equity 5: Strengthen HRSA Program Management and Operations

BPHC – Mo Money & Mo Money • Additional $1. 5 B for CHC’s in 2015 • More to come in 2016 – NAP, Dental, BH, School-Based… • Minnesota FQHC PPS Reform? Coming Soon to a Health Center near you , 2018. • Financial Cliff? Hogwash!!!!!!!!!!

Affordable Care Act v. Winners: • • FQHCs Large Integrated Delivery Systems (Kaiser) The uninsured patient Healthcare Attorneys, Accountants, & Consultants v. Losers: • • Hospitals (not initially, however long-term) Primary Care Physicians in small practices

Losers v. Hospitals: • Expanding by purchasing or merging with other hospitals • Purchasing primary care physician practices v. Primary Care Physicians: • Retiring early • Merging practice into Hospitals, FQHCs & IDS (Kasier)

BPHC - Keeping Them Happy v Improve Patient Access (More Users) v Improve Patient Quality

BPHC - Trends • Service Area Overlap (PIN 2007 -09) • No more Financial Recovery Plan - Effective 11/01/14 • Development of a Merger PIN or PAL in 2017? • Creative Approaches to Increase Access

Service Area Overlap ØUDS Mapper – Most CHCs do not provide the amount of care to the underserved as they think? ØThe BPHC will allow CHCs to open a site wherever there is patient NEED! • • • No distance requirement What state boundaries (don’t fence me in) Play offense, not defense (write that letter of support)

No More Financial Recovery Plan ØThe Board & Management Team must correct the problems, not the BPHC. • • You broke it, you fix it You are on your own ØMajor issues with the Boards • • • Conflicts of interest Self interest, too much in the “details” of operations Not business oriented ØNot enough qualified CHC management • • Steep learning curve Inadequate compensation

Development of a Merger PIN or PAL ØCHC merger is longer a four letter word (actually 6 letters) ØMergers with all types of health care organizations are happening (hospitals, insurance companies, IPAs) ØThe BPHC does not announce them, many FQHC’s have merged in recent years: • • Peak Vista CHC & Plains Medical Center (Colorado) • • San Ysidro Health Center & Comprehensive Health Center (CA) North Lakes Community Clinic (North Woods & The Lakes CHC) Wisconsin Alta. Med Health Services & Community Care Health Centers (CA)

Creative Approaches to Increase Access ØThe BPHC has been expanding “in scope services” • • Physician specialty services Critical Access Hospitals ØThe BPHC will allow organizations to “rent” staff • • • Family Health Center of Marshfield (Wisconsin) Lutheran Family Health Centers (Brooklyn, NY) Rural Health Care (Fort Pierre, S. Dakota)

Family Health Center of Marshfield ØFamily Health Center of Marshfield, Inc. (FHC) is a federallyfunded Community Health Center program designated under section 330(e) of the PHS Act. Throughout its history, FHC has served the health care needs of low income, underserved populations residing in the largely rural areas of central, northern and western Wisconsin. Through its collaboration and partnership with Marshfield Clinic, a 501(c)(3) not-forprofit, multi-specialty physician group practice, FHC offers health care services at 21 FQHC clinical sites, including 10 dental centers. FHC has a defined service area in the rural areas of central, northern and western Wisconsin. Largest CHC in State.

Family Health Center of Marshfield • FHC is a member of the large and complex Marshfield Clinic Health System. FHC contracts with Marshfield Clinic (MC) to maintain an adequate core staff appropriate for serving the patient population and for carrying out the approved Scope of Project. Each FHC clinical staff member is an employee of MC and leased to FHC. • FHC maintains a fully staffed health center management team as appropriate for the size and needs of the center. The Key Management Staff are not employees of FHC. The only employee is the Executive Director. FHC has a management agreement with Marshfield Clinic that provides the remaining management and all staff positions.

Specialty Services Allergy and Asthma Oncology (Cancer Care) Anesthesia Ophthalmology and Optometry (Eye Care) Audiology Oral and Maxillofacial Surgery Bariatric Surgery Orthopedics Cardiology (Heart Care) Pain Management Comfort and Recovery Suites Palliative Medicine Dental Pediatrics Dermatology Physical and Occupational Therapy Ear Nose and Throat (ENT) Physical Medicine and Rehabilitation Emergency Medicine Plastic and Cosmetic Surgery Endocrinology (Diabetes and Metabolism) Podiatry Family Medicine Primary Care Gastroenterology (Digestive Care) Psychiatry and Psychology General Surgery Pulmonary Medicine (Lung Care) Genetic Services Radiology Hospitalists (Hospital Care) Rheumatology and Arthritis Care Infectious Diseases Sleep Medicine Internal Medicine Sports Medicine Neurosciences (Neurology) Urgent Care Obstetrics and Gynecology (OB/GYN) Urology Occupational Health Wound Healing

Lutheran Family Health Centers ØThe NYU Lutheran Family Health Centers (LFHC) network provides high quality, affordable outpatient primary health care and support services close to home. As one of the largest Federally Qualified Health Center (FQHC) networks in the nation, LFHC includes nine primary care sites, 28 school based health/dental clinics and numerous social support services. With approximately 100, 000 patients, the LFHC network handles over 620, 000 visits annually. Revenue at $200, 000.

Specialty Services • • • Allergy Arthritis Asthma Breast Health Dermatology Diabetes Dentistry & Oral Health Ear, Nose and Throat Endocrinology Gastroenterology Hematology • • • Nephrology Neurology Oncology Ophthalmology Orthopedics Podiatry Rheumatology Surgery - General Thoracic Surgery Urology

Rural Health Care, Inc. ØRural Health Care, Inc. (RHCI) was founded in 1987 and has established itself as a regional healthcare leader. With an emphasis on primary care services, RHCI offers rural health care delivery sites conveniently located in seven central South Dakota locations, and one in southwestern Minnesota.

RHC, Inc. Sites Fort Pierre SD Oahe Valley Health Center Gettysburg SD Community Care Clinic Highmore SD Highmore Clinic Murdo SD Jones County Clinic Presho SD Stanley Jones Memorial Clinic Onida SD Onida Clinic Chamberlain SD Dakota Family Medical Center Worthington MN Access Family Medical Clinic Pierre SD Buchanan Elementary School

Avera Health ØAvera, A Health Ministry • Avera, the health ministry of the Benedictine and Presentation Sisters is a regional health system based in Sioux Falls, S. D. , comprising more than 300 locations in 100 communities throughout South Dakota, Minnesota, Iowa, Nebraska and North Dakota. Avera serves a geographical footprint of more than 72, 000 square miles and 86 counties, and a population of nearly 1 million. • As a $2 billion fully integrated health system, Avera Health includes Avera Medical Group, which is comprised of physicians and advanced practice providers who serve patients at nearly 200 locations across the five-state region.

Avera / RHC, Inc. Affiliation ØRHC was awarded two BPHC NAPs, one in September 2015 in Worthington, M. N. and one in 2014 in Chamberlain S. D. ØBoth were Avera outpatient clinical sites. ØAll employees including physicians, dentists and staff are leased from Avera. ØRemember, the BPHC awarded two New Access Point grants ($650, 000) to RHC over the past two years. ØThe BPHC must like this type of arrangement?

Really………. . ØLike it or Not, we had better be aware of it and other such arrangements that the BPHC is approving!!!!!!!!!!

Down Home on the Farm…. ØHow can we take advantage of these National, State and Local healthcare trends? ØDon’t live in 1995? ØThe best years are NOW! ØHe who waits becomes merger bait….

Creative Thinking is Needed ØDevelop relationships with healthcare systems and hospitals. ØPrimary care is our bread and butter… ØThink BIG - IPA and / or HMO. ØProvider contract relationships • Physician groups • Specialty physicians

Risk Spreading Health Spending in U. S. 0. 97 100% 0. 80 80% 0. 64 60% Health Spending 40% 0. 24 20% 0% Top 10% Top 20% Top 50%

Risk Spreading 50% of the population uses only 3% of the health care dollar !

Community Health Centers

Old School……… No Margin No Mission

Today……… No Outcomes No Income

Questions?