Overview

When appropriate and where resources permit, your center is encouraged to develop an affiliation with clinical training programs. For linkages to occur, there needs to be a benefit both to the organization and the educational setting. Each needs to believe that their mission is enhanced by the relationship with the other party and both should want to serve the needs of the underserved. The American Academy of Family Physicians (AAFP) has developed a manual on how family practice educators and community leaders can work together to bring family practice residents into the community setting. While the manual focuses on primary care residents, its information and the process utilized to establish linkages is applicable to both urban and rural settings and other primary care practitioners. Highlights from this manual are outlined below.

AFFILIATIONS WITH TEACHING PROGRAMS

The first step in developing linkages with the educational community is to examine the pros and cons of such a relationship. Exhibits 14-1 and 14-2 identify benefits and drawbacks. If, after examining these factors, it is determined that a relationship is beneficial, the next step is to identify individuals or groups to consider in the linkage development. Some of these individuals and groups are identified below:

• Area Health Education Centers - programs aimed at attracting and retaining health care personnel in scarce areas;
• Residency Program Directors - individuals responsible for overseeing resident training programs and ensuring program requirements are met;
• State Licensure Boards - responsible for granting permission for individuals to practice their profession within a specific state;
• State Government - some training/residency programs are funded or sponsored by state universities or state hospitals; and
• Students/Residents - individuals interested in securing primary care training in underserved areas.

Exhibit 14-3 presents a sample checklist to follow for creating linkages. Although this document relates to physician linkages, it has application to other disciplines as well, e.g., dental and mental health professionals. These steps can be modified to suit the particular primary care professional group of interest and the unique setting. Predictors that can lead to a successful linkage are noted in Exhibit 14- 4.

ESTABLISHING NETWORKS

Health care needs in underserved communities are extensive and often cannot be met by any one organization. Accordingly, it is important that your center be an integral part of the health care system in the community. You can begin by establishing relationships with other clinicians in the area. These relationships can be formal or informal. As discussed in Chapter 9, the aim of networking is to exchange information, share resources, and expand service provision. By forming relationships, organizations can offer quality health care services more efficiently and effectively.

Each center will differ with respect to the relationships it should establish. Networks might include hospitals, health care systems, clinicians, managed care organizations and/or community consortiums. They might offer patients different options involving choice of clinicians, costs and services. They might pay clinician participants on the basis of fee for service, capitation or salary. There will be infinite variations as no two networks are exactly alike, but they are likely to share several similar characteristics:

• a community health focus;
• "seamless" continuum of care;
• management within fixed resources; and
• community accountability.

Primary care clinicians should give consideration to developing relationships and possible networks with the following organizations/agencies:

• state and local health departments, mental health/ substance abuse programs and social service agencies;
• State Medicaid agency;
• Early Periodic Screening Diagnosis and Treatment (EPSDT);
• cancer screening programs;
• telemedicine programs;
• universities, medical schools, dental schools, nursing schools, PA and mental health training programs;
• hospitals;
• managed care organizations (e.g., HMO/PPO);
• other public and private health care cliniciansoutpatient clinicians, home care programs, long term care facilities, mental health and substance abuse programs, dental services, etc.;
• extension services;
• MCH programs-children and youth, maternity and infant care, dental health for children, and Title V family planning;
• local schools;
• primary care professions training programs;
• state/local economic development agencies; and
• primary care associations.

Formal relationships can take many forms, ranging from minimal integration such as alliances, networks, affiliations at one end of the continuum to more integrated forms such as joint ventures and mergers. A new site looking to establish a formal relationship with another organization may be faced with issues of fear over perceived competition, resistance to change, and suspicion regarding the reasons for the relationship. The University of North Dakota School of Medicine, Center for Rural Health, has published a useful booklet on Networking and Coalition Building - Working Together for Rural Action. The booklet discusses networking models, the functional relationship of networks, initiating new activities, and building coalitions. The information provided in the booklet is sufficiently general to apply to both rural and urban sites. Copies of this publication may be obtained by calling the UND Center for Rural Health at 701-777-3848 and asking for an information specialist.

There are numerous examples of successful service linkages for you to learn more about. Exhibit 14-5 presents a synopsis of 16 primary care models from various regions of the country that have established a variety of linkages and collaborative relationships in both urban and rural settings. The range of linkages include those with nursing schools, dental schools, medical schools, telemedicine programs, churches, social service agencies, integrated service networks, hospitals, various voluntary and government agencies, etc. Each example includes a name, address, and phone number to facilitate follow-up should you wish to obtain further information. Additionally, readers who wish immediate access to five case studies of rural health network development are invited to access the following Web site, http://www.academyhealth.org/ruralhealth/casestudies.pdf.

MANAGED CARE NETWORKS

It is becoming increasingly important for entities to establish networks and linkages to respond to the rapid expansion of managed care/capitated payment for services. For this reason, we have included a brief discussion of managed care in this manual.

According to Rakich, Longest and Darr, the first "managed care" programs can be traced to health maintenance organizations ( which were previously called prepaid group practice plans). For a fixed premium, plan enrollees had all their services covered by salaried physicians. The term "managed care" now is more broadly defined to include organizations that:

• offer one or more products that integrate financing and management with the delivery of health services to an enrolled population;
• are responsible for delivering services (directly or through networks) and either share financial risk or have some incentive to deliver efficient services; and
• use an information system capable of monitoring and evaluating patterns of utilization and financial outlays.

Organizations and arrangements that meet this definition are numerous and it can be difficult to keep up with all the latest labels and abbreviations. Exhibit 14-6 defines eight such organizations and arrangements and provides the reader with a brief overview of the more common managed care terms.

MANAGED CARE NEGOTIATIONS

Despite the outcome of health care reform it is clear that more and more care will be delivered through managed care plans. As such, it is important that the primary care site be prepared to deal with this eventually. The Public Health Service has developed A Manual for Negotiating with Managed Care Plans which is available from the HRSA Parklawn Library at 301-443-2673. Although the manual was intended to provide primary health care centers with the skills and tools required to effectively negotiate a contract with a managed care plan and to manage that relationship, the information contained in the manual is valuable to any center faced with a growing managed care environment. See Exhibit 14-7 for a preview of the manual's Table of Contents.

Your practice site may from time to time be presented with opportunities to solidify contractual linkages to Managed Care Organizations (MCOs) under a variety of organizational arrangements, such as Primary Care Case Management (PCCM), Preferred Provider Organization (PPO), Independent Practice Association (IPA), Health Maintenance Organization (HMO), Health Insuring Organization (HIO), etc. Your decision to affiliate with one or more MCOs is a crucial one that has major implications for the financial viability of your practice site as well as patient accessibility to the spectrum of services being covered within the benefit plans of your Center's patients.

Recall from the discussion of fee schedule development in Chapter 10 that it was for the most part assumed that your Center's fee schedule would be developed from a methodology known as the Resource-based Relative Value System (RBRVS) and that in general fees would need to be established as a sufficient level to cover the Center's reimbursable costs. Now with MCO affiliation comes the possibility that some of the financial risk of cost in providing care to patients enrolled in managed care plans may be shifted to you - the provider - under a different form of reimbursement known as capitation. A summary of the key features of Fee-for-Service vs. Capitation are outlined below:

Readers should be particularly careful to note how these different reimbursement systems may impact the financial incentives of providers who wish to "earn more." Each system clearly has both advantages and drawbacks. While reimbursement to practice sites under managed care can take the form of either negotiated capitation or fee-for-service payments, sometimes it is a hybrid of both systems. For example many states have what is known as a Primary Care Case Management (PCCM) program wherein participating primary care physicians are provided both a monthly capitation amount for acting as a "gatekeeper" to other specialty, hospitalization and ancillary services plus regular fee-for- service reimbursement for their own primary care services.

Under a provision of Federal law known as Section 1115 and 1915(b) waivers many states have sought to achieve greater costs savings through mandatory enrollment of Medicaid patients into MCO programs which in turn have sought to exert greater control over the cost of providing care to Medicaid beneficiaries within their networks. Providers opting out of such Medicaid MCO networks have seen both their Medicaid enrollments and resulting Medicaid revenues drop. On the other hand Providers participating in Medicaid MCO networks have also experienced challenges in maintaining their revenue base under various MCO programs designed to control both enrolled beneficiary costs and utilization of services.

Federal grant-supported Health Centers known as Federally Qualified Health Centers (FQHCs) serving both Medicaid and Medicare patients have as a general rule sustained their participation in MCO networks in order to fulfill their mission of serving the underserved. Except in the case of Medicaid MCOs operating under the more comprehensive provisions of Section 1115 R and D waivers FQHCs have for the most part been "shielded" from adverse financial consequences Medicaid Managed Care through their special status as "Federally Qualified Health Centers." Irrespective of more restrictive capitation and/or discounted fee-for-service terms that apply to other non-FQHCs within the MCO network, FQHCs are in effect guaranteed unique reimbursement terms for both their Medicaid and Medicare patients based on either retrospective or the prospective cost of providing FQHC services.

While assuring your Center's financial viability under managed care is of primary importance, the implications of involvement with managed care go far beyond the financial arena and into the patient care arena as well. For example a particular MCO contract may also limit the Health Center's ability to prescribe certain (more costly) medications or it may restrict the panel of specialists to whom the Center's physicians can refer patients or it may limit inpatient services to certain hospitals only, etc. It is therefore essential that Health Centers exercise caution in negotiating contractual terms of their managed care linkages on a playing field that is as "level" as possible. This is a complex undertaking and while it will not be possible within the scope of this Chapter to advise all Health Centers how to proceed in a step by step fashion, there are a number of resources that are available for their use. As previously noted in this chapter, you may wish to examine a resource entitled A Manual for Negotiating with Managed Care Plans. While the Manual was intended to provide Community and Migrant Health Centers with skills and tools to negotiate contracts with managed care plans and advice relating to how to manage MCO relationships, the information contained in the Manual is valuable to any Health Center faced with the challenges of a growing managed care environment. Other resources you may find useful include the following: Managed Care Internal Operations Self-Assessment Tool for FQHCs and Managed Care Market Area Self-Assessment Tool for FQHCs. The aforementioned three publications may be ordered from the HRSA (Publications) Information Center at 1-888-275-4772 or alternatively at the HRSA Parklawn Library at 301-443-2673.

In addition to the above resources, you are also invited to explore some key questions in your journey toward developing successful relationships with Managed Care Organizations (MCOs), such as the following:

• Exhibit 14-8   Key Questions the Health Center May Use to Structure Goals
• Exhibit 14-9   Key Questions to Structure Information on Your Health Center
• Exhibit 14-10 Key Questions to Structure Information on the Market
• Exhibit 14-11 Key Questions to Structure Information on MCOs
• Exhibit 14-12 Key Questions for Evaluating a Capitation Rate
• Exhibit 14-13 Key Questions for Evaluating Risk Arrangements

Finally your attention is called to a supplemental list of Managed Care resources as noted in Exhibit 14-14 that should be able to provide you with further information and consultation in working with this kind of linkage for your Health Center.