NEJM: CHAMPs, not cuts, are needed

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A perspective published June 1 in New England Journal of Medicine called for a novel care delivery model to sustain community health centers (CHCs) and preserve access to care for Medicaid beneficiaries and other low-income patients while controlling costs.

“At precisely the time when we need CHCs more than ever, many cash-strapped states are contemplating deep Medicaid cuts that could threaten their survival,” wrote Richard E. Rieselbach, MD, from the University of Wisconsin School of Medicine and Public Health in Madison and Arthur L. Kellermann, MD, MPH, of RAND in Santa Monica, Calif.

According to the authors, Medicaid and the State Children’s Health Insurance Program insure more than 76 million low-income patients. “When the Patient Protection & Affordable Care Act is fully implemented, Medicaid will cover an additional 16 million people who are currently uninsured. Many of the newly insured will seek care from CHCs, which currently treat 20 million Americans annually. The total could reach 50 million by 2019.”

Rieselbach and Kellerman outlined a model, Community Health Center and Academic Medical Partnerships (CHAMPs), that would combine the subspecialist expertise, medical technology and inpatient care of local academic medical centers (AMCs) with the primary care expertise of CHCs, utilizing an emerging subgroup of CHCs known as teaching health centers (THCs) to create a distinctive form of accountable care organization (ACO), the authors stated.

The authors asserted that a collaborative approach offers advantages over fee-for-service Medicaid or managed care:

  • THCs would take a more robust approach to primary care than is typically found in AMCs, which tend to emphasize subspecialist practice.
  • AMCs might well find THCs more philosophically attuned to the principles of practice integration and team care than an ad hoc network of community practitioners would be.
  • The faculty practice plans found in most AMCs offer a ready-made administrative structure for managing the CHAMP’s performance, quality of care and finances. CHC governance models, for their part, reserve a majority of board slots for consumers, giving community members an important voice in their own care.
  • In contrast to the situation at Medicare ACOs, all the care of a CHAMP’s enrollees would be attributable to that organization. This structure should permit more effective care coordination and lead to greater cost savings.
  • CHAMP ACOs would pursue a more collaborative approach to cost containment than is the norm under Medicaid Managed Care, which often pits payors against providers, leaving patients caught in the middle. CHAMPs would provide AMCs and THCs with incentives to work together to provide high-quality care at an affordable price.

“Because CHAMPs would be built on a backbone of primary care, they should be able to operate less expensively than an organization built around hospital-based specialist care,” the authors wrote. “To encourage efficiency, CHAMPs should accept global capitation, with proper adjustment for case mix. This payment approach would give CHAMPs a powerful incentive to devise and refine their strategies for achieving high-value care by reducing waste and needless duplication of services.”

“CHAMP ACOs would combine the best qualities of AMCs and CHCs to serve economically disadvantaged patients who have a high incidence of chronic conditions,” the authors concluded. “A pilot program dedicated to testing this concept could generate the data required to evaluate the model.”