Q&A: Louise McCarthy on the health of California’s CHCs and FQHCs post-pandemic
Louise McCarthy is the President & CEO of the Community Clinic Association of Los Angeles County (CCALAC), where she represents the interests of LA area Community Clinics and Health Centers, and those they serve. Prior to taking this role, McCarthy served as CCALAC’s Vice President of Governmental Affairs for three years. Before joining CCALAC, McCarthy was the Assistant Director of Policy for the California Primary Care Association, where she worked on statewide legislative, regulatory and administrative issues impacting California’s community clinics and health centers.
In this Q&A, McCarthy talks about the financial health of Community Health Centers (CHCs) and Federally Qualified Health Centers (FQHCs) post-pandemic, and how they are trying to rebuild access in communities that have lost access to health care.
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Sydney Kurle: So tell me about the report you commissioned from California Health Care Foundation, “Holding On: How California’s Health Centers Adapted Operations and Care for Patients During the Pandemic?”
Louise McCarthy: “So with this report, we actually started approaching CHCF in 2018 because we knew there was a recession coming, and we wanted to be ready for it. But it took some time to work out the kinks, figure out what we’re going to work with, etc. And then recession readiness turned into recession response, because this project was funded in February 2020… One piece is recognizing recessions continue to happen, thinking about the counter cyclical nature of it, in the time the community needs us most, is often the time when the resources run out. Just really thinking about that approach to recession.
But on top of this we were going into strategic planning in 2020, before this [COVID-19} all started. We paused this planning, because I didn’t really think our members could think about the next five years while they’re in the middle of a pandemic, but we’re coming out of that now, and are going to be bringing our strategic plan to our members in June. Certainly equity is the underlying theme of everything, somehow the world got woke to equity, finally. And even though that’s been the DNA of the health center movement all this time, we’re really doubling down on equity as our overarching theme of everything we do.
But then beyond that, is transformation. And making it a continued transformation. Because we know that we’re not transforming to a state, we’re going to be in a state of transformation. And really being able to demonstrate the value of the community health centers. They did a great job during the pandemic stepping up and demonstrating that they’re the equity answer, and the equity partner for communities, but we’re going to have to continue to demonstrate that role in the quality of care they provide to the patients, the communities, the health plans and other partners, and especially to our workforce.
So burnout came out as one of the top issues that the health centers are facing from this crisis. The pandemic has taxed our workforce in ways that are just unimaginable. So really trying to think about how you build resilient systems that can weather all of these types of vagaries as they come. Just looking forward and what we’re getting into this report is one thing, one piece, giving us data and some underlying pillars to hang on to as we’re thinking about what the way forward is. And it’s really looking at the resilience needed in all of our systems.”
SK: Large FQHC’s and CHC’s reported the largest losses during the pandemic. Why was that?
LM: “So what we found from this analysis, and research, the larger centers, meaning the more patients you have, the more you relied on Medi-Cal, and the more services you have. The why is that Medi-Cal is a per-visit payer. And so when your visits stop, your payments stop. So that’s one piece of it. But then it’s just by rote, then the more you rely on Medi-Cal, and this payment system that they have, which is based on volume, you’re going to crash and burn. So if you had other payers like Covered California, or something like that, you might have done a little bit better. One other thing that I would say as well is that additionally, larger health centers were not eligible for certain funding under the CARES act, and different programs that came out last year as well. So PPP loans, for example, were not available to them.”
SK: So one way these centers were able to make up costs was through telehealth visits. How do you expect telehealth to stick around post-pandemic? What are you hoping for in order to keep this method of treatment?
LM: “We’re coming out of the pandemic and thinking not just about this year, or next year, but the next five years out and beyond. For example, if we had an alternative payment methodology that wasn’t based on visits, which we’ve been working on for a very long time, If that had been in place prior to this happening, this would have been a way different story. We did get telehealth flexibility, but it’s just doubling down on this per-visit payment system. So as we look forward, we will want to see continued investment in telehealth, but with the long-term idea that there needs to be a transition to alternative payment methodology. That’s the goal, to do telehealth, but as a bridge. So that we can get out of the, what I’ll call, the tyranny of the visit. So then you can actually get into providing care with the best ways you see fit.”
SK: Would that be a change to value-based payments, or something else?
LM: “Value-based payments would have a massive effect. But the proposition that we have isn’t purely value-based pay, it’s really just looking at smoothing the cost curve. But it’d be relative to smoothing the delivery mechanism by which the finances come. Then a lot of value comes after that. So if you would have spent $300 over the course of the year taking care of Louise on visits, why don’t we just divide that by 12. And then you figure out how best to take care of Louise. So it does incentivize value. Because from the health center standpoint, we still have the same quality metrics, and all of the same goals that we need to meet, but we finally get to figure out a way to do it without putting it solely on the backs of providers and physicians. And I think one of the exacerbating or mitigating factors from all of this is because of the workforce shortage, if there are no providers, there are no visits. But if you can get folks to do the other sets of services that folks really need that aren’t traditional visits, you can deliver serious value there. So it is moving to value but not in the same sense like a pay-for-performance would be.”
SK: One of the strategies to keep costs low were staff reassignments and furloughs. How do you expect these changes in staffing to affect post-pandemic staffing, given the provider shortages that already exist?
LM: “First of all, we have to double down on workforce, there’s no way we can’t. It’s not going to change anything as far as our system goes unless we really get more workforce. But that’s everything from providers, to mid levels, to billers and coders, reception and security. So one piece is there needs to be that infusion. But then along with that is switching up the model. So getting everyone to work to the top of their scope. California finally got some legislation that finally got through related to nurse practitioners’ scope of practice. And we have seen just with other flexibilities that have happened during the pandemic, there’s been more willingness to recognize how high folks can work within their scope of licensure. So I see the solutions being maximizing the scope of the people we have and bringing in new folks. But then also looking at the care team as really being that model. It’s not the individuals, it’s the way you put them together that makes the care happen.”
SK: Site closures were most likely to affect low-income Californians, what plans are there to fill that gap post-pandemic?
LM: “Honestly, we’re looking to the federal government for some relief on this piece. The American Rescue Plan did bring in a billion dollars community health centers in California. However, we know that in 2020, health centers sustained somewhere around $1.4 billion in losses. The investments made to date have really been about shoring up, but we are incredibly hopeful that the infrastructure package that’s being discussed now, actually has capital in it. So American Rescue Plan supported services, vaccines, COVID response, but it doesn’t really help us add new spaces or sites. And so we’re hopeful that the investment in infrastructure will help.
As well as more coverage expansions. We know the governor wants to expand Medi-Cal to more folks, to the extent that there are more people covered, then we can do expansions and make them sustainable. It’s one thing to open a building. But you need to actually have a payer source for the people that go there. So I think it will be the other piece around site closures.
But back to telehealth. What is the site anymore? And what’s the purpose of the site? So we have been trying to be really mindful of why we have the locations we have and what they’re for. And really bringing people in when they only need to come in. So they’re not taken away from work or childcare.”
SK: What effect will the postponement of routine procedures have on costs post-pandemic?
LM: “We’ve got a couple issues coming at us that I think we’re all really scared of. But even before going into this pandemic, we were going through a strategic planning process and our members already brought up the fact that there was an increasing burden of chronic disease within their patient population, and that a large proportion of the patient population was moving into their senior years. And so we’ve already got some of this push towards a higher need population, then boom, we’ve got COVID. So not only do we have those folks deferring the care, and so their conditions are getting worse, but these are the folks that are impacted by COVID-19. We don’t know what multiplier that puts on their health status, whether it’s their heart, their lungs, even, you know, the fog of COVID brain and some of the neurological impacts of it.
So, because we know that the map of COVID-impact is the map of where the health centers were, we’re absolutely, unfortunately, confident that we are going to be seeing people who are sicker than they would have been pre pandemic. But beyond that we are looking and we’re deploying remote patient monitoring devices. So even if folks aren’t feeling safe, leaving their home and coming in, we try to put some tools in their hands so we can help them monitor their conditions from home.”
SK: So the Governor’s revised budget should be coming out soon, what funding are you looking for in that budget?
LM: “So a couple things we’re looking at. One is continuing to reimburse for telehealth. And not just video care, but telephonic as well. Because that has been a game changer for mental health. So really looking at the investments around telehealth specifically and making sure that the payment parity for phone and video care.
We are also moving a couple pieces of legislation at the same time, which are connected to budget one being the same day visit. So being able to provide a behavioral health visit on the same day as a physical which, unfortunately, just comes down to a budget ask. But those are the biggest ticket items, I think what we’re going to be watching going forward is how the state responds to funds it receives from the federal government from these various packages that come out as well. So at present, I mean, we know we have an optimistic governor and who has big plans, but we really want to see what our state does with the federal relief it receives.”
SK: Epidemiologists are predicting the occurrence of more and more pandemics in the coming years. How are California’s FQHCs and CHCs preparing for the future?
LM: “This is going to be happening for a while, especially with these variants. Health Centers have already stepped out beyond their usual personal health care services, because typically I go to my doctor to get tested for something because that’s my personal health, not because it’s my occupational health. Which means I’m getting tested to get cleared for work, or because it’s public health. And because we’re worried about this broader monitoring and surveillance function. Well, health centers have really stepped in to that. So they’ve stepped out of personal health, and their footprint has gone into public health surveillance, as well as occupational health. That’s not just testing, that’s labs associated with testing, but also the vaccines.
Also recognizing that all of the models in which we provide care will probably need to be re-engineered, thinking about the flows, the amount of time you let someone sit in a room with another person, all of these things. The proximity of all of these of all of our dental chairs in which we work on people’s mouths. All of that needs to change. But I think as far as the financing component is recognizing this larger role of community health centers in health care. Additionally, concurrent with this is a continued investment in our public health systems. In LA County, our public health lab wasn’t ready for this. It definitely wasn’t funded for this. And so really thinking about the amount of infrastructure they’ve had to build up in response, making sure that that gets maintained, and that we don’t just turn the lights off after this pandemic.”
This interview has been edited for clarity and length.