From the 2023 HVPA National Conference
Ariel Leong BS, MS (Johns Hopkins School of Medicine), Razeen Karim BS, Mark Schuweiler BS, Xiyu Zhao BS, Ting-Jia Lorigiano MD, MBA, Sarah Conway MD
Johns Hopkins Medicine, an academic medical center (AMC), recently transitioned a portion of its Obstetrics and Gynecology and Pediatrics care to a new, nearby FQHC clinic opened by Baltimore Medical System. This collaboration allows for increased access and decreased cost to patients, expands services under the FQHC structure, and creates a more viable financial model for primary care services in a medically underserved area.
As part of this transition, we analyzed the financial feasibility of performing prenatal ultrasounds in the FQHC clinic. The current ultrasound clinic, located in hospital space, receives both facility and professional fees and would be transitioning to an FQHC under their reimbursement model. We looked at differentials in reimbursement rates and performed sensitivity analysis to look at volume needs and potential investments by Medicaid Managed Care Organizations (MCOs) that may support the financial sustainability of this high-value partnership. We describe the first financial implication case for ultrasound-related AMC-FQHC partnerships in the literature.
Assess the financial feasibility of expanding routine prenatal ultrasound care to an FQHC-academic partnership clinic in an all-payer state.
The annual cost of the FQHC ultrasound clinic was assumed to be similar to current ultrasound clinic costs at Johns Hopkins Bayview Medical Center (“Bayview”). Annual revenue was estimated based on Bayview patient volume and existing payor mix. As no other FQHC in the state offered on-site ultrasound services, reimbursement rates were estimated: for self-pay patients from Bayview , for commercial from other non-hospital-based facilities, and for Medicaid from the state fee schedule. The prenatal ultrasound CPT codes used were 76801, 76805, 76811, 76815, 76816, 76817, 76820, and 76821. Five two-variable sensitivity analyses were created (Figures 1-5). Three included varying MCO reimbursement rates, MCO-provided subsidies for sonographer FTEs, and percentage conversion of self-pay patients to MCO coverage at different patient volumes. The other two varied percentage conversion of self-pay patients to MCO coverage with self-pay and MCO reimbursement rates.
The baseline payor mix for ultrasound services provided by Bayview was 4.5% Medicaid, 17.8% MCO, 55.2% self-pay, and 22.5% commercial. The FQHC ultrasound suite’s expenses are 63% greater than its revenue. At maximum patient volume, equalization of revenue and expenses would require 88% subsidy of the sonographer’s FTEs; a MCO rate enhancement of 5.5-fold; >100% conversion of the self-pay patients to MCO insurance; 33% self-pay to MCO conversion combined with a 69-fold increase in the self-pay reimbursement; or 33% self-pay to MCO conversion combined with a 2.74-fold MCO rate enhancement.
Our sensitivity analyses suggest that it is unlikely that ultrasound services would financially break even in the FQHC environment given the current payor mix and reimbursement opportunities. Insurance contract negotiations and the implementation of the Healthy Babies Equity Act, a Maryland legislative act extending Medicaid coverage to undocumented pregnant immigrants, may impact the feasibility of financially sustainable AMC-FQHC partnerships (Healthy Babies Equity Act of 2022).
While broader AMC-FQHC partnerships can create a financially sustainable model for primary care services, our case analysis highlights the difficulty of select additional services. However, in our case, factors such as the Healthy Babies Equity Act and insurance contract negotiations may increase the viability of the ultrasound transition and enable the co-location of critical obstetrical services.
Maryland Medical Assistance Program – Children and Pregnant Women (Healthy Babies Equity Act), (2022). Retrieved from https://mgaleg.maryland.gov/mgawebsite/Legislation/Details/HB1080?ys=2022RS