This month, Sanjay Basu, Waymark’s Head of Clinical, took the opportunity to speak with Christina Severin, President and CEO of Community Care Cooperative (C3). She previously served as President and Chief Executive Officer of Beth Israel Deaconess Care Organization and as President of Network Health, a nonprofit Massachusetts health plan.  

Sanjay: You are leading a very unique organization that is an Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs) in Massachusetts. Effectively, this ACO allows FQHCs to take on value-based risk contracts and therefore flexibly deliver whole-person care services for an entire population. Can you tell us a bit more about your model and how it operates?

Christina: Our governance model is a 501(c)3 where FQHCs come into the company two ways. From a governance perspective, FQHCs come into the company as Corporate Members who appoint two Directors, typically the CEO and the Chief Medical Officer. Health centers also come in as participating providers. So the FQHCs compose both the governance model and the participating primary care provider network.

This unique structure allows management to come-in with industry know-how on negotiating with HMOs, working with state government, working with federal government, understanding how to set up operations that are needed to effectively run an ACO, be able to have a data warehouse, a strategic plan, and an actuarial system for adjudicating our internal system of sharing risk between C3 and health centers.It also requires that this management be accountable to a Board of Directors who are composed of the stakeholder FQHCs.

Beyond C3, there are some primary care associations (PCAs) that are organizations supported by the Health Resources and Services Administration to support policy and technical support for FQHCs. Some of these are starting affiliated organizations that are ACOs or clinically integrated networks, but we have not run across an organization that is as large as C3, and we have not run across a FQHC organization that is taking two-sided risk as C3 does.

Sanjay: A common adage is that “if you’ve seen one clinic, you’ve seen one clinic.” What are the strategies you have used, in your extensive experience, to help adapt to different clinics that are at various stages of their value-based care journey, especially as they adopt different approaches to comprehensive care management and have different levels of resources and different community histories and backgrounds?

Christina: I know that common adage. What we like to say is: “if you've seen more than one health center, you know that health centers are much more similar than they are different.” When we can all get together to leverage our commonalities, we can all do better together. We have created an ACO family which is a safe home for health centers regardless of size or experience with value based care.

For example, on the governance side, it doesn't matter if you are a very large health center like Lynn Community Health Center or Brockton Neighborhood Health Center, or a very small health center like Island Health on Martha's Vineyard. Each health center joins as a Corporate Member, and Each Corporate member appoints two Directors; it’s a Senate model.

On the risk, we tailor how much up and downside risk a health center takes based on what is a best fit for them. What's the best fit? Well, it's something that is a fit for their balance sheet. We don't want someone taking an amount of downside risk that would represent material financial exposure. We also don't want someone taking a huge amount of risk if they don't have experience doing value based work. So we offer a variety of flavors of risk taking so that a health center can take an appropriate position in getting started in taking two-sided risk.

Our goal is as health centers stay and they learn and grow and mature in their skillset, they will take on more and more risk. That is what we have seen since we started full company operations in 2018. For every health center that has made a change to the level of risk that they're taking, they've moved on to take more risk. No health center has moved down to take less risk.

‍Sanjay: As a clinician serving patients at a FQHC, I find that we have gone through an extensive period of staff burnout and extraordinary efforts to care for people during COVID. Can you talk a bit about what you have observed about the FQHCs you work with as they emerge out of the public health emergency stage of the pandemic, what concerns they have, and efforts to address them?

Christina: Health centers have been very, very impacted by staff burnout and other aspects of dissatisfaction that has led this country to be in the midst of the Great Resignation. It's also similar to what other industries have experienced. It's not only the burnout from the pandemic, it’s also an awakening to a moral injury that many healthcare workers are afflicted with, based on the way that the US healthcare system is organized. Health centers get more work with less financial support than larger systems. The base salaries of staff also tend to be higher at larger systems. The clinicians come to the health center because they're committed to serving the population that gets care from the health center, however, the financial perversity is why health centers have been impacted by the Great Resignation as much as they have.

I think that health centers have also been given the opportunity to work with the provider community on fixing things that haven't worked for providers. For example, this might be being able to continue with remote work even after the Public Health Emergency ends. They have new structures with the management team for providers to have a louder voice. There are other ways that a clinic can be modernized to make it more efficient and cause less burnout of the provider community. Furthermore, health centers have also seen local and national support to improve the future of the workforce, from loan repayment, to assistance with recruitment and retention.

It's going to take a while for us to get back to where we were with the workforce. There are efforts underway that are a really good start, and I think that people who are far more expert than me on workforce development are working really hard on current ideas and on ideas to start even further upstream, such as engaging with high schools to start students early on a track headed toward health careers. There is a way to provide financial support for those health career tracks. If it's done right, this will also result in a workforce that hopefully will be more representative of the population served. For example, if a health center has a population that is 80% Black patients, it would be great if 80% of the primary care providers were also Black. Some of these efforts should start early on in high school and college to offer career tracks to interested students and are a great way to develop a diverse pipeline of qualified medical professionals.

Sanjay: What advice would you give to an organization like Waymark that seeks to train new community health workers, and aims to help primary care practices in a variety of different communities?

‍Christina: I would say that to make sure that the medical community really understands the full scope of what community health workers can do when they're out there at “the top of their license.” Oftentimes, particularly prior to the pandemic, community health workers would be hired and really not supported to their full potential; they’d end up spending a lot of time in clinic doing roles and responsibilities that were somewhere in between clerical, administrative and medical assistant. At times the care team doesn't always recognize the gem that is a well-trained community health worker, because people with lived experience are really powerful in supporting clinical care in a way that’s different from a clinician. That extends into subspecialized community health workers, such as parent partners, peer specialists, and recovery coaches.