CMS Waiver Answers Safety Net's $64M Question

"An actuary worked with us to develop per-member, per-month figures, but we'll have a better sense in three months of how much we're spending outside and how much stays inside," says Corlett, noting that initial projections indicate that about 25 cents of every dollar the system will spend on this population will go outside the system to federally qualified health centers and other ancillary providers.

The fact that MetroHealth Care Plus will be paying outside entities is early practice for the types of shared risk contracts many healthcare organizations will have to take on as both government and commercial payer sources look to force providers to take risk surrounding quality of care.

Though hospitals and health systems in other states should investigate such a waiver, especially if their state will not be setting up its own insurance exchange, Corlett says it won't come easy.

First, the matching funds could only be used if the hospital were to designate funds (in this case, the county subsidy) toward caring for the uninsured population. MetroHealth was able to designate its county subsidy because represented state or local funds not previously used in the Medicaid program.

Technically, a state could contribute additional funding to get the matching funds MetroHealth got in this case, but that's unattractive for the same reasons some governors are resisting the Medicaid expansion—their state budgets are riddled with healthcare expense already.

Corlett says state and CMS officials granted the waiver in part because they were intrigued with a program at MetroHealth called Partners in Care, which was essentially a patient-centered medical home for the uninsured. That program will now morph into MetroHealth Care Plus.