Introduction:
Federally Qualified Health Centers (FQHCs) serve as an essential access point for uninsured, underinsured and high-need patients, and are uniquely positioned to address both primary care and health-related social needs (HRSNs) of underserved populations. Because of their mission of serving those who may otherwise not have access to care, FQHCs historically have focused on the Medicaid population and the enhanced reimbursement afforded to them through States’ Medicaid Prospective Payment System (PPS) rates. The lag between Medicaid PPS rate increases, complexity to re-set the PPS rate and increasing costs of operations continue to strain resources, and potential cuts to Medicaid eligibility may further reduce Medicaid volume and therefore reimbursement. Anticipating these reductions, FQHCs can leverage their enhanced services and expertise in care coordination to attract and maintain Medicare or soon-to-be Medicare-eligible members to increase volumes and participate in Medicare-specific programs that build capacity for managing risk.

Value-Based Care Strategy:
Value-based payment (VBP) provides FQHCs with a reimbursement model that better aligns with health centers’ holistic, person-centered approach to health care delivery, allowing FQHCs to capitalize on addressing patients’ HRSNs, as they often already do. Given the need for FQHCs to grow Medicare and Dual Eligible panels, CMS’s Medicare Shared Savings Program (MSSP) is a key VBP model FQHCs should consider to gain exposure to risk-based arrangements.

MSSP is often a favorable first step for organizations like FQHCs to enter VBP arrangements, as it is low-risk in the initial program years and offers an added incentive for FQHCs to grow their Medicare patient population to supplement current Medicaid volume. MSSP participation requires that health centers form or join an Accountable Care Organization (ACO) serving a minimum of 5,000 Medicare beneficiaries, which may be achieved through a FQHC-led ACO (e.g., Independent Physician Association) or by partnering with other organizations through a multi-provider ACO. While participating ACOs are expected to gradually take on more risk over time, the limited downside risk in the early years of MSSP participation allows FQHCs to adjust to this new reimbursement model while capitalizing on the shared savings achieved through the delivery of efficient and effective care for their patients. Representing the strong alignment between MSSP and FQHC services and sustainability, participation in this model by FQHCs has increased from just 60 delivery sites in 2016¹ to more than 7,000 in 2025².

If considering participation in MSSP or other risk-based arrangements, such as dual eligible special needs plan (D-SNP) value-based payment contracting, it is important for FQHCs to build the necessary infrastructure for success under these VBP models. Key capabilities to enhance VBP performance, leading to increased revenue, include:

• Population Health Management and Data Analytics
• Risk Stratification
• Care Management & Care Coordination
• Social Determinants of Health (SDOH) Screening
• Performance Measurement & Quality Improvement
• Financial Modeling

Leveraging these capabilities, FQHCs will be able to create more efficient and effective processes, as well as tailored strategies to meet community health needs.

How COPE Health Solutions Can Help:
COPE Health Solutions (CHS) has extensive experience in Medicaid, Medicare, Dual Eligible and Commercial revenue optimization strategies, including value-based care enablement. With active partnerships supporting FQHCs through all aspects of MSSP participation, our firm can provide the expertise, analytics and operational support necessary for success under value-based payment models, and can partner with your organization in developing the strategy and infrastructure required for long-term sustainability. Analytics for Risk Contracting (ARC), our market-leading population health management platform, can provide actionable data and insights as well as care management and financial management tools to improve quality outcomes and financial performance.

For more information about strategies and holistic platform and expert solutions to power growth in Medicare and Dual Eligibles, including how to leverage analytics and care management for success in value-based payment models, reach out to COPE Health Solutions at info@copehealthsolutions.com.

Endnotes

¹ https://pmc.ncbi.nlm.nih.gov/articles/PMC11574694/
² https://www.cms.gov/files/document/2025-shared-savings-program-fast-facts.pdf