Medicaid Funding for Community Health Workers: Lessons Learned from Families USA’s Health Action 2017 Conference

Last month, CHLPI attended Families USA’s annual health advocacy conference, Health Action 2017, in Washington D.C. Given the tumultuous path of health policy in today’s world, the conference’s goal was to prepare health care advocates as they seek to defend and bolster progress that has been made since the implementation of the Affordable Care Act. CHLPI brought along student Jacob Barrera to gain insight into the ideas and strategies that health advocates are using to protect access to affordable care. Jacob is pursuing his Masters of Public Health from the Harvard T.H. Chan School of Public Health. 

Image via @FamiliesUSA on twitter.

Community Health Workers (CHWs) are considered trusted members of their communities, bridging the gaps between the health care system, social services, and the community. Their jobs are multiple and not necessarily defined—health educators, community navigators, and enrollment specialists, just to name a few. At Families USA’s Health Action 2017 Conference in Washington, D.C., many of the panelists presenting at a workshop on funding and integrating CHWs echoed the same research findings on the effectiveness of CHWs—they can improve health care outcomes and reduce costs incurred by the health care system as a whole, particularly for those living with HIV and other chronic conditions. The goal of the panel on CHWs was to talk about ways to fund and integrate them through Medicaid as a billable service.

According to panelist Gail Hirsch, Co-Director of the Office of Community Health Workers for the Massachusetts Department of Public Health, there is a clear notion to recognize and strengthen the field of CHWs, but there is disagreement as to how this should happen. Gail, along with co-panelists Abby Charles, Senior Program Manager for the Institute for Public Health Innovation and Charlie Alfero, Executive Director of the Southwest Center for Health Innovation reached a consensus regarding standardization of the scope of practice and core competencies of CHWs. However, there were dissenting opinions in the audience, with one audience member claiming that the standardization and training of CHWs was not necessary according to the rules set forth by the Centers for Medicare and Medicaid Services.

In building an argument for standardization of scope and core competencies, there is an aim to build a consensus on the value of CHWs from the perspective of providers, payers, and policymakers. Charles explained that there is currently a return on investment of 3:1, on average, which is something that is leveraged in Medicaid Managed Care Organizations (MCOs) for internal investments in CHWs. This return on investment is due, in part, because CHWs reduce barriers such as education disparities, citizenship, and language barriers that hinder access to health care and other community resources.

Charles noted that despite this return on investment, the challenges to funding and integrating CHWs in Medicaid persist. One of the main challenges is simply getting buy-in from Medicaid. Other challenges that came up across the panel include the lack of understanding of the value and cost-effectiveness of CHWs, the concerns that individuals have about the fraud and abuse within the CHW field, the fact that CHWs are not the biggest priority for Medicaid agencies, and a national trend away from the fee-for-service model.

A model that has effectively funded and integrated the CHWs into their field of practice is through the MCOs run by the University of New Mexico, with Charlie Alfero at the helm. These MCOs have incorporated CHWs into different levels of care. Each service is billed through the university, which is then reimbursed by Medicaid. This is a means of trying to create a separate revenue stream that is not linked to physician revenue. According to Alfero, this creates important short-term profits for the health care center. This is the only model that seems to be getting any money from Medicaid for the work that is being provided by CHWs, and it may be a model for other organizations to design their own CHW program that is both adequately funded and sustainable.

An Accidental Case Study: Emily’s Bone Marrow Donation

This blog post was written by Nate Szyman, a Student in 2016 Fall Semester of Harvard Law School’s Public Health Law and Policy Seminar

Recently I spent the day at the hospital with my wife, Emily, as she donated bone marrow to an anonymous recipient. It was an amazing experience—considering the life-altering impact of Emily’s courage and generosity continues to inspire me. As we drove home that day, I felt grateful for the talented and dedicated healthcare professionals that made the procedure possible, and I was encouraged by the fact that they do this hard work every day.

But walking with Emily through her donation process also left me feeling concerned that the high stakes of healthcare make it hard for advocates to address its systemic inefficiencies. As I describe below, Emily’s donation process involved numerous inconvenient appointments, concerning payment structures, conflicting information, and even sparring healthcare professionals (not to mention the surgery itself!). But because a sick person needed Emily’s healthy bone marrow, it was hard for us to advocate for our preferences and concerns about the process.

Scheduling Emily’s procedure and pre-surgical appointments was inconvenient and stressful for our family. The nearest harvesting facility was unavailable when she began the process, so she had to drive over 45 miles from our home to a surgical center. Emily traveled to the provider’s facility at least once during each of the four weeks leading up to her harvesting procedure, creating multiple scheduling headaches for our family as we rearranged our lives so that I could watch our two daughters. And it was hard to understand the necessity of these trips—they were primarily to draw blood, etc. for lab work, and the tests were often duplicative.

The payment structure added mistrust and frustration to our experience, and over time I grew concerned that Emily’s preferences and concerns were not being prioritized. I could not understand why Emily needed to travel to the provider’s facility rather than have the tests done at a local lab. Given the unique circumstances of donation harvesting, I was nervous that the provider might take advantage of the fact that Emily did not pay for any services (which would ultimately be covered by the recipient’s insurance) to bill for unnecessary testing. But information asymmetries and the recipient’s dependence on Emily made it hard to push back on any of these very inconvenient procedures.

Further, some information provided by the registry and the provider conflicted, which made the process more confusing than necessary. For example, they shared different understandings of what the normal anesthetic approach was (the provider suggested a more expensive option) and of what normal post-operating procedures look like. And Emily’s doctor was reticent to prescribe pain medication for her post-op recovery even though the registry materials said that taking these pills was part of a normal recovery process. Emily had to ask for the script multiple times.

After the long drive home, I helped Emily into our apartment and then ran to three pharmacies trying to fill Emily’s prescription. It turned out that the doctor had given her an unusual dosage. The third pharmacist told me that no one would have these pills and that I would need a new prescription. I called the on-call doctor at the provider’s facility, and he told me that he could not e-file for pain medication, despite the pharmacist’s assurances that he could. In fact, the pharmacist said she could not fill an emergency prescription, which the doctor proposed we do to solve the problem, because she knew that e-filing for pain medication was possible and that emergency prescriptions are only permissible when there is no other way for the patient to receive the drugs.

The situation was tense, and I realized that I would have to put my frustration and anxiety aside in order to mediate between these two healthcare professionals, who seemed more interested in calling the other rude/incompetent than in helping Emily. One hour and three phone calls later, they finally agreed to provide Emily an emergency prescription that would last one day. Apparently the doctor was unable to e-file pain medication prescriptions due to his office’s technical limitations, though the pharmacist was right that it was legal for her to receive them. I had to return the following day to pick up another prescription adequate for the rest of Emily’s recovery.

Fortunately, Emily recovered well, and we soon heard that the recipient’s transplant procedure was successful. Emily and I were thrilled and again amazed at this incredible experience. As I mentioned at the start, helping Emily donate bone marrow encouraged me that the healthcare system is filled with good people doing good work. Here everyone worked together to save a life.

Still, I’m unsettled by the experience. For I know that Emily would chose to donate in a heartbeat despite the unjustifiable inconveniences of the process. I would do the same. It was totally worth it. By jumping through these hoops, Emily helped someone live. How can we weigh personal inconveniences imposed by healthcare processes, no matter how significant, when we face life-and-death circumstances?

This problem weighs on me—health care matters so much that we will put up with nearly anything, and if we will put up with nearly anything, then it will be hard for us to make changes for the better.

« Previous Page