Realizing the Value of CHWs — New Opportunities for Sustainable Financing
N Engl J Med. 2019 May 23;380(21):1990-1992. [Pubmed Abstract]
Lapidos A, Lapedis J, Heisler M
Health care financing in the US, especially since the passage of the Affordable Care Act (ACA) or “Obamacare,” has increased opportunities for financing peer support and community health worker (CHW) programs. In this week’s Tuesday Tip, our colleague, Michele Heisler, and two of her other colleagues from the University of Michigan, Adrienne Lapidos and Jeremy Lapedis outline the case for routine financing of CHWs and several possible mechanisms and paths to accomplish this.
Opportunities include 2018 Medicare provisions to cover CHW and other nonmedical benefits especially for those with chronic diseases. This follows earlier Medicaid provisions included in the ACA to cover CHW and other supportive services for those with mental health and chronic conditions. Medicaid has also updated rules to encourage Medicaid MCOs to cover services including those addressing social determinants of health such as transportation and access to healthy food. CHW services will also benefit from value based payments that reimburse health care organizations on a per-member-per-month or similar flat basis that leaves the organization free to allocate resources as it sees fit.
Fee for service reimbursement remains the dominant source of health care financing in the US. With it, provisions for quality control are essential to prevent CHW programs, along with other services, from being lured by “volume over value.”
Successes include Medicaid reimbursement for peer support specialists in mental health care, now offered by over 40 state Medicaid programs.
The article points out an important reciprocity between sustainable financing and quality improvement. As health care organizations are reassured that reimbursement for peer support, peer specialist, and CHW services is something they can count on, their incentive to build and invest in quality improvement will be increased, growing the field and, eventually, enhancing the public health.