By EWA MATUSZEWSKI
I wrote in February that we are entering the era of the community health worker (CHW). I reiterate that today, but fear that I spoke too soon on one aspect of the CHW movement. Unsurprisingly, it’s reimbursement. Here’s what I said then:
“Many insurers are also beginning to recognize the community health worker as the new, must-have care team member for an efficient connector between clinician and community…Some services of a CHW are reimbursable to the provider; however, they must be connected to a clinical organization.”
While I was accurate in noting the existence of reimbursable services, I believe I was too optimistic in how I presented the information. The reality is, as our learning organization, Practice Transformation Institute, welcomed several freshly minted Community Health Workers following a commencement celebration earlier this month, reimbursement for billable services they are prepared to provide are in limbo.
Data continues to affirm that CHWs are critical members of the public health workforce who connect individuals with resources, advocate for communities of all socioeconomic backgrounds – but especially those facing health and racial inequities – and, on net, contribute to improving the quality of healthcare. Yet, at this relatively early stage of true integration of CHWs into clinical practice teams, there are limited professional and career building pathways. In turn, this can lead to low wages and lack of career advancement, further resulting in turnover, attrition, and workforce instability. (Wow – I’m certainly sounding contrary to the optimistic tone I sincerely used in my February post!)
The fight for reimbursement has two funding barriers. The first is having enough revenue to offer higher salaries. The second is the availability of sustainable funding so that positions are not tied to time-restricted grants or other one-off funding sources.
There is historical precedent for dependable CHW funding and reimbursement. In 2007, the American Medical Association’s National Uniform Claim Committee introduced CHWs as a category in its health care provider taxonomy using the Health Resources and Services Administration definition of CHWs. A variety of funding mechanisms are also currently available to support the engagement of CHWs in public health activities and the list includes commercial, managed care and public insurance programs (e.g., Medicaid and the Children’s Health Insurance Program [CHIP]). Additionally, Medicaid 1115 waiver (see Section 1115 of the Social Security Act) can be used to bill for services using the Current Procedural Terminology® (CPT) code “Patient Self-Management and Education” for up to four hours per month in 30-minute increments.
Yet, the lack of standardization for coding and billing, not to mention universal acceptance, is detrimental to an organization’s ability to fully integrate CHWs and optimize their contributions. As we seek solutions to some of healthcare’s most vexing challenges in the categories of equity and social determinants of health, insufficient and unreliable funding mechanisms for CHWs are creating access to care roadblocks.
I’m slightly embarrassed to admit that I had a letter written for the aforementioned CHWs to sign at the commencement service, asking that commercial health insurers consider how comprehensive and consistent funding across the board can ultimately save not only healthcare dollars, but strengthen the health and well-being of traditionally underserved communities. Can you imagine completing an internship and 166 hours of training and realizing you are entering a field that is openly hesitant about consistently paying full market value for your skills?
I’m an ardent cheerleader for CHWs and fully believe in CHW training – that’s why I’ve been so determined in my efforts to recruit CHWs to the field. But attracting individuals willing to commit to CHW careers amid such uncertainty gives me pause. I am now compelled to get more aggressive with payers in asking for clearly defined billing codes and parameters that guarantee payment for defined CHW services. To do otherwise would be unfair to the next cohort of CHWs slated to begin their learning journey in June – and the others we hope will follow.
I am confident that Michigan’s multi-payer committee will begin discussing in earnest how to recognize CHWs as true members of a community care team, and that each payer will develop a fee schedule commensurate with the work being done. Did I hear someone say SDoH support?