In recent years, California Medicaid insurer Health Net has doubled down on its support of community health worker (CHW) initiatives. In a recent interview, two Health Net leaders spoke about CHWs’ role in care navigation and trust-building, especially for high-risk populations.
Health Net, a Centene company, provides health plans for those who qualify for Medi-Cal or Medicare. It has more than 117,000 network providers who serve more than 3 million members across California.
Dorothy Seleski, president of Medi-Cal at Health Net, and Pooja Mittal, M.D., vice president and chief health equity officer, spoke about the impact of the state’s CalAIM Medicaid transformation effort on the deployment of community health workers.
Healthcare Innovation: Could talk a little bit about some of the ways Health Net’s work with organizations deploying community health workers is evolving?
Seleski: Both in Los Angeles and in the Central Valley we have been supporting promotores for years. We have long felt that community members are well suited to help their neighbors understand the importance of accessing the healthcare system and of preventive health services. Through the CalAIM initiative, one of the new benefits was Enhanced Care Management (ECM), and as that benefit is described, there is both a clinical aspect to it, but very central to the benefit is this idea that community partners, neighbors, family members, promotores and others are critical to helping these patients who are at the top end of the population health management pyramid. They have a lot of needs and potentially have the most distrust of the healthcare system.
We have strongly encouraged our ECM providers to leverage community health workers as part of their ECM teams. Then a year and a half ago, the state actually made community health workers a separate benefit. So CHWs can provide ECM services, but the CHW benefit is only available to non-ECM enrolled patients. So you can work with a CHW in two different ways. We doubled down on that. We understood from our community, listening that the health plan is not going to convince somebody to engage in the healthcare system. It’s going to be their pastor, their neighbor, or the food bank that they’ve relied on for sustenance.
HCI: Would you say that CHWs are now a fairly significant aspect of your health equity strategy?
Mittal: ECM is for the highest-risk, highest-needs population, whereas eligibility for CHW services is super broad. When you look at our population at Health Net, about 70% of our population is eligible for CHW services, and I think ECM is more like 15 percent of our population. Between them, it’s a significant population of ours that’s eligible for these services. So as we think about it from an equity strategy, what these folks can provide is that connection to the community. It’s building trust, but it’s also more fundamentally connection back to the healthcare system — care navigation, right? Encouraging people to take care of their diabetes. It is a flexible way of interacting with our members and meeting them where they are and getting them what they need.
The other thing that makes it a central part of our strategy is that each community has had these type of folks for a long time. The Latino community has had promotores, and there are CHWs who work in all types of communities. There are community health representatives who work in the Native American communities. It’s just such a culturally ingrained group, so Health Net being able to support them more broadly is even more empowering for that workforce.
Seleski: Not only is it a payable benefit, which is great, but we try to emphasize the idea that your organization is already doing this work. This is incremental revenue to you. Administratively we can connect you to people to help you, because you know community organizations don’t tend to know how to bill. They live on grants and donations. Think of this as incremental revenue for you to do what you’re already doing, but more importantly, to be able to secure your mission, because now there are additional funds. That’s where [the vendor] Pear Suite has come in for us. They are not the only group, but they came in early and developed with us. They listened to what we had heard from the community and what we knew they needed, and that’s where a lot of their administrative support has been directed — on how to document and how that documentation easily becomes both a bill and an account receivable, because, again, revenue cycle management is not part of their language.
HCI: I read that the community health workers are required to have a supervising provider organization that must be licensed — it might be a hospital, an outpatient clinic, a local health jurisdiction or a community-based organization. I was wondering if, so far, you’re seeing one type of group being the most active in this space.
Seleski: We actually did a statewide survey on this early on, when the benefit was starting. Generally, what we saw is that those supervising providers primarily came from the community-based organizations. So that that was another impetus for us to work with Pear Suite, because as we looked at the ratios, one thing that is clear both in CHW work and in doula work is that an apprenticeship type model is not enough to train them. We’ve done a lot of investment in training for CHWs. They have to learn how to do the work in the community, and that happens through the support of a supervising provider, or even peer support, actually.
One advantage that we saw of Pear Suite is that as they were able to bring in this EMR-type support. It gave them next best action, and that allowed better support for the CHWs who might not have a lot of time with their supervising providers. People could learn as they went. So not only were they getting billing support, but they were learning as they go.
Hospitals in California previously had some incentives to hire comparable positions, specifically around behavioral health, and that funding ultimately went away. What is both surprising and a little bit troubling to me is that we are two and a half years into the benefit. We are only now, through repeated conversations with our hospitals, getting some interest from some hospitals in thinking about including community health workers, either in their outpatient departments or more importantly in their emergency rooms.
HCI: What about FQHCs?
Seleski: I love the idea. FQHCs, however, are financially disincentivized to bill for community health worker services. They may have CHWs, but we are never going to know it, because they’re financially disincentivized to bill us for that service.
HCI: From Health Net’s perspective, are there quality improvement teams using population health tools to identify members who could use these services, and then reaching out to the supervising organizations or directly to community health workers to offer a prioritized list of people who could benefit?
Mittal: Yes, we are doing that. It’s proven to be variably successful, primarily because outreach is not paid for as part of the benefit, and it takes a lot of administrative time to do that outreach. But we have had some success in doing that in discrete programmatic supports or supporting people with diabetes or with asthma, and the trend is showing that there are improvements in health outcomes.
HCI: Could Health Net see the results of that in improved quality measures for those patients?
Mittal: Yes, we have some preliminary data showing a trend toward improvement in health outcomes and in those quality measures.
HCI: What would you say is the biggest challenge in getting this all up and running initially? Is it a big educational task to have everybody understand the whole CalAIM setup?
Mittal: I would say three things. Overall, one of the biggest barriers has been educating providers about these benefits. It’s difficult to get providers to refer to these services, difficult for them to even understand it. I work in an FQHC, and most of my peers there don’t understand CalAIM and don’t even know what benefits are available to their members.
Specific to this community health worker benefit, there are two main challenges. One is that people are spending a lot of their time doing outreach. Creating the conditions for those referrals to happen organically has been a big challenge, whether that means embedding a CHW in an emergency room or a clinic or having a CHW work with WIC, for example. The second is really the payment piece, because, like Dorothy said, most of these folks are used to being paid in grants. Being able to switch from that method to claims-based billing, and then waiting a couple of months for the payment has been a huge challenge. A lot of what we have been working on at Health Net is explaining to people how to braid funding, how to be successful at doing claims-based reimbursements and why they should buy into this model, because it’ll help them to be sustainable.
