Policy and Reimbursement Committee

Examine the role of CHWs in the models under consideration by the Governor’s Council on the Montana State Innovation Model Design and other Montana initiatives

• Evaluate the use of CHWs with Medicaid populations and care coordination models including PCMH, CMS funded care coordination projects and ACOs
• Identify policies and reimbursement models that support the use of CHWs through Medicaid and private payers

Organizations and agencies that have a role in implementing CHW policies and reimbursement models that will aide in the sustainability of the use of CHWs in Montana area asked to participate on the Committee and may include:

• Agencies:  DPHHS, Governor’s Innovation Council, MT Department of Labor
• Payers:  BCBS, Pacific Source, Medicaid, New West
• Systems and delivery models:  PCMH (CSI, Providence), ACO (National Rural ACO), Billings Clinic, CHCs, Mountain Pacific Quality Health Foundation and other grant funded programs (e.g. PCORI, community paramedicine), Indian and Tribal Health,
• Other:  AHECs, MUS, foundations

• Quarterly conference calls and/or one or two face to face meetings in Helena, for 1-2 hours
• Staff research and support provided to the group

CHWs are gaining interest at a national level.  The focus on population health, care management, improved patient outcomes, and social determinants of health is creating innovative models of care.  Patient Centered Medical Homes, Accountable Care Organizations, State Innovation Models, CMS Innovation Center projects, Patient Centered Outcome Research, and the CDC are providing a focus on care teams and approaches that include CHWs.  CHWs are part of the care team in Integrated Behavioral Health and Medicaid Home Health models - which are growing in national prominence and under consideration for the Montana State Innovation Model Design.

The Association of State and Territorial Heath Officials (ASTHO) tracks CHW training and Certification requirements.  The CDC, in a 2014 cooperative agreement with the Arizona Prevention Research Center of the University of Arizona examined demographic information, training and work environment, job related roles and activities and target populations.  The CDC assessed and summarized the strengths and limitations of the evidence base behind a number of chronic disease policy interventions that included CHWs and determined the potential of these interventions for chronic disease policy.  The greatest potential was CHW deployment into inter-professional teams under provider supervision for interventions focused on access, patient self-management, cost reduction and improved social outcomes, especially for groups with significant health disparities.(1) Another CDC report summarized evidence around CHW interventions designed to prevent chronic diseases, and evidence that CHWs could be a cost-effective way to improve outcomes.  CHW interventions are currently being evaluated as part of numerous CMMI Innovation and Patient Centered Outcomes Research grants. 

Six states used State Innovation Model Test Awards, Round 1 (CMS) funds to support a CHW component of the demonstration project (AK, ME, MA, MN, OR, and VT) and eleven states in Round 2 (CO, CT, DE, ID, IA, MI, NY, RI, OH, TN, WA).  The models provide extensive documentation on the CHW roles, integration into care teams, integrated care model delivery, payment models, and addressing broad determinants of health outcomes for Medicaid participants.

Short term grants and contracts create opportunities for innovation and establishment of CHW services, but potentially create unstable work environments.  More predictable payment models include reimbursement through Medicaid (CMS-2334-F) for Essential Health Benefits for preventive services recommended by - rather than provided directly by - a physician or other licensed practitioner.  State plan amendments are required to tap into this reimbursement.   Per member, per month payments to managed care providers provides an option for CHW salaries, and state-initiated waivers, such as those allowed under 1115 of the Social Security Act provide opportunities to pilot budget-neutral demonstration projects. Private payers may also include CHWs within per member, per month payments or other negotiated payment models.  Outcomes of State Innovation Model awards, Center for Medicare & Medicaid Innovation (CMMI) projects and Patient-Centered Outcome Research Institute (PCORI) grants may provide additional models and incentives for adopting CHW models into care teams.