Strategies for Integrating Community Health Workers into Health Care Teams: Financing Options Under Medicaid

With growing interest in roles for community health workers (CHWs) in health care, states and other stakeholders face challenges in creating sustainable financial models for employment of this workforce. Medicaid was designed to finance clinical care, and CHWs are not clinicians, yet there is mounting evidence of their capacity to remove barriers to care, increase uptake in preventive services such as immunizations and screenings, increase adherence to treatment, and encourage positive self-management practices for chronic illness. Medicaid rules for preventive services now allow payment for services by non-licensed providers when “recommended” by licensed clinicians. This change has stimulated greater interest in CHWs nationwide. Some states such as Oregon, South Carolina and Vermont are experimenting with primary care structures that include financing for CHWs. Some advocates are calling for CHWs to play a central role in addressing social determinants of health within primary care teams. Other demonstrations are showing success for CHWs in activities such as care coordination for high utilizers, enabling individuals to remain in home- and community-based long-term care, and reducing hospital readmissions. Each of the many options for Medicaid financing of CHWs has its challenges, but “payment reform” has opened some new doors.  However, in practical terms, state officials are reluctant to commit upfront investment, setting a high bar for evidence of cost savings. The authors were commissioned by the University of Arizona to prepare a policy brief on Medicaid financing options for the Arizona Department of Health Services, and this presentation will summarize their findings.