Health Plans

How CHWs Help Health Plans

mayo1Under health care reform, new payment models are shifting the incentive structure to outcome-based approaches which reflect total cost of care. New care models need to deliver on the Triple Aim:  better outcomes, healthier populations and lower per capita costs. Thousands of previously uninsured patients will soon be enrolling in health plans without a medical home and little understanding of how to appropriately use their benefits and the health care system. And with increasing attention to and accountability for outcomes and reporting by  race and ethnicity, health plans will need to address deep and preventable disparities with an effective combination of upstream and downstream approaches. CHWs are part of the solution.

  • Are you finding patterns of preventable emergency room utilization?
    • CHWs have been found to divert patients from high-cost emergency room visits by connecting them to primary care and identifying other after-hours options.
  • Are you seeing an increase in avoidable complications related to asthma, diabetes, HIV and other chronic illnesses?
    • CHW health education and care coordination strategies have been found to be beneficial in team-based approaches that target chronic illness. For example, around the US, comprehensive asthma interventions for low income children build on and extend clinic-based care with team-based CHW strategies and home-based environmental approaches. Click here to learn more about the Community Asthma Initiative, Boston.
  • Are you concerned about obesity and rising rates of prediabetes?
    • CHWs can be employed in individual-level and community-level approaches to address this epidemic.
  • Are your pregnant enrollees initiating prenatal care early in their pregnancy?
    • As trusted members of the communities they serve, CHWs can conduct outreach and home visits to provide education, help address barriers related to keeping appointments, and handle non-medical issues that can get in the way of a healthy birth.
  • Are you concerned about addressing low birth weight babies and infant mortality rates?
    • Team-based CHW strategies used in New York, Ohio, and Wisconsin are improving outcomes which disproportionately affect African Americans.  They can also address interconception needs.
  • Are you seeing a need for improvement in your HEDIS and CAHPS scores? 
    • Consider how CHW strategies can help make a difference. Contact the Alliance for information.

Spotlight: Molina Healthcare Inc., Long Beach, CA

Recognized as the largest family participating Hispanic-owned business in the US, Molina Healthcare Inc. is a family-owned, publicly-traded managed care organization serving nearly 4.3 million individuals and families who receive their care through Medicaid, Medicare or other government-funded programs in 15 states including Wisconsin, Michigan and Ohio in the Midwest. In 2005, Molina instituted a team-based CHW model program through contractual arrangements with a focus on decreasing emergency department visits for non-emergent conditions and to ensure appropriate management of chronic disease s such as diabetes in order to improve quality of life. Initially available in 11 New Mexico counties and now available in in most of the state’s 33 counties, the program pays a monthly capitated fee, now over $320 per member per month, to selected provider networks for care coordination for members identified as “high utilizers” using measures such as ED use and prescription drug costs.

A comparative, longitudinal evaluation of this model published in 2012 studied preliminary outcomes related to resource utilization, coast and savings and found that “the incorporation of field-based, community health workers as part of Medicaid managed care to provide supportive services to high resource-consuming enrollees can improve access to preventive and social services and may reduce resource utilization and cost.” Based on a sustained ROI of at least 3:1 related to reduced total cost of care, Molina’s corporate office is expanding this model from New Mexico to all states where it has a Medicaid contract.

Reference:  Johnson, D et al. Community Health Workers and Medicaid Managed Care in New Mexico. J Community Health: 2012 June: 37(3): 563-571.