In the first two parts of
this series, we examined the expanding roles for Community Health Workers
(CHWs) in primary care and multiple ways CHWs can contribute to financial
performance. We also challenged a common
question: “How much can a CHW bill?”
This question focuses
only on direct reimbursement and disregards much of the financial value CHWs
can create. A more useful question for physician leaders is, “How can a CHW
be deployed across our practice’s payer and patient mix to generate sufficient
financial and clinical value to justify the investment?”
This answer to this
question depends on practice size, payer mix, eligible patient populations,
participation in care management programs, and strategic use of CHWs across
multiple reimbursement and value-based opportunities.
The numbers demonstrate
how this looks in practice.
Start with the Investment
Before calculating the
return, practices need to understand the CHW investment. For illustration purposes, assume that one
full-time CHW ha a fully loaded annual cost of approximately $85,000 (including
salary, benefits, payroll expenses, training, technology, supervision, and
other employment-related expenses).
An $85,000 annual
investment amounts to approximately $7,083 in financial value per month to
reach break-even. The important point is
that $7,083 should not come from one payer, one set of allowable billing codes,
or entirely from direct reimbursement.
Revenue We Can Measure
Several existing revenue
sources provide a starting point for calculating CHW financial contribution.
Medicare and Community Health Integration (CHI)
Medicare Community Health
Integration (CHI) is very relevant, because many CHI activities align closely
with CHW roles, including patient-centered assessment, care coordination,
health system navigation, facilitating access to community-based services,
patient education and self-advocacy support, and communication with the
healthcare team.
For 2026, the national
Medicare non-facility payment for G0019 is approximately $86 for the first 60
minutes of CHI services during a calendar month. Additional qualifying time may be billed
using G0022. Actual reimbursement varies
geographically and according to applicable Medicare rquire4ments.
At approximately $86 per
patient per month, the financial contribution becomes meaningful quickly.
Table 1. Active CHI Patients per Month Approximate Annual G0019 Revenue
|
Number of Patients |
Approximate Annual Revenue based on $86 PMPM |
|
25 |
$25,851 |
|
40 |
$41,362 |
|
50 |
$51,702 |
|
75 |
$77,553 |
|
83 |
$85,825
|
In
this example, approximately 83 continuously eligible and billable CHI patients
per month could generate annual G0019 revenue sufficient to cover the
fully-loaded cost ($85,000) of one CHW.
This does not imply that
every CHW should carry a panel of 83 CHI patients or that CHI alone should
finance the position. Relying on one
reimbursement mechanism misses the larger CHW revenue opportunity.
Transitional Care Management (TCM)
Transitional Care
Management (TCM) provides another source of CHW financial value. The CHW dose
not independently bill TCM services. However,
the CHW can help the practice identify eligible patients following discharge,
conduct outreach, address SDOH barriers (e.g., transportation), review an
reinforce care plans, facilitate timely follow-up, and escalate clinical concerns
to the appropriate care team member.
In 2026, national
Medicare non-facility reimbursement is approximately $220 for CPT code 99495
and $299 for CPT 99496, depending on the complexity and requirements of the
transition.
If CHW-supported
workflows help a practice achieve eight additional TCM episodes per month
(using a blended reimbursement of $240 as an example), the practice could capture
approximately $23,000 in additional annual TCM revenue.
Again, this revenue is
NOT billed independently by the CHW and depends on the structure and processes
of workflows incorporating CHWs, where appropriate. .
Michigan Medicaid
Michigan Medicaid provides direct reimbursement for
qualifying CHW services, creating a strong potential revenue stream for
practices serving Medicaid beneficiaries.
This is especially important when building the business case
for CHWs. Practices do not need to rely solely on Medicare CHI reimbursement to
support CHW investment; CHW capacity can be aligned across Medicare, Medicaid,
and commercial care management populations.
Medicaid CHW reimbursement may contribute significantly to
the cost of a CHW position.
Provider Delivered Care Management (PDCM)
For practices participating in Blue Cross Blue Shield of
Michigan’s Provider Delivered Care Management (PDCM) program, CHWs may also
contribute to reimbursable are management activities within program
requirements.
CHWs support patient outreach, care coordination, chronic
disease management, transitions of care, self-management, and patient
engagement. PDCM is another source of financial return, particularly for
practices with well-established care management infrastructure.
PDCM is best calculated based on individual payer agreement,
patient enrollment, and patient risk mix.
Potential CHW Return on Investment for a Small Practice
As an example, we will define a small practice as one with
four or fewer physicians employing one fully-loaded CHW at an annual cost of
$85,000.
Table 2. Potential CHW Revenue in a Small, Multi-payer
Practice with one CHW
|
Financial Contribution |
Example Annual Value |
|
40 active Medicare
CHI patients/month |
$41,362 |
|
8 additional completed TCM episodes/month |
$23,040 |
|
Michigan Medicaid
CHW services |
$10,000 |
|
Subtotal measurable financial contribution |
$74,402 |
|
Amount to reach
break-even |
$10,598 |
This practice would need
approximately $883 per month in additional revenue to reach the $85,000
break-even point. This may be from PDCM,
additional CHI services, additional Medicaid CHW services, other commercial
care management programs, or other payer-specific reimbursement opportunities. This calculation has not assigned financial
value to Medicare Advantage quality performance, shared savings, reduced ED
utilization, reduced hospital admissions, improved patient engagement, or
increased staff capacity resulting from integrating CHWs in workflows.
Practice Size, Payer Mix, and Patient Opportunities
The potential return on investment
for CHW integration varies with practice size, payer mix, and patient
opportunities. This is illustrated in
the following example.
Table 3. Illustrative ROI by
Practice Size and Programs
|
Financial
Contribution/Revenue |
Small
Practice |
Medium
Practice |
Large
Practice |
|
Active CHI patients/month |
40 |
50 |
75 |
|
Approximate annual
CHI revenue |
$41,362 |
$51,702 |
$77,553 |
|
Additional TCM episodes/month |
8 |
12 |
16 |
|
Approximate Annual
TCM revenue |
$23,040 |
$34,560 |
$46,080 |
|
Illustrative Medicaid/PDCM/other |
$21,000 |
$25,000 |
$35,000 |
|
TOTAL MEASURABLE FINANCIAL CONTRIBUTION |
$85,402 |
$111,262 |
$158,633 |
|
Illustrative CHW cost |
$85,000 |
$85,000 |
$85,000 |
|
Net Measurable
Contribution |
+$401 |
`+$26,262 |
`+$73,633 |
|
Illustrative ROI |
~0.5% |
~31% |
$87% |
These examples illustrate how
aligning CHWs with payer mix and eligible patient/program populations change
the financial potential. A small practice may reach break-even with one CHW,
while a medium or large practice may have greater opportunity to add CHW
capacity and reimbursement.
Small practices may also elect to
share a CHW as they build program capacity.
These examples do not include all
activities where CHWs may contribute to revenue, such as Medicare Advantage
Stars, quality incentives, shared savings, reduced unnecessary ED utilization,
and improved patient experience.
Summarizing the Business Case
The question is whether one or more CHWs can generate break-even
revenue to provide a practice with financial value. The strongest CHW business model is built by
deliberately and strategically deploying CHW capacity across populations, payer
programs, and organizational priorities to create sufficient combined
value. This creates the combined
financial and clinical value of adding CHWs as essential members of the care
team.
NOTE: Financial examples are presented as
illustrations and are not guarantees of financial performance or return.
Practices should verify current payer policies, contracts, and fee schedules
when developing financial projections.
