Introduction
Last month, we discussed how Community Health Workers (CHWs)
create value across multiple payers, including Medicare, Medicaid, and
commercial insurance and through programs such as Provider Delivered Care
Management (PDCM), Transitional Care Management (TCM), and other value-based
initiatives. A question frequently asked by physician leaders is, “Can a CHW
generate enough financial return to justify the investment?” Increasingly, the answer is yes, but not
for the reasons many practices expect.
The Wrong Question
Many practices or organizations begin by asking, “How much
can a CHW bill?” This is an
understandable question, but it is the wrong place to start.
As discussed last month, the financial value of a CHW should
not be measured by a limited number of billing codes. Instead, physician leaders should evaluate CHWs
based on their contribution to direct reimbursement, care management, quality
performance, operational efficiency, and value-based payment
opportunities.
Table: Examples of Community Health Worker Financial Opportunities
This table demonstrates that the financial value of a CHW extends
well beyond direct reimbursement. It is recommended to check with the payer to
determine payment policies and approval rules.
A single patient interaction may simultaneously support billable
services, quality performance, care management objectives, care coordination,
education, reduced avoidable utilization, and improved patient experience. Viewed together, these contributions create a
cumulative financial impact that often exceeds the value of any individual
billing code.
For physician leaders, the important question is how to
maximize the financial and clinical value created by CHWs across multiple payer
programs.
Michigan’s Leadership in Team-Based Care
Michigan has long been a leader in developing and
implementing innovative models that support coordinated, team-based care. Programs
such as Patient-Centered Medical Homes (PCMH), BCBSM Provider-Delivered Care
Management (PDCM), and value-based payment initiatives have established a
strong foundation for integrating CHWs into primary care.
Emerging direct reimbursement opportunities and value-based payment models now provide the financial foundation to support that integration, enabling physician practice to align improved patient outcomes, with sustainable practice performance.
