Community Health Workers and Medicaid Managed Care in New Mexico

Johnson D, Saavedra P, Sun E, Stageman A, Grovet D, Alfero C, Maynes C, Skipper B, Powell W, Kaufman A
Source: J Community Health
Publication Year: 2012
Patient Need Addressed: Care Coordination/Management, Chronic Conditions, Patient satisfaction/engagement
Population Focus: Complex care, Medicaid beneficiaries
Intervention Type: Staff design and care management
Study Design: Pre-post with Comparison Group
Type of Literature: White
link: https://www.ncbi.nlm.nih.gov/pubmed/21953498
Abstract

We describe the impact of community health workers (CHWs) providing community-based support services to enrollees who are high consumers of health resources in a Medicaid managed care system. We conducted a retrospective study on a sample of 448 enrollees who were assigned to field-based CHWs in 11 of New Mexico’s 33 counties. The CHWs provided patients education, advocacy and social support for a period up to 6 months. Data was collected on services provided, and community resources accessed. Utilization and payments in the emergency department, inpatient service, non-narcotic and narcotic prescriptions as well as outpatient primary care and specialty care were collected on each patient for a 6 month period before, for 6 months during and for 6 months after the intervention. For comparison, data was collected on another group of 448 enrollees who were also high consumers of health resources but who did not receive CHW intervention. For all measures, there was a significant reduction in both numbers of claims and payments after the community health worker intervention. Costs also declined in the non-CHW group on all measures, but to a more modest degree, with a greater reduction than in the CHW group in use of ambulatory services. 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.

Insights Results

Overview of article

  • The role of community health workers (CHWs) described in the current study to improve access to primary care and decrease pharmaceutical and hospital based utilization was deemed a viable model and replicated by other Medicaid Managed Care Organizations in New Mexico. A broadly trained, “generalist” as opposed to a narrowly trained, disease-specific CHW appears most suitable to this managed care role
  • Reimbursement for CHWs is often inconsistent because their work is often funded by grants / Additionally, in most states, CHWs are not allowed to bill Medicaid or Medicare directly for their services. The desirability of a CHW career is thus diminished due to financial insecurity. Moreover, the appeal of CHW services to payers of healthcare has heretofore been nominal due to the lack of conclusive studies demonstrating their effectiveness in improving the quality and cost of healthcare for underserved populations
  • By institutionalizing CHW roles within managed care organizations, 2 objectives may be met. The first is to stabilize the financial compensation for members of this emerging workforce. The second relates to access to utilization data, necessary in assessing whether the work of CHWs leads to improved quality of care at lower costs
  • This paper reports on how the University of New Mexico Health Sciences Center Department of Family and Community Medicine trained CHWs as case finders into a system of more broadly trained health workers. The immediate objective was to decrease emergency department (ED) visits for non-emergent conditions and to ensure appropriate management of chronic diseases such as diabetes with the primary goal of improving quality of life

Methods of article

  • Data was collected on services provided, and community resources accessed. Utilization and payments in the emergency department, inpatient service, non-narcotic and narcotic prescriptions as well as outpatient primary care and specialty care were collected on each patient for a 6 month period before, for 6 months during and for 6 months after the intervention. For comparison, data was collected on another group of 448 enrollees who were also high consumers of health resources but who did not receive CHW intervention

Results

  • The CHWs were classified as Client Support Assistants and provided services through education, advocacy, and social support. For example, they were responsible for making home visits to assess members’ needs, promoting increased access to preventive care, and providing culturally sensitive health education and advocacy. These are just a few examples. but overall, these services addressed patient needs around navigation, access, chronic disease management, and health literacy
  • The difference in cost from 6-months before to 6-months after CHW intervention for the 448 patients in the study sample was calculated. Costs were lower in all categories: Emergency Department—$425,551, inpatient—$872,694, non narcotics prescriptions—$699,129, and narcotics prescription—$42,091. The total cost differential was $2,044,465 less post intervention compared to pre intervention
  • There was a clear regression to the mean in counts and cost in the high utilizer, non-CHW member population. However, the overall magnitude of the reduction in resource utilization appeared to be significantly higher in the CHW than in the non-CHW intervention group

Key takeaways/implications

  • Moving forward, to more accurately gauge the impact on resource utilization of the CHW program, a study that is prospective and that randomizes members into and out of the CHW intervention is called for
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