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Ongoing hurdles
Community health workers’ somewhat murky role in the healthcare system can present logistical reimbursement challenges and raise concerns among state officials about spending.
Fee-for-service payment structures, like California’s, may shoehorn the activities the workers can provide into fitting within existing clinical systems, said Sweta Haldar, co-author of the Kaiser Family Foundation report and policy analyst for the organization’s racial equity and health policy program and the program on Medicaid and the uninsured.
A general lack of reimbursement codes exacerbates the issue. In 2016, the Centers for Medicare and Medicaid Services introduced “Z codes” allowing clinicians to add a patient’s social determinants of health needs as a diagnosis to their medical chart, but the codes do not authorize payment for treatment of these non-medical services.
“The fee-for-service model for billing doesn’t really work for the kinds of services community health workers provide,” Haldar said. “They have a really expansive role, and they’re very grassroots-oriented, and the medical model of reimbursement [makes it] difficult to capture the amount of value they provide through that discrete, fee-for-service billing model.”
More broadly, some state Medicaid officials may feel paying for non-licensed clinical services represents an extra line item that underfunded, understaffed programs cannot afford, said Kate McEvoy, executive director of the National Association of Medicaid Directors, a trade group for state Medicaid officials. It could also spark pushback from providers, who argue that Medicaid payment should be prioritized for licensed clinicians, rather than community health workers, she said.
The trend “is moving away from the historical norm of licensed clinicians being really the center point of care that’s received,” McEvoy said. “Community health workers typically aren’t licensed. They’re people with a lot of lived experience. That’s something that is over time being more and more embraced by traditional healthcare practices, but it is a learning curve.”
Some argue that if public funds are going to be spent on the workers, standardization in their training and the services they provide is necessary. States are increasingly developing certification programs for community health workers, or delegating training responsibilities to managed care companies, McEvoy said.
“Community health workers want to be recognized as a distinct professional path,” McEvoy said. “They want to have that social valuation of the work they do. They want to have the support of certification and also ongoing training to make sure that they feel equipped to perform their jobs.”
Requiring a standard certification could present hurdles for would-be community health workers, however, particularly if they must pay out of pocket for the credential.
Yuri Bejarano, who immigrated to the United States as a teen, is part of the care management team at Baylor Scott and White Health in Waco, Texas. She provides translation and navigation services, teaching people to advocate for themselves within the healthcare system, she said.
Although Texas’ Medicaid program doesn’t cover her services, the state does require certification to become a community health worker. Six years ago, Bejarano decided to pursue the role. But she couldn’t afford the fees related to the 160-hour course.
“I was just very poor at the time,” she said. A social worker she called for advice agreed to front the costs for the training program, helping launch her career.
“When I educate a patient, I feel like I’m not only educating them, but I’m educating their descendants as well,” Bejarano said. “Because if the patient follows a healthy lifestyle and is taking care of their mental and physical well-being, I feel that sets an example for their children and grandchildren. In a way, you are changing generations to come.”
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