The Rising Prominence of Community Based Organizations

By Bella Kirchner, Special Projects Manager

As healthcare reimbursement models evolve to pay based on value (high quality care at lower costs) rather than on volume, healthcare plans and providers are focusing on the factors outside of healthcare that can impact a patient’s health.

Studies show that addressing these factors can lead to better health outcomes, which in turn, lower the cost of care. For many decades, the healthcare industry has focused on using clinical medical care (e.g., office visits, medications, hospitalizations) to improve the health of their patients. However, research shows that much of a person’s health is actually not determined by clinical healthcare, but by a person’s individual behaviors and social & environmental factors, often coined “social determinants of health.” When you don’t take care of a patient’s basic needs, their overall health suffers.

The realization that these factors have a major impact on both health outcomes and the cost of care has led to changes in both care and reimbursement models. While all of these changes are pushing health plans and providers to focus on social determinants, they are quite aware that they’re in the business of health, not social care, and know that working towards more formal partnerships with Community Based Organizations (CBOs) is going to be critical to successfully providing social care.

The Role of CMS

The Centers for Medicare and Medicaid Services (CMS) has also bought into the importance of addressing social determinants and is pushing the industry in that direction in the form of a new way to payment model that was introduced last year. The new payment model will be implemented in 2020 and specifically impact Medicare Advantage (MA) plans. MA plans are private health insurance plans that those eligible for Medicare can purchase. These plans provide Medicare beneficiaries additional benefits beyond traditional Medicare, such as dental and vision coverage and, starting in 2020, social care benefits as well. The reason why this is so significant is because of the huge and growing number of Medicare Advantage beneficiaries. While Medicare Advantage already had over 20 million enrolled members in 2018, there appears to be a strong growth trend that indicates this number could grow much higher. Between 2017 and 2018 alone, 1.5 million new members signed up, a growth of eight percent from the previous year.

When CMS starts to pay for social care, there is suddenly a much larger pool of people whose health plans have a specific interest in ensuring their members get these services—and those health plans are likely going to turn to CBOs to help provide those services. This is a great opportunity for health plans and CBOs to work together to improve the health and social care landscape.

Working Together

The idea of healthcare organizations and CBOs working together is not a new one. In a study from December 2017, Scripps Gerontology Center surveyed almost 600 CBOs and found that just over a third of them already had contractual relationships with healthcare entities, with the two most common entity types being Medicaid managed care organizations (MCOs) at 35% and hospitals/hospital systems at 28%.

However, this was before the new CMS social care reimbursement model for Medicare Advantage plans was released. With the new social care payment model being rolled out in 2020, there is an entirely new and very large group of people (over 20 million) whose health plans have specific financial incentives to connect them to certain social care services. CMS, in line with its new payment model incentivizing social care, is also encouraging tighter integration between health plans and CBOs. CMS recognizes that these services aren’t normally provided by health plans and so, as outlined in their recent announcement, is pushing Medicare Advantage plans and CBOs to become more closely connected by encouraging the following:

  • Plans can contract with CBOs to provide new “social care” supplemental benefits CMS will be reimbursing for; and
  • CBOs can help the plan determine if a member meets eligibility requirements for supplemental benefits.

No Longer an Afterthought

CBOs, rather than an afterthought, suddenly become major players in this new reimbursement model. Because reimbursement models are driven by better health outcomes (which are tied to getting better social care) and because CMS will be paying for certain types of supplemental social care benefits, plans become more inclined to ensure their patients are screened and receive these services.

Of course, this transition will not happen overnight. Because this move for health plans to arrange social care is so new and complex, it’s likely that they won’t dive into the deep end right away, but will instead start by dipping their toes in the water. They will likely lean on existing partnerships and will establish new ones gradually. The perspective of the CBOs cannot be lost in this transition as well. There are larger questions around what role CBOs want to play in this healthcare game and about who is going to do the work.

Who Does the Work?

As CMS, health insurers, and healthcare providers begin to navigate this new territory of having to refer to and help arrange social care, many questions start to arise around who does the work.

Who will be responsible for…

  • Identifying patients’ social needs?
  • Connecting patients to the appropriate services and ensuring those needs are fulfilled?
  • Communicating about the end result to invested/interested parties (i.e., doctors, care managers, other social service providers, care givers, health plans)?

No one industry or organization can do it all. The siloed models of the past will not work and so an entire network of players is going to have to come together.

While in theory this reimagining of the health and social scare landscapes sounds great, there are concerns about how to make this work on the ground. The Blue Cross Blue Shield Foundation of Massachusetts recently published a report on how CBOs are responding to the healthcare market moving into the social care space in Massachusetts. For so long, we’ve heard about this new focus on social determinants from a healthcare perspective so this study is a welcome opportunity to hear from CBOs about the industry transition.

In the study, CBOs definitely recognize the benefits of being more closely connected to healthcare organizations—more financial incentives, financial risk moving to health care organizations (spurring more interest in care coordination), better access to financial and political resources, better policy. However, CBOs also have a number of concerns, including the potential of quickly running out of capacity due to new higher-volume sources of referrals (health plans and healthcare organizations), the focus away from their original missions in their attempt to partner with healthcare organizations, the inability to have strong negotiating powers at the table with large, well-funded healthcare organizations, and the larger impact on the entire social care system.

Looking Forward

In order to efficiently and effectively coordinate, offer, and provide the social care so many people desperately need, healthcare entities and CBOs are going to need to come together and have conversations about how to make this work on the ground. Financial incentives are finally aligning, which means there will likely be more formal contracted relationships. However, the conversation cannot end there. These incentives are only the beginning of a challenging but exciting opportunity to change the health and social care landscapes.

Given the number of people who are in need of this help, and given the major differences in how healthcare entities and CBOs operate and think about these problems, they are going to need to think carefully about how to design a system that can truly make larger impacts on the health and quality of life of the people that they serve. It’s exciting to see these two worlds come together and start these discussions and it’s especially encouraging to see the impact these types of partnerships are going to have on those patients and community members that really need the help.