Enhancing the role of community health workers (CHWs) and integrating them into primary care teams is one important way to expand patients’ access to primary care, improve patient health outcomes, reduce strain across the care team, and enhance equity for CHWs themselves through career advancement. NYHealth submitted the following public comments in support of a proposed federal rule to provide Medicare reimbursement for CHWs:
September 11, 2023
The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1784-P
P.O. Box 8016
Baltimore, MD 21244-1850
RE: File Code CMS-1784-P; Medicare Program; CY 2024 Payment Policies under the Physician Payment Schedule and Other Changes to Part B Payment and Coverage Policies
Dear Administrator Brooks-LaSure:
The New York Health Foundation (NYHealth) appreciates the opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) on the Notice of Proposed Rulemaking regarding the Medicare Physician Fee Schedule for Calendar Year 2024, namely the creation of a Community Health Integration (CHI) service to be conducted by Community Health Workers (CHWs) and other “auxiliary professionals.”
NYHealth is a private, independent, statewide foundation dedicated to improving the health of all New Yorkers, especially people of color and others who have been historically marginalized. NYHealth has long supported efforts to strengthen the CHW workforce across New York State and enable CHWs—trusted members of communities uniquely equipped to form relationships with patients—to contribute to improved patient care and outcomes. NYHealth previously supported approximately 40 organizations representing CHWs, health care providers, community-based organizations, payers, and policymakers to develop recommendations regarding CHW employment, training, and financing in New York State. An ensuing report, “Paving a Path to Advance the Community Health Worker Workforce in New York State,” includes especially relevant recommendations about CHW training and a standardized scope of practice.
NYHealth is now focused on enhancing the role of CHWs and integrating them into primary care teams. Doing so is one important way to expand patients’ access to primary care, improve patient health outcomes, reduce strain across the care team, and enhance equity for CHWs themselves through career advancement.
Through this proposed rule, CMS will leverage its role as the largest health care payer in the country to expand access to services provided by CHWs and to drive innovation by other payers. In New York, a recently CMS-approved State Plan Amendment will also support new CHW services for pregnant and postpartum Medicaid beneficiaries. CMS’s proposed Medicare benefit will be a critical, complementary source of support for other CHW services.
We commend CMS for proposing to establish a Medicare benefit that will allow providers to code and bill for CHI services provided by CHWs—an important first for Medicare beneficiaries. We support these especially noteworthy provisions:
- CHWs employed by both health care providers and community-based organizations (CBOs) would be eligible to provide CHI services. This expansive eligibility will allow providers and partner CBOs to integrate CHWs into care teams in ways most aligned with their organizations’ needs, resources, and constraints. We applaud CMS’s requirement that providers and CBOs have “sufficient clinical integration” to allow them to coordinate these CHI services. In our experience, partners have been most successful when they have sufficient data-sharing and routine communication to promote effective collaboration. We encourage CMS to consider marshalling its resources to build the IT and related capacity needed for CBOs to integrate with providers.
- CMS has defined new billing codes that are applicable to federally qualified health centers (FQHCs) and rural health centers (RHCs). Our partners in New York State confirm that existing definitions of care management for FQHCs and RHCs do not fully encompass the range of CHI services; the new benefit will help fill this gap.
- CHWs can provide these services under the general, rather than direct, supervision of a billing practitioner. This model of supervision will afford CHWs the flexibility to provide patient support in clinical, community, and home-based settings and mitigate against increased administrative burden on billing practitioners.
We offer the following recommendations for CMS to consider as it finalizes and implements this benefit:
- We encourage CMS to consider expanding the eligibility for CHI initiating visits to include annual wellness visits and emergency department visits. It is in these types of visits where patients often reveal their barriers to care, challenges, and social needs—precisely the clinical encounters where initiating CHI would be most valuable.
- Include telehealth services as a modality for CHI service delivery, in addition to in-person services. Allowing for CHI to be delivered in a hybrid format, including by telehealth, will benefit patients who face barriers to in-person care. Telehealth also enables CHWs to leverage technology to expand their reach in the face of workforce strains. The inclusion of audio-only, in addition to audio-video, services will ensure that virtual care is accessible to and equitable for marginalized patients. The New York City Health and Hospitals Corporation, the largest public hospital system in the country, found that three-quarters of telehealth visits in its primary care settings were scheduled as audio-only visits. Patients who were Medicare or Medicaid beneficiaries, Black or Hispanic, or spoke a language other than English were more likely to use audio-only visits [1]
- Further consider if CMS can waive cost-sharing requirements for CHI services as an additional preventive service. If not, CMS should require patient consent to receive CHI services given the potential for cost-sharing requirements. While we appreciate that CMS is attempting to remove administrative barriers, enabling patients to make informed decisions about their care must remain a central tenet.
- Consult with CHWs and providers as decisions are finalized on service length of time, frequency limits, duration, and required training for CHWs. The experience of NYHealth partners has shown that it takes time—often for multiple hours, with many regular touchpoints, and over many months—for CHWs to earn the trust of patients and to address the multiple challenges they uncover when providing support services. CHWs should be equipped with the knowledge, skills, and defined core competencies to provide high-quality patient support. At the same time, we recognize that CHWs with longstanding professional experience and no formal training may already be capable of providing high-quality patient support. CMS should ensure that training requirements do not pose practical and financial barriers to CHWs. As CMS considers the question of training—whether formal or informal—it should work directly with CHWs to define requirements and to develop the content and delivery modes for training.
We commend CMS for its leadership in uplifting the potential of CHWs to improve health outcomes and equity with a reliable source of payment. We thank you for the opportunity to provide comments on these proposed regulations. If you have additional questions, please reach out to Ali Foti, Program Officer, at foti@nyhealthfoundation.org or (212) 584-5659.
Sincerely,
David Sandman, Ph.D.
President and CEO
New York Health Foundation
[1] Chen, K.; Zhang, C.; Gurley, A.; Akkem, S.; Jackson, H. (2023). Patient Characteristics Associated with Telehealth Scheduling and Completion in Primary Care at a Large, Urban Public Healthcare System. Journal of Urban Health, 100(3), 468-477. doi: 10.1007/s11524-023-00744-9.
