What Does It Take To Be a Successful, Reimbursable Health Promotion Program?

Building relationships with state Medicaid agencies and local health plans is essential for sharing the value of evidence-based health promotion and disease prevention programs and obtaining reimbursement for those efforts, according to a new report from the National Council on Aging.

The council, with support from the Administration for Community Living, contracted with Health Management Associates to develop the report, titled “Reimbursement for Evidence-Based Health Promotion Programs in the Community.”

The report is based on a extensive literature review and interviews with many stakeholders.

from state Medicaid and state and city aging agencies officials. The goal, it says, was to identify “promising practices establishing reimbursable, evidence-based health promotion programs and approaches that may be replicated in other states in Medicaid, Medicare Advantage and other emerging markets to support program sustainability beyond grant funding.”

One of the report’s principal findings is the importance of “ongoing, regular communication” with state agencies about evidence-based programs and the improved health outcomes they can achieve.

The report also recommending building relationships through statewide networks of community-based organizations that have experience with Medicaid and Medicare Advantage health plan contracting. “These entities provide business function support including marketing, negotiating contracts, executing required paperwork, delivery system development and management, and complying with health care privacy laws,” the report says. Some of the networks named in the report include the Partners in Care Foundation in San Fernando, California; The Healthy Living Center of Excellence in Lawrence, Massachusetts; and The CommunityCare Linkprogram in New York

Community-based organizations should position themselves as community partners that can identify the most suitable evidence-based programs, based on community needs, the report says. “It is important for CBOs (community-based organizations) to demonstrate their essential knowledge of local geographies, communities, and residents to health plan and system partners."

Community-based organizations that entered into contractual relationships with health plans often benefited from using grant funding to build out the organization’s capacity and infrastructure, the report notes.

The New York City Department of Health obtained grant funding from the state of New York to develop a model contract for health plans and community-based organizations. The model is designed to support contracting with Medicaid, Medicare Advantage and commercial health plans.

Community-based organizations will also benefit from establishing reimbursement relationships with multiple payers to diversify business and funding streams. “CBOs with a single payer source may experience disruption in referrals and business due to discontinuance of health plan and/or program coverage of services,” the report says.