Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep200: Who reaches Medicaid patients before they lose coverage? with Colby Takeda of Pear Suite
Transcript
- Speaker 1 0:00 And I think that's one of the key things around community health workers is you know they've been doing work for free for decades, and this is kind of the first time with reimbursement where they're actually able to get compensated for their time and energy and and and value that they're bringing to the healthcare system. And to all of a sudden take that away and and assume that people would just do this for free because that's part of their you know job description or part of their mission is you know somewhat misguided. Speaker 2 0:25 Welcome to Off the Chart, a business and medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Luttrell. I'm the associate editor of Medical Economics, and I'd like to thank you for joining us today. In today's episode, I sat down with Colby Taketa, co-founder and CEO of Parasuite, a company that helps community health workers sign contracts with health plans and get paid for their work. Starting January 1st, 2027, most adults who got Medicaid through expansion will have to prove that they're working in school or doing community service in order to keep their coverage. And some states and health plans are turning to community health workers to help reach them. In today's episode, we talk about what those workers can and can't do, whether that outreach actually gets paid, how a small practice can partner with them, and what physicians should be asking their state and health plans before January. And a quick note before we get started: if you want practical help with collections, patient payments, and your own long-term finances, join us for the Medical Economics Practice Academy Beneath the Surface: Efficiency, Revenue, and Burnout on Thursday, november 19, from one to 4pm. Eastern. It's a free virtual event, and you'll find a link to register in the show notes. With that said, Colby, thank you for joining us. So now let's get into the episode. Colby Taketa, thank you so much for joining me today. Speaker 1 1:49 Happy to be here. Speaker 2 1:50 I guess just to get started, would you mind introducing yourself and telling me a bit about Parasuite, what the company does, and how it got started? Speaker 1 1:56 Yeah, absolutely. Yeah, really proud of what we've done at Parasuite. I originally was in the public health field and was doing work during COVID and recognized there's a big need and and gap in the infrastructure for community-based organizations working on the social determinants of health. And think about a church, a nonprofit, a community-based group going to homeless shelters, even groups like libraries and and community centers were doing work around food and housing and transportation, and there's just a big need. I mean, a lot of these groups were working on paper and spreadsheets, or not even documenting their data around who they're helping, what their needs are, and how they can help them navigate to resources. And so we thought, let's just build something that's for them. You know, built by community health workers for community health workers. We decided to start with documentation systems, but quickly realized that they really needed more. They needed building support. They needed support getting contracts with health plans. They needed help with compliance working in the healthcare system. This is the first time that many of these groups have ever interacted with health plans and health systems. So we ended up building what we call the backend infrastructure for community-based care, everything from documentation around a member's needs to helping document care good plans and and helping individuals navigate the social resources as well as getting connected to the healthcare system. So how do we find a provider? All that can be documented in our system. And what's great about Parasuite is it also aligns with billing and and that that new codes that have come out, and so Paris we recognize a big gap in the the ability for these community-based providers to get paid and compensated for their work. Since 2021, there have been new codes in new states that allow community health workers and other community-based providers to get reimbursed for their services. And of course, you can't do that without submitting a claim, and so we basically help organizations document the good work they're doing every day, submit it as claims, and get them compensated so they can sustain this work and expand their impact. Speaker 2 3:50 For for physicians who might not be familiar with community health workers, could you kind of explain both how you yourself got into that work, and then what that looks like day to day for someone who's really never seen one in the field? Speaker 1 4:02 Yeah, absolutely. You know more about myself. I was actually working in the senior industry and the aging space, so helping seniors navigate the end of life and and challenges around getting older, getting therapy, experiencing different cognitive decline. And it was interesting because in our setting it was all about how do we help them live their best life as independently as possible. Of course, that involves things like food and housing, getting social engagement to reduce isolation and loneliness, being able to transport yourself to physical or medical facilities and other spaces like your church or your community center, so we kind of really wrapped around an entire what we call whole person care side of of these individuals and older adults. That actually led me to doing more work in the community health space with community health workers, and just you know identifying that there was a big gap in this this work. What was fascinating is that every time I would. Connect with a physician or a clinician, and tell them what I was doing in the space around food and housing. You know, it sometimes took a little while for them to recognize that there's these people, individuals, what we call community health workers, that are doing this work, and they've been doing it for decades. It's not a new provider type. It's these are individuals that are have lived experience, who have an understanding of community resources, who can really build trust with individuals that are experiencing challenges around housing and food and transportation, and are really really good at solving those problems. These sometimes might go by different names. So these individuals, some cases are called care coordinators. Other times they're advocates. In the Hispanic Latino community, they're called promotores, and so despite you know them being around for decades, there hasn't been much integration between these community-based providers and clinicians, which is kind of you know why we exist now. Is we want to bridge those gaps and allow for clinicians to partner alongside community-based workers, community health workers, and make it easier for them to send referrals to individuals to help them fill out SNAP benefits, or help them get housing through through filling out you know Section Eight housing applications, or help them navigate to transportation options for them to get to their provider in a reasonable time without having to skip appointments or end up in the ER. And so, community-based providers are kind of everywhere. Everywhere, we're meeting them every day, and of course, they've been doing this work for decades. and And this is the first time we're actually helping them get paid, but also helping them work alongside clinicians, sometimes in person in the clinic, but most times virtually or in people's homes. Speaker 2 6:36 So, I mean, yeah, coming up on on January 1, 2027, states have to start enforcing new Medicaid work requirements. A handful of states have started already. Could you talk about kind of what you're seeing in those states so far, and you know what you expect once the rest follow? Speaker 1 6:52 Yeah, it's been really exciting to see how much CHW is being leveraged for a lot of this work. You know, this is something they're really skilled with. You know, on a topic that's really sensitive, but so important to Medicaid members. Redetermination, you know, is going to be really challenging, and we're already seeing some challenges from states like Nebraska where they're already rolling this out. But I think there's a lot of opportunity to partner with trusted individuals, community health workers who have the knowledge and skills to kind of address these challenges. I think in some states we're seeing a lot of confusion. There's a lot of people getting involved in this work, right? The counties, the states, the Medicaid offices, health plans, health plans are leveraging providers like clinicians to support with redetermination and work requirements reporting. So I think the big question first is like, what is the state's plan, right? Who's going to take lead? Is there timeline? Is there is there multiple layers where the state goes first? They send out their letters. The letter has to be, you know, addressed by the family. If not, the health plan will step in and send out their own reminders. And they may be using their own system, like texts or email or or phone calls or even some AI tools. And so, I think understanding what a state or health plan strategy is in addressing work requirements reporting or other kind of retermination reporting is, and then what the role of community health workers could be, right? Are they supplementing the in-house health plan staff? Are they coming in after and and calling and following up with anyone who hasn't responded to initial attempts by the health plan or the city or the county to to make you know redetermination possible and easy. So I think it's it's been growing great. We've been in quite a few conversations with health plans to help to coordinate the role of community health workers, and some of them are taking a really big role in in doing outreach. Sometimes even before the health plan does it. And so just that awareness, the fact that they already have these relationships, has been so helpful for health plans to know that they can be a trusted partner in the redetermination process. Speaker 2 8:45 Yeah, and you kind of talked about that that communication there. You've argued in the past that people will lose coverage as part of HR one here, not because they're ineligible, but because they you know maybe are unaware. No one's reached out to them in time. Where exactly does that break down, and who does that fall on? Speaker 1 9:02 Yeah, I think there's. I mean, you know, just like with other past experiences with the COVID pandemic and vaccinations. I mean, I think I think trusted information sources is so critical, right? Who are you getting information from, and and and what are those sources, and and how do we follow through with them? I think it's one thing to kind of get information, you know, whether it's in paper or by phone or email or in text, but being able to follow through with it and actually complete whatever task is being asked of is is another thing. I think a lot of individuals that we work with, a lot of Medicaid members, will be challenged by some of the steps and applications or online portals that they have to navigate to actually complete the the process and keeping their coverage. I think we're we're worried about people who, for some, English is not their first language, right? Others who maybe have some challenges with tech literacy and not be able to log on to the online portals that health plans or states are requiring them to upload their documentation to. Others are just. Are afraid of other, you know, things right now, whether it be, you know, enforcement of ICE or other challenges with the the healthcare system or economy right now. That's that's creating some barriers for these individuals to access care or access resources. And I think at a time when when other things are happening, giving them information or sharing information about themselves could be a risk, and and I think they're they're fearful of that. So I think trust is so critical, and I think that's again where CHWs can really step in. I mean, they are trusted local individuals who have been doing this work for decades. They might be your your your fellow church members or your neighbors or people that you see at the nearby community center. So I think being sure, ensuring that they have the right information and can be trusted messengers of the information is so critical in this time. Speaker 2 10:47 When a community health worker does sit down with somebody to help them gather pay stubs or fill out a form, is that reimbursed? Is that paid for by Medicaid? Speaker 1 10:55 Yeah, there actually are some differences in state policy regarding what is reimbursable or not, and I think every state, when they created policy regarding Medicaid reimbursement for CHW services, they may or may not have included language that would allow for something like redetermination to be. So I think every state is kind of navigating through either FAQs or webinars and educating existing providers of what is eligible or not. Some health plans have taken upon themselves to infer or interpret the documentation in policy around what is eligible or not, or they're finding other ways to compensate CHWs. And I think that's one of the key things around community health workers. Is you know they've been doing work for free for decades, and this is kind of the first time with reimbursement where they're actually able to get compensated for their time and energy and and and value that they're bringing to the healthcare system. And to all of a sudden take that away and and assume that people will just do this for free because that's part of their you know job description or part of their mission is you know somewhat misguided. So I think it's exciting to see you know CHWs being leveraged for this time, but to I definitely encourage you know states and health plans and other county officials and public agencies to really consider like what is the value that health plans are can can get from these community health workers and how do we make sure we compensate them and value them properly so we can really appreciate their time and and energy in this space. Physicians Practice 12:24 Hey there, Keith Reynolds here, and welcome to the P2 Management Minute. In just 60 seconds, we deliver proven, real-world tactics you can plug into your practice today. Whether that means speeding up check-in, lifting staff morale, or nudging patient satisfaction north, no theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch, but the best ideas don't all come from our newsroom. They come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to feature it. Shoot me an email at kreynolds@mjhlifesciences.com with your topic, a quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next P2 Management Minute. One Speaker 2 13:16 of the exemptions that's listed in HR1, as far as the new Medicaid work requirements is for people who are considered medically frail. Physicians expect that to be handed those forms. Do community health workers have a role in that, or is that entirely on, say, a primary care physician? Speaker 1 13:33 Yeah, I think this is a really key distinction between community health workers and other you know provider types. You know, community health workers are seen as non-clinical in their ability, so they they actually can't diagnose individuals. They can't prescribe anything, of course. They can't educate people on you know how to take our medications. And I think being sure that we keep those kind of guardrails and and swim lanes clear is is so critical. And in working with community health workers, in other times it can go the opposite way, where clinicians sometimes you know think CHWs are admin assistants or can do office work and you know staple papers and and hand out you know forms and and and sometimes they will do that. But I think we only make sure that we're always elevating you know people to the top of their license and in this case certification. If there is certification for CHWs, this has actually been one of the challenges to date too is every state has different requirements around the training and the backgrounds of CHWs to become you know approved to either bill for services or work with in in different settings or work with health plans or health systems. So I think until we can kind of get consensus around what that the standards are, it'll be tough to kind of nationalize this workforce in a way that other provider types have, but yeah, definitely want to be sure to keep CHWs kind of focused on social challenges and and social you know opportunities, resources, and finding ways to of course get them connected to different caregivers or care providers. One of the biggest things. We do with health plans is is just help people get to a PCP. If you Speaker 3 15:03 don't have a Speaker 1 15:04 PCP, a lot of things like case measures, screenings, vaccinations can happen. So, if anything else, we always encourage our CHWs to ensure that each Medicaid member has a PCP and knows how to get in touch with them and feels comfortable with them and can you know schedule an appointment. If we can ensure that, then you know that the likelihood of them engaging in preventative measures or getting care when they need it in ways that are you know not relying on emergency rooms and and other high utilized services is going to be quite well reduced. Speaker 2 15:37 And I guess kind of building on that communication, that collaboration between physicians and and community health workers, can a physician's office work with community health workers directly, or does that have to go through a health plan? And then, what would that take? I guess as far as a small independent practice trying to you know do that outreach and work with community health workers. Yeah, Speaker 1 15:58 because DHWs have only recently kind of been incorporated in many things, and I will say, you know, federally qualified health centers and some clinics have been using CHWs for quite a while, but it hasn't seen at the scale that we're seeing it now. But there are different models, right? Sometimes a clinic or a hospital system or other care setting will actually hire their own CHWs to work in house and be employed by the same entity. Other times, it's just not feasible, both financially, but also you know, takes the management team to hire and train and and supervise CHWs, and they rather partner with existing CHWs in the community. And so, first is you know, what's the setup and what's the makeup or what's the philosophy for how a provider wants to partner with or work with CHWs? Is it hire their own. Is it get contracted CHWs or partner with the existing organization that already has CHWs, but maybe more community based? Once you establish that that philosophy, you can figure out how do we operationalize this, right? How do we you know share data with them? How do we communicate with them? How do we make referrals to them? Is it directly through an organization, or is it through a hub? There's an exciting movement right now around community care hubs. The idea that maybe each individual organization doesn't have to have their own contract with the health plan or health system, but actually can work through one lead entity, and the lead entity can kind of serve as the matchmaker, right? They can receive referrals from a health system or health plan, and then pass it on to small organizations based on fit, right? Location, language, competencies, needs, priority populations. These are all ways in which you can prioritize the fit between a CHW being matched with an appropriate community member. But back to your question, you know, health plans can certainly refer, and and they've been utilizing CHWs to do things like closing PDS gaps or or addressing some you know gaps in care that might lead to higher utilization or or not getting people the preventative screenings and measures that they we know that will help to improve healthcare. But health plans aren't the only you know source. We're also seeing referrals from health systems, from EMS, from health departments, as well as from community-based settings as well. So you can see, imagine you know an individual going to the YMC and you know there to to get their diabetes prevention program. But if they have other challenges around housing, maybe the YMCA isn't fit to provide that navigation. They want to refer to a housing agency or housing group that can help them navigate a housing application. So yeah, referrals from all directions, and of course the data sharing gets really exciting and complicated at the same time because you have to figure out how to work across you know a documentation system that a health plan uses versus an EHR and a health system versus the state Medicaid program that the the public agency setting. Speaker 2 18:31 So going back to to Pear Suite, it says it's helped 3000 frontline workers contract with health plans. Could you kind of talk about the outcome data there, and you know what you're able to to show a health plan to justify the spend. Speaker 1 18:46 Yeah, it's been exciting. You know, I think before when we started this work, we were just providing software for these groups, and we quickly realized that give them great software isn't enough to make them successful. Right? If they can't get a contract with a health plan, if they can't get credential with Medicaid office. If they can't understand compliance and meet the audits, they're going to lose their contract immediately if they can even get one to begin with. And so we've since you know expanded kind of our scope and and do a lot of ongoing support for CHWs to ensure they can one start working with a health plan and be successful in getting paid, but also make sure that their work aligns with what the health plan wants. And a lot of that is tied to quality. It's tied to compliance because of that. And we've actually taken on a role beyond just being a software technology provider. You know, health plans look to Pearstreet to be really the guide and the coach to ensure high quality and do QA and do audits so that anyone who's operating under our NPI meets those standards, right? Because essentially we're responsible. We have the contract with the health plan. We're responsible for the members' care, and therefore we have to ensure that anyone under our contracts or subcontractors are meeting these requirements. So we are really taking on a lot of that risk. But it also gave us an opportunity to dive in and help these providers become better, help them become more efficient with their time, help them make more money, help them. Ensure quality outcomes tied to things that the health plan cares about. We're seeing about 78% engagement across the board with CHWs working with the member to help them close their care gaps and helping them address needs around food, housing, transportation. So their willingness to actually complete tasks like enrolling in SNAP or getting their their vaccinations completed, or getting their annual wellness visits completed. One health plan recently reported to us that they're seeing when a CHW works with their members, they're three times more likely to see their PCP within six months. So just like day like that is really valuable. It doesn't just result in fluffiness; it actually results in ROI and and and cost savings as well as increased revenue for these health plans, and so I think we want to make sure we tie all of their work to things that the health plan cares about, which was a big challenge, right? A lot of these health plans, you know, they speak a certain language that community-based organizations haven't understood to date. They haven't had to deal with you know everything from NPIs or Z codes or you know CPT codes, and so helping to translate that for these different two different groups has been one of our our big assets, and and how we help support these community-based providers. Speaker 2 21:09 Excellent. What should a primary care physician be doing between now and and January? Speaker 1 21:15 Yeah, I think understanding you know what their local market's strategy is for helping to keep Medicaid members enrolled and vet their benefits, understanding what the county or the state is doing because everyone's going to have a process. I think a lot of states are already listing out their process online or documenting timeline. I think because enrollment is going to start or the timeline starts in January, a lot of groups or a lot of states are sending out documentation in September, October to kind of get ready for that timeline, but also realizing that there might be groups on the ground, resources, community-based organizations that could be a great source of information, and also technical support when it comes to helping someone fill out these forms or get their work requirements in, or even finding work to begin with. Right, a lot of community-based organizations offer volunteer opportunities or offer training in a form that can help meet the requirements that is needed to one both get the education you know requirement checked off or actually finding a job to begin with. So I would definitely encourage you know these physicians and clinics and and different practices to reach out to the state and their health plan to understand what their strategy is and then understand what local providers like community health workers could could do to to assist. Speaker 2 22:23 Is there anything that I didn't ask you about that you think is important for for physicians or for the audience to keep in mind? Speaker 1 22:29 Yeah, I just really encourage everyone to look into community health workers, and there's probably already a lot of community health workers already in your area. You know, these groups go by different names, like I mentioned, but they're so valuable and they're so essential to building that trust and closing key care gaps. They can really be a great partner for clinics and practices. I think we're seeing such great results from CHWs when they're empowered and uplifted and valued. And so I just encourage them to you know thank them for what they do, but also finding ways to work with them. I think is always solutions at play, and certainly if we can help, I'll be happy to as well. Speaker 2 23:01 Great. Well, Colby, thank you again. This is you know great work you're doing. Congratulations with your on your success with Pear Suite, and thank you for taking the time today. Speaker 1 23:10 Yeah, appreciate it. Thanks so much. Speaker 2 23:20 Once again, that was a conversation I had with Colpita, co-founder and CEO of Parasui. And a quick reminder: the Medical Economics Practice Academy is coming up on Thursday, november 19, from one to 4pm. Eastern. It's free and virtual, and the registration link is in the show notes below. With that said, my name is Austin Luttrell, and on behalf of the whole Medical Economics and Physicians Practice teams, I'd like to thank you for listening to the show and ask that you subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing strategies, stories, and solutions for your practice. And you can find us by searching off the chart wherever you get your podcasts. Also, if you'd like the best stories that Medical Economics and Physicians Practice publish, delivered straight to your email six days of the week, subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. Off the chart, a business of medicine podcast is executive produced by Chris Mazzolini and Keith Reynolds, and produced by Austin Latrell. Medical Economics and Physicians Practice are both members of the MJH Life Sciences family. Thank you.