Traditional social service providers, whether they partner with Managed Care Organizations (MCOs) or not, will experience substantial changes in their direct service and funding relationships. For some, such changes will mean the actual elimination of their role in such services. Other human services entities, particularly those in behavioral health or case management services, will experience the shift of government grants and contracts to new payers – MCOs – to enhance Medicaid match, ensure coordination across a medical continuum, and streamline efficiencies in information technology and administration. The question is how can traditional social service providers not just survive, but thrive, in the convergence of healthcare and social services?
New Medicaid managed care systems in states with high in-patient Medicaid dollars, such as Illinois, will require healthcare systems to operate within in a more holistic perspective that addresses the multiple social determinant needs of vulnerable populations. Sometimes called Community-Based Organizations (CBOs), traditional social services entities provide something that few health systems understand yet is critical to the Patient Centered Medical Home model (PCMH) – how to engage and assist the most vulnerable of clients with multiple needs to make behavioral changes with their lives.
While the holistic view of the healthcare changes allows for this new convergence, there is a significant challenge in this population health strategy. Healthcare and traditional CBOs have not traditionally worked together in integrated business models. One comes from a medical model that focuses on episodic and acute issues while the other focuses on a social work framework with the whole person in mind. Even the language of describing clients differs. Patients who don’t follow through on medical recommendations and prescriptions are deemed “non-compliant.” In the social work world, such clients are viewed as having not created an effective helping relationship with professionals and need support for motivation. Essentially, various engagement strategies that are person-centered are tried until something works.
Even if social service agencies do not actively engage in Medicaid-funded Managed Care, they will be impacted by potential changes in payers and purchasing in the human services realm. As with any new business model, some type of new culture will emerge, typically one with the most leverage. As of now, larger health plans and systems have the edge for the following reasons:
- Administrative efficiencies, particularly around IT, benefit larger systems and interoperability.
- Medicaid expansion will require a “population health” perspective, thereby forcing health systems to pay attention and seek to understand, monitor, and influence social determinants in the community.
- Medicaid expansion will lead to a primary care physical shortage, thereby requiring more non-medical issues such as procedures, community coordination, follow-up, etc. to be directly handled by nurses, paraprofessionals, and care coordinators within healthcare settings.
- Community prevention programs typically managed within a human services environment will be likely shifted into a new medical model.
States with county based social services systems, such as in Wisconsin, are experiencing movement to merge social service functions and traditional public health activities, especially in rural areas. In urban areas with publicly financed hospitals, such health systems are building their own social services infrastructure. For example, Broward Memorial Hospital in Broward County, FL (population of 1.8 million), a health system funded by dedicated tax dollars, regularly competes with traditional services for local contracts on prevention programs such as Healthy Families and county-funded behavioral health dollars. Smaller agencies, despite their community-based perspectives and fund-raising prowess, are at a significant disadvantage.
In Illinois, providers of the state’s Family Care Management program—a program that serves pregnant women, infants, and children with high-risk medical conditions—have been put on notice by the Illinois Department of Human Services that such program competencies will be managed by MCOs in the future. And community-based paraprofessionals, such as those doing community health worker activities, are typically being hired outright by MCOs. CBOs who have significant capacity and cultural competencies in deploying similar types of activities in cost effective manners are not being actively engaged as business partners to provide such services.
New Business Strategies for CBOs
Compared to the size and scope of healthcare, how can CBOs have any leverage in a new business relationship with healthcare? The answer comes in relentlessly articulating their competencies within a new framework. Marketing should establish business development strategies in areas that CBOs typically have a hard time talking about – reducing costs and creating shared savings. And the traditional language that CBOs use must also be reevaluated. The lingo around mission for CBOs must be augmented by a specific business value-proposition that supports the Triple Aim for MCOs of increased access, enhanced quality, and reduced costs per patient over time.
Without articulately how their competencies can be redirected in supporting the overall goals of health plans, CBOs risk being perceived as charitable organizations that have minimal added value in the new health convergence with social services.
authored by Gregory J. Kurth, Founder + CEO of Social Wealth Strategies, a consulting practice for social services and community-based organizations.