Community Based Organizations and the Value They Bring to Health Plans [Interview]

A Passionate Advocate for Real Improvements in Health Outcomes

Pamela Mokler, MSG, President at Pamela Mokler & Associates, Inc. is a dynamic Gerontologist, healthcare consultant, and former managed care executive. With approximately 20 years of experience launching and executing innovative programs, she has always been committed to integrating the fragmented systems of care. Above all, she has been committed to improving the lives of the elderly, those with disabilities, the institutionalized, and the homeless. 

In early 2019, Pamela Mokler sat on a panel at IEN’s Medicare Advantage Product Design & Management Event in California. The discussion centered around strategies to identify health-related benefits that deliver ROI for health plans. Included in this discussion was an in depth look at the benefits community partnerships can bring to health plans. IEN interviewed Pamela for more insight on community partnerships and their value to health plans addressing Social determinants of health in their member populations. 

Addressing Social Determinants of Health through Community Partnerships

Traditionally, managed health plans have predominantly operated in the medical space. They have been instructed, by the Centers for Medicare and Medicaid Services (CMS), that whatever they do for their members has to be because of a medical necessity.

However, the healthcare industry is beginning to realize that the primary drivers of health outcomes are the socioeconomic and environmental factors affecting how people live and work: social determinants of health (SDOH). Social determinants of health really drive healthcare costs and outcomes. The current healthcare system does not meet the needs of older adults and disadvantaged individuals; this is primarly because these exterior factors have not been considered. As a result, care often remains uncoordinated and fragmented for the individuals who need it most.

Fortunately, the health care system is moving away from paying care providers based on visits or services. Now, the system is moving toward paying care providers based on health outcomes. Addressing SDOH through partnerships with community providers can greatly improve those outcomes.

A Closer Look at Community Partnerships: Benefits and Challenges of Partnering with Community-Based Organizations

After Pamela’s dynamic discussion at IEN’s event in September 2019, she agreed to meet with IEN a second time to further discuss the topic. Below, Pamela elaborates on the complexities and challenges of working with community-based organizations. Most importantly, she explains how the lives of members can be improved dramatically by the healthcare system further incorporating these partnerships.

Can you define community partnerships and some examples of the services they provide?

There are amazing community providers in the aging, disability, and affordable senior housing networks. Most entities that provide these non-clinical social services are local public or private non-profit organizations – commonly referred to as community-based organizations (CBOs). In addition to focusing on individuals, CBOs also generate improvements to meet community needs at the local level. They work to increase the availability of services and programs in these communities.

While CMS funds healthcare for the elderly, disabled, and economically challenged, funding for CBOs has historically been a patchwork of different sources. CBOs typically get funding from government agencies, grant funding from foundations, fundraisers, etc.. As a result, we have an extremely fragmented system of organizations. This fragmented system is attempting to improve health outcomes via social/community improvements. Healthcare, mental health services, social services, Long Term Services and Supports (LTSS), long term care services, and affordable housing are all operating in separate silos. There has been little communication and data sharing between these silos. Consequently, it has been very challenging for healthcare providers to directly improve health outcomes by addressing SDOH via CBOs.

Despite the challenges, partnerships with these CBOs have existed in larger health plan organizations for some time. Larger health plans have community benefit programs that have existed separately from their medical programs.

CBOs can help medical providers understand an individual’s care preferences. For example, I formerly served as a VP of LTSS for a Californian health plan. We launched a partnership with the Long-Term Care Ombudsman Program (LTCOP). The goal of the partnership was to jointly visit institutionalized health plan members. LTC Ombudsman are public advocates for institutionalized individuals. They helped us identify which members were willing and able to transition into the community and ensure residents’ wishes were being honored. Normally, the LTCOP operated separately from health care payers.

Can you define person directed care? Also, can you explain how the benefits provided by community partnerships can be a valuable asset to person directed care?

“Person-directed care” is a philosophy that encourages individuals and their caregivers to express choice, preferences, and practice self-determination in meaningful ways at every level of daily life. Values that are essential to this philosophy include: choice, dignity, respect, self-determination and purposeful living

The goal of patient-centered health care is to empower patients to become active participants in their care. This requires that physicians and other health care providers develop good communication skills and address patient needs effectively. Partnerships with CBOs can be a very valuable asset to help providers meet their patients’ needs.

How is the industry utilizing community partnerships to provide more holistic care?

Broad changes are beginning to take shape in the healthcare space. Payers of healthcare are incorporating SDOH into their thinking when reimbursing for healthcare services. Also, they are beginning to incorporate SDOH when providing incentives to healthcare providers. With SDOH properly incorporated into these incentives, the healthcare providers will be more motivated to properly address patients’ social needs and improve their health outcomes.

In addition to these changes, CMS has begun allowing Medicare Advantage plans to pay for supplemental benefits; these benefits are primarily social in nature and directly impact a member’s health conditions. Many CBOs offer these supplemental benefits.

Also, states are increasingly shifting long-term care risk to Medicaid managed health plans. As a result, this requires them to partner and contract with CBOs to ensure access to services that allow older adults and individuals with disabilities to continue living independently in their communities.

It is so exciting that CMS and many states have begun to recognize the importance of these partnerships and the benefits of bringing these silos together. Health plans can now partner and contract with these community providers rather than trying to reinvent the wheel and figure out how to provide these services themselves.

Can you describe some of the challenges that Health Plans can face when working with community partners?

Many CBOs work to promote sustained health, prevent disease, and address health disparities. However, many CBOs lack the capacity to plan, implement, and evaluate their efforts. This greatly limits the degree to which the effectiveness of interventions can be measured. Increased accountability by funding organizations and an increased emphasis on evidence-based interventions have heightened the importance of CBOs’ intervention capacity. For example, systematic data reporting has become critical to continued program funding. Furthermore, prevention programs are increasingly dependent upon a seamless loop of fiscal support and an organization’s ability to provide evidence of success and lessons learned.

As a result of this and other factors, not all CBOs have the desire or capacity to contract with health plans. Most lack knowledge of clinical processes, quality requirements, and other reporting requirements, claims processes, etc. Also, most CBOs are unable to get credential and clinically-focused contracts need to be revised with language that focuses on social services rather than clinical interventions.

However, several foundations and associations are helping CBOs develop the capacity to contract with health plans to provide an integrated approach to care management. Many health plans, especially those that have been at-risk for long term care institutionalization, have begun contracting with CBOs. It may take some hand-holding to get these organizations up-to-speed with health plan requirements. However, the extra effort is worth it to ensure individuals have access to critically needed social services and support. These partnerships can increase access to medical, physical, behavioral, mental health, and community-based social programs and services. These services will allow individuals to receive the right care at the right time and in the right place.

A Major Step Toward Improving the Health of Our Communities

Partnerships between health plans, health systems, and CBOs increase the ability of physicians, nurses, social workers, community health workers and others to access community-based programs and services that will positively impact health care outcomes and the total cost of care. These partnerships are essential if we want to address the effects that SDOH have on the health of our communities.

Pamela earned a Master of Science degree in Gerontology from California State University Long Beach in 1997. She was honored as a Distinguished Alumna in 2003. Pam served as Executive Director of an Area Agency on Aging, as Founder and President of an affordable housing services company, and over 15 years as an executive and consultant to managed health plans throughout the country. As of 2020, Pam is actively working with several start-ups and a healthcare tech company to facilitate contracts with managed health plans. She recently conducted a Post-Acute Strategic Assessment & Plan for a large healthcare system. She helped lease a Recuperative Care/Medical Respite facility to health plans in Los Angeles county. This facility is giving health plan members experiencing homelessness a place to recover following hospitalizations and nursing home stays.

Looking for essential new information on evolving CMS models?

IEN will be hosting the 2nd Annual Medicare Advantage Product Design & Management in February 2020 in Atlanta, GA. Learn from experts as they share insight on CMS models, incorporating SDoH, enhancing bids, and more.

See Topics & Speakers for the upcoming MA Product Design conference

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