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Evidence-Based Programs Paper Authored by HMA Colleagues

Health Management Associates (HMA), in contract with The National Council on Aging (NCOA), and with support from the Administration for Community Living (ACL), recently provided research and strategy services to support the goal to increase the adoption of evidence-based health promotion and disease prevention programs, known as evidence-based programs (EBPs) by Medicaid, Medicare, and other health insurance markets.

EBPs include Chronic Disease Self-Management Education (CDSME) programs and falls prevention programs. HMA colleagues Principal Sarah Barth, JD and Research Assistant Sarina Coates-Golden, BA, drafted the paper, Reimbursement for Evidence-Based Health Promotion Programs in the Community – Strategies and Approaches to Medicaid and Medicare Advantage Coverage, which identifies:

  • Medicaid authorities and financing mechanisms through which states have adopted evidence-based health promotion programs
  • Promising practices establishing reimbursable EBP 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
  • Barriers to adoption of evidence-based health promotion programs and actionable steps to avoid or address
  • Actionable information to move forward relationships with state Medicaid programs or Medicaid managed care organizations.

Five target states and one city were selected for examination based on publicly financed programs, Medicaid and/or Medicare, and adoption of EBPs as a reimbursable service. Those selected were California, Colorado, Maine, Massachusetts, Washington and New York City.

Report findings and common themes include:

  • Building relationships with state Medicaid programs and agencies on aging is important to sharing the value of EBPs for incorporation as a Medicaid reimbursable service.
  • Building partner relationships with health plans at the local level is essential to advancing discussions about contracts to provide EBPs funded by Medicaid and/or Medicare.
  • Community based organizations (CBOs) that entered into contractual relationships with health plans often benefited from efforts using grant funding to build out CBO capacity and infrastructure to ready the organization to engage in business relationships with other health care entities.
  • Establishment of reimbursable EBP programs beyond grant funding is often supported by a CBO network that brings together CBOs under one umbrella and provides business acumen and support.
  • Focused efforts that demonstrate, identify and clearly communicate the return on investment (ROI) to health plan partners are key to reimbursement.
  • Health plans are looking for value-based payment (VBP) relationships and CBOs’ ability to take on risk.
  • CBOs can benefit from establishing reimbursement relationships with multiple payers to diversify business and funding streams.

The report made recommendations and outlined next steps for moving forward with reimbursable relationships with public and private payers. View the full entire report.