Massachusetts Community-Based Organization Perspectives on Medicaid Redesign

Abstract

Introduction:

The purpose of the study is to investigate how community-based organizations perceive Medicaid policy changes to address the social determinants of health.

Methods:

This study included 46 key informant interviews, representing 44 community-based organizations across Massachusetts conducted from September 2017 to March 2018. The interviews were designed to collect community-based organizations’ perceptions of Medicaid policy changes. An Advisory Board was empaneled for feedback on data collection and analysis. Massachusetts was chosen as a study site in light of explicit policy efforts to incentivize healthcare organizations to take a more active role in social determinants of health, most notably through the creation of Medicaid Accountable Care Organizations.

Results:

The community-based organizations expressed optimism about future partnerships with healthcare organizations. This optimism existed alongside the recognition that healthcare organizations and community-based organizations can have conflicting agendas, including misaligned outcomes of interest and timelines. Community-based organizations struggled to define a clear strategy for partnership in the face of incomplete information about how the final Medicaid redesign would proceed and what healthcare providers would be looking for in a partner.

Conclusions:

Changes to Medicaid policy can catalyze interest in partnership between healthcare organizations and community-based organizations. To minimize the impact of conflicting agendas, policymakers and healthcare leadership should ensure community-based organizations are part of strategy development and social service program implementation.

INTRODUCTION

Healthcare organizations are recognizing the role that social and environmental factors play in the health and healthcare utilization of vulnerable populations.^1,2 Following population health–driven policy and value-based payment incentives, healthcare organizations are developing strategies to address these social determinants of health (SDH).^3,4 As healthcare organizations and Accountable Care Organizations (ACOs) in particular consider investing in or developing programs to address SDH, there has been an upsurge in the literature to highlight benefits of investing in community partnerships and social service programs for high-need, high-cost populations.⁵ Researchers have focused on: (1) the business case for healthcare organizations to undertake new ventures and (2) managerial aspects of relationships between healthcare organizations and community resources that are likely to determine joint venture success.^6–10 To date, explorations of healthcare’s involvement in SDH investment and programs have focused on the ramifications for healthcare organizations but neglected to consider the perspectives of community-based organizations (CBOs) involved with similar depth.

Several states are implementing Medicaid managed care models to incentivize providers to reduce healthcare costs and utilization while achieving health improvements by addressing SDH.^11–13 Among the notable examples are ongoing Delivery System Reform Incentive Payments and Medicaid 1115 waivers.^14–17 The Massachusetts Medicaid redesign, in particular, required the formation of ACOs across all healthcare organizations caring for eligible Medicaid enrollees.^{11–13,18,19} The ACOs are required to screen for health-related social needs and are encouraged, but not required, to create relationships with CBOs to respond to positive screens.¹⁵ The Massachusetts Medicaid ACOs launched in March 2018. The waiver also allowed ACOs to use Delivery System Reform Incentive Payments dollars for “flexible services” not historically covered by Medicaid starting in January 2020. State policymakers limited the use of flexible services dollars to housing- and nutrition-related needs for Medicaid enrollees.¹⁹

Little scholarly attention has been paid to the impact of changes to Medicaid policy on social service providers. As policymakers pursue population health strategies with ACOs or similar programs, healthcare organizations are experiencing pressure to create working relationships between healthcare organizations and CBOs, sometimes referred to as community–clinical linkages.²⁰ Consideration of how these policy changes may impact the role of CBOs is necessary, as CBOs have historically led efforts to improve SDH for vulnerable communities.¹⁷ Understanding the CBO perceptions of these changes is critical to achieving a clear role definition for both ACOs and CBOs amid Medicaid redesigns.

METHODS

The research question was: how do CBOs perceive the impact of a Medicaid redesign, with particular focus on their view of healthcare organizations’ movement into SDH program development or investment? This study was conducted in Massachusetts, a state with a particularly robust CBO sector, and undergoing a Medicaid redesign with explicit emphasis on addressing SDH.²¹

Data were collected via key informant interviews, as qualitative methods are well suited to assessing how people perceive, describe, and interpret their experiences and context surrounding their lives and work.²²

Study Sample

For study purposes, healthcare organizations included both delivery organizations (health systems, clinics, provider groups) and payers (commercial insurers, public insurers, MCOs). CBOs were defined as nonprofit organizations that work at a local level to improve life for residents and are not focused primarily on healthcare promotion or delivery. Recruitment targeted organizations providing direct social services (Table 1). Organizations that focused on mental health or long-term services and supports were excluded because their role as healthcare providers was contractually specified in Medicaid ACO requirements in the Medicaid redesign.²³ Most mental health and long-term service and support organizations had longstanding contractual partnerships with healthcare organizations. CBOs, by contrast, had few longstanding institutional relationships and were beginning to consider such arrangements during the study period.

Table 1.

Organizational Characteristics of Participating Community-Based Organizations

Characteristics	n (%)
Interviewees, n=46
Sector
Food	13 (6)
Housing	33 (15)
Community centers	17 (8)
Legal services	4 (2)
Multi-service centers	15 (7)
Transportation	2 (1)
Workforce development	11 (5)
Domestic violence	2 (1)
Early childhood education	2 (1)
Survey respondents, n=40
Geographic location
Greater Boston	75 (30)
Western mass	18 (7)
Eastern mass/cape	8 (3)
Number of employees
<15	20 (8)
15–60	23 (9)
61–145	10 (4)
>145	48 (19)
Annual operating budget FY17 (millions)
<1	10 (25)
1–5m	9 (23)
6–10m	9 (23)
11–20	2 (5)
>20	16 (40)
Government funding % of total of budget
<25%	43 (17)
25%–50%	18 (7)
51%–75%	10 (8)
>75%	10 (8)
Has a national provider identification number	28 (11)

FY, fiscal year; m, millions.

The sample population included leadership (executives) and senior staff (directors and managers) from a diverse set of CBOs across Massachusetts. Interviewees included representatives of CBOs offering a range of social services, with a greater emphasis on services that had been prioritized by ACOs locally and in the literature, including housing and nutrition.^24–28

Measures

The authors interviewed 46 individuals, representing 44 CBOs. Initially, the authors contacted CBO leadership who attended public events to discuss integration of health and social services within Massachusetts, including open meetings held by Medicaid during the 2016–2017 redesign process and a local philanthropy’s participant list from a Social Equity Convening in 2014.^29,30 Subsequent recruitment of eligible CBO leadership was done using snowball sampling techniques.³¹ Individuals from CBOs who felt they could speak to past, present, or future partnerships with healthcare organizations, or individuals with familiarity with the impending Medicaid policy initiatives, were specifically recruited for participation.

All interviews were conducted either in person or over the phone between September 2017 and March 2018, lasted approximately 1 hour, were audio-recorded, and professionally transcribed. The interview guide was developed using information-gathering interviews with key stakeholders from Massachusetts ACOs. Further details regarding interview guide development and interview questions are available online (Appendix Text 1, available online). Interviews were conducted until thematic saturation was reached. Following interviews, all participants received a closed-ended survey to describe their organization size and scope of service delivery with greater precision. This study was deemed exempt by the Tufts Medical Center IRB.

Statistical Analysis

Two coders (EB and LT) used a modified grounded theory approach and a constant comparative method of qualitative coding.^32,33 Team members independently analyzed transcripts, generating common codes from the data to summarize key ideas. The team reviewed the initial codes and combined them into broader concepts and coherent themes. Both coders iteratively reviewed all transcripts, consolidating and splitting concepts, then adding and combining new codes as needed. Analysis progressed from a description of the data to explanation or interpretation of the patterns and their broader meanings and implications. All final codes and themes were agreed upon and applied systematically across transcripts. Final codes and themes were presented to an advisory panel and CBO convening during the midpoint (February 2018) and after coding completion (June 2018) for feedback (Appendix Text 1, available online). Themes were revised based on advisory panel input.

RESULTS

The final sample included 46 key informant interviews, representing 44 CBOs across Massachusetts. Table 1 highlights the sectors and demographics of the included CBOs. The follow-up survey response rate was 87% (40/ 46), including CBOs from 22 ZIP codes, which represent 8 of the 14 counties in Massachusetts. Of those, 75% (n=30) had headquarters located in greater Boston, 18% (n=7) in western Massachusetts, and 8% (n=3) in eastern Massachusetts.

The CBO leaders provided insights as to how their organizations were perceiving and anticipating policy changes at the state level. Three key themes emerged: (1) enthusiasm for policy changes driven by a desire for cross-sector collaboration, (2) competing agendas between CBOs and ACOs, and (3) incomplete information available for planning and partnership.

Interviewees discussed prior experiences collaborating with healthcare organizations, which provided useful context for their perspectives. When asked how CBOs anticipated how the new ACOs might partner with them to address adverse SDH, many drew on prior ad hoc experiences and informal partnerships with healthcare organizations. These interactions often took the form of time-bound, small-scale research grants, or pilot projects. In some cases, CBOs described having multiple simultaneous but uncoordinated research projects ongoing with researchers from the same academic medical center. Based on prior experiences working with healthcare organizations, CBOs were under no impression that any of these research projects would necessarily scale or become standard practice. These types of collaborations between CBOs and healthcare organizations often stemmed from interpersonal relationships rather than institutional collaborations.

A consistent theme that emerged from interviews with CBOs was one of overall enthusiasm for the Medicaid redesign policy changes despite concerns about conflicting agendas between the 2 sectors. A policy environment defined by missing information allowed CBO hopes and fears to proceed mostly unchecked during the study period. Representative quotes from all themes are included in Table 2.

Table 2.

Representative Quotations From Major Themes

Theme	Quotations
Theme 1: enthusiasm for policy changes driven by a desire for collaboration
CBOs as experts	“I think that hospitals, healthcare systems, can only take care of what happens inside their walls or during a service visit. In actuality, the boots on the ground, out in the community, after you go back home, it makes sense to engage partners that will help people be successful and prevent those re-hospitalizations that are so costly both in terms of services and also just in fines and everything that goes along with it.” “Our portfolio can incorporate multiple things as long as they’re pointed in the right direction of reducing poverty. They’re kind of selected for that openness.”
Avoiding competition	“We’re not like a for-profit organization… I feel like what big companies like to do, and for-profit companies like to do, is streamline as much as possible, do the same thing over and over, and that’s not what we do.” “(If I were an ACO) be thinking, ‘I have a phenomenally sophisticated administrative base. I have very smart people working for me. I have a certain amount of money sloshing around that I can invest, unlike most human services agencies. Why don’t I build it and build it to my specifications… and at least see how it goes?’” “I would say (health care organizations) probably would’ve looked at us and s aid, ‘the liability risk is just way too great and the margins suck, we’re not going anywhere near you. Are you kidding me?’”
Theme 2: competing agendas between ACOs and CBOs
Outcomes of interest	“…Not every [homeless] person is a frequent user of the healthcare system. I think sometimes the hospitals think, ‘Gee, my ER person that’s been in 15 times… I’ve got a guy who keeps coming to the ER. I’m pretty sure he’s homeless. He has oxygen and he’s been in the ER 4 times this month.’ The irony of this fellow, unfortunately is that he’s actually not chronically homeless and so I can’t get him housed quickly… The hospitals and HUD are really ships passing in the night a little biton this stuff” “We have a third of the people enrolled and they are able to track the A1Cs we can see… over time are doing better. I’ve learned a lot about all this because I’m not a doctor, but I just know people’s health’s improving.”
Timelines	“The temptation [for the ACOs] to say ‘we’re going to take all of the community-based programs… and we’re going to require that they demonstrate a [return on investment] within a 6 month period of time, and if they don’t we’re not going to continue.”
Theme 3: incomplete information	“I know [HEALTH SYSTEM] has written us into their ACO agreements but we’re still trying toknow and understand what that is specifically. You know, they’re like, “Ah, we wrote you in.” But they haven’t really shared the details of what they want from us yet. Or invited us to the table to discuss those things.” “Honestly my fear right now, we are so late as a community. Like, quality metrics at [Medicaid] are being finalized right now. We were not invited to the party.”

ACO, accountable care organizations; CBO, community-based organizations; ER; emergency room; HUD, Department of Housing and Urban Development.

Enthusiasm for Policy Changes Driven by a Desire for Collaboration

The CBOs largely agreed that the current Medicaid policy shifts would create positive opportunities to partner with healthcare organizations. Two groups with distinct rationales for this enthusiasm emerged. The first group believed that CBOs had unique capabilities to address SDH and were, therefore, optimistic about the priority Medicaid policymakers had put on their topic area of expertise. This group believed that their knowledge and unique role in the community-made CBOs better equipped than healthcare providers to deliver social services effectively. As healthcare providers began to investigate their options for addressing social needs identified in the required screening, CBOs believed that partnership—and ultimately, potentially contracts—would become the obvious strategy for healthcare providers to pursue. Many believed that ACOs would value CBOs’ detailed community knowledge and longstanding relationships. Several CBO leaders suspected their community strengths would facilitate achieving quality and utilization goals for potential partner ACOs as well (Table 2).

The second group offered a different rationale for enthusiasm based on a more competitive assessment of the social service delivery landscape. These CBO leaders were excited about the Medicaid redesign mostly because of policymakers’ encouragement that healthcare organizations partner with CBOs for social services rather than develop their own programs. In the eyes of these leaders, the alternative scenario—in which health care developed its own social service capacity or contracted it from a for-profit or government provider—would have been less advantageous to their organization.

Competing Agendas Between Community-Based Organizations and Accountable Care Organizations

The CBO leaders recognized that healthcare organizations’ desire to operate efficiently and at scale to optimize financial return might lead them to consider inhouse social service programming. Among CBOs focused on nutrition, several leaders saw for-profit contracting as the biggest threat. Food services could be delivered efficiently and at scale by well-known national companies who would be able to take on larger contracts. More generally, CBOs worried that for-profit organizations would be attractive partners to ACOs because CBOs reliant on government contracts to maintain financial viability would be constrained in what they could offer (Table 1). Language in the Medicaid redesign to prioritize and encourage CBO partnership allayed many fears that ACOs would keep the SDH incentive dollars to pursue such for-profit contracting or design their own social service programs.

The CBOs highlighted how they felt their mission, interests, and objectives were not aligned entirely with those of the newly formed ACOs. Differences in outcomes of interest between CBOs and healthcare organizations were highlighted across all CBO sectors as a potential source of tension between the CBOs and ACOs when looking to define partnership or programmatic success. In particular, CBO leaders from the housing sector expressed concern about how homelessness, which is strictly defined by the Department of Housing and Urban Development (HUD), is not well understood by healthcare partners. HUD funding, which is the largest source of income for most homeless shelters in Massachusetts, is tied directly to performance reports that measure several quality indicators, including the number of new individuals to homelessness in a city.³⁴

The ACOs sending patients to homeless shelters who do not meet the HUD definition of homelessness is a direct threat to the bottom line of the community homeless shelters. When ACOs refer patients who they think may be homeless, but are not, the homeless shelters see an unintentional worsening of their performance measures, which has the unintended consequence of reducing funding for and availability of much-needed community resources that are essential to achieving the ACO population health improvement goals.

Other interviewees discussed conflicts between ACO- and CBO-appropriate timelines to achieve desired outcomes. CBOs mentioned long timelines required for their work to demonstrate impact. Several interviewees used words like “intergenerational impact” to describe their organizations’ outcomes of interest. This multidecade perspective far exceeds 90-day readmissions or even year-over-year time horizons for measuring quality outcomes common among healthcare organizations. Clinical outcomes like HbA1c or systolic blood pressure, which are prioritized by healthcare organizations precisely because they can be measured and intervened upon in a 2-year funding cycle, were seen as outside the scope of what CBOs could influence and potentially distracting to their central mission. CBO leaders defined success by achieving a community-level change and patient-driven outcomes, rather than intermediate health outcomes, which are standard quality metrics for health care.

Incomplete Information Available for Planning and Partnership

The CBO leaders repeatedly described a sense of missing or incomplete information regarding the Medicaid redesign, creating an environment in which it was challenging to report either strategies or concerns with confidence. Some of this confusion was a function of slow federal approvals of the waiver, but even after approval, CBOs felt uninformed about key aspects of the Massachusetts implementation process. Policymakers at state and organizational levels frequently provided incomplete information about the role that CBOs would play in the Medicaid redesign, leaving much of the CBOs’ role to their imagination. Published literature describing the redesign emphasized provider-level shared savings without defining what types of professions would qualify as providers, leaving CBOs hopeful that they would be eligible.^15,17,35 Similarly, much has been written about a new risk-adjustment methodology wherein Massachusetts Medicaid ACOs that have unhoused patients assigned to them will receive additional funding.³⁶ It was unclear until recently whether the additional funding was intended to cover medical costs or to fund housing solutions, leaving housing CBOs to believe that there may be funds earmarked for their services. Lack of communication from Medicaid ACOs about what would be provided in exchange for CBO participation in a contract added further uncertainty. These gaps in information existed alongside aspirational rhetoric that identified CBOs as new partners in improving the health of Medicaid enrollees in Massachusetts, thereby allowing CBOs to persist in viewing the policy changes favorably.³⁵ During the study period, the Medicaid waiver language was still pending final approval from the Centers for Medicare and Medicaid Services. As such, CBOs were not alone in their confusion as both newly formed ACOs and policymakers were unclear about what the final Medicaid redesign would ultimately entail.

Exacerbating these unanswered questions about the redesign was the fact that CBOs were primarily excluded from the policymaking process. Several CBO leaders described waiting for ACO contracts to arrive on their desks from healthcare organizations but had no clear expectation about what would be in them or how the CBO would be expected to contribute to cost reduction efforts. Other CBO leaders raised concerns that state policymakers were making decisions about how contracts between health care and CBOs should be structured without input from the CBO sector. Although a working group had been convened to advise state policymakers on social service integration, many CBOs remained unclear as to what influence that group’s recommendations might have or what the timeline for changes would be. Throughout the present study, ambiguity persisted about whether and if the Flexible Services portion of Medicaid’s waiver would be approved by the Centers for Medicare and Medicaid Services. The status of this part of the waiver bore particular relevance to CBOs insomuch as that program would provide funding for services not historically covered by Medicaid dollars. Throughout this study, interviewees asked the research team: “What have you heard?”

DISCUSSION

This work fills an essential gap in the literature by highlighting the perspectives of CBOs as policymakers move to align the 2 sectors to address social needs and improve population health. Although several previous analyses have identified and explored the views of health policymakers at both the state and organizational level,^5,6,8,37 this study is among the first to systematically interrogate the perspectives of CBO leadership on their role in health improvement activities. Creating lasting, mutually beneficial partnerships between these 2 different sectors requires stakeholder engagement on both sides, where policy efforts have traditionally focused mostly on outcomes, evaluation, and incentives for the healthcare sector only.

If future Medicaid redesigns emphasize SDH, the current findings suggest policymakers should prioritize recruitment of CBOs into both the policymaking and policy dissemination processes. Allowing CBOs to shape and understand the policy goals will help to ensure the delineation of appropriate roles for healthcare organizations and CBOs. Although there is no legal requirement for either state government or Medicaid ACOs to include CBOs in the policymaking process, the appropriate role for CBOs will be challenging for the health policy community to ascertain without engagement. If policymakers include CBOs in the policy design process, they must be meaningfully rather than perfunctorily included. Including CBOs “in name only” risks undermining a fragile trust between healthcare organizations and CBOs. Some states have tried to include CBOs as part of their Medicaid redesign plans; evidence suggests that few, if any, have yet achieved this goal.³⁸

Limitations

Several limitations deserve note. The study sample was limited to CBO leadership in 1 state and may not be generalizable. Though 9 sectors of social services were represented in the final sample, housing was represented heavily compared with other sectors, which may limit generalizability; however, is representative of the current environment in Massachusetts, as there has been a concerted movement toward a “Housing First” approach to homelessness, including the integration of health care and social services.³⁹ The study question was not comparative, and the sampling strategy was not designed to solicit differences in perspectives between CBO sectors. Future work should continue to explore the perspectives and roles for CBOs in health improvement activities with particular attention to variation within the CBOs. Finally, in most cases, the study team interviewed only 1 person from each CBO. In larger organizations, their perspectives may not represent the perspectives of all staff, particularly those working at the front lines.

CONCLUSIONS

As health policymakers consider how best to improve Medicaid programs and ACOs, CBOs are poised to be eager participants in improving the health of vulnerable populations. Turning CBO optimism into a working relationship with healthcare organizations will not be straightforward, but CBOs’ decades of experience addressing SDH warrant efforts at engagement.