The Health Care Authority.  The Health Care Authority (HCA) is a state government agency that purchases health care for more than 2.5 million Washington residents through Apple Health (Medicaid), the Public Employees Benefits Board (PEBB) Program, the School Employees Benefits Board (SEBB) Program, and other programs.  HCA has undertaken numerous health care transformation projects in pursuit of its stated mission to provide equitable, high-quality health care through innovative health policies and purchasing strategies.

Community Health Workers.  Community health workers are a category of health worker without a health care license who assist individuals and communities adopt healthy behaviors.  The role of community health workers was recognized in the Affordable Care Act as individuals who may provide important services as members of an interdisciplinary care team.  The Department of Health (DOH) administers a 10-week free training program for community health workers, which is informed by the work of statewide task forces on the role of community health workers convened in 2015 and 2019.  DOH defines a community health worker as a front line public health worker who is a trusted member of the community or has an unusually close understanding of the community served, whose trusting relationship enables the worker to serve as an intermediary between health or social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.

The Multi-Payer Primary Care Transformation Model.  The Multi-Payer Primary Care Transformation Model (model) is an initiative proposed by HCA in 2020, with the stated purpose to create better health and better care through multi-payer payment reform and care delivery transformation.  Primary care clinics certified as ready would accept a value-based payment, based on the number of enrolled clients served, to replace patient billing systems that incentivize volume of patient services over outcomes and quality.  In exchange, the clinic would agree to provide a range of services falling under the umbrella of whole-person integrated healthcare, report data, and be evaluated under a centralized evaluation and quality measurement system.  The model has undergone a public comment period and two stakeholder surveys, with the last survey completed in December 2021.

Subject to funding, HCA must establish a pediatric community health worker program for reimbursement of services to patients up to age 18 provided by community health workers in primary care clinics whose patients are significantly comprised of kids enrolled in the Medicaid program.

HCA must work with stakeholders to develop a multi-payer primary care transformation model and begin phasing in value-based payments and accountability for primary care clinics for clients of the Medicaid program, PEBB, and SEBB by January 1, 2023.  The model must explore sustainable reimbursement options for integration of community health workers in primary care to address the health-related social needs of families.

The Department of Health must contract with an organization that represents pediatric primary care needs to convene community-based organizations dedicated to children's mental health to establish and implement an equity-focused curriculum to prepare community health workers to meet the unique needs of children, adolescents, and their families by January 1, 2023.

The committee recommended a different version of the bill than what was heard.  PRO:  The purpose of this bill is to create a health navigator to help clients of primary care practices.  We should limit this to pediatric practices.  Community health workers perform the same role as health navigators with a different title.  Many evidence-based programs can be implemented by community health workers.  They can address social needs which are important but are not a good use of psychiatrist time.  I have seen the benefit non-licensed staff have in family's lives.  We can build a bridge of trust and catch kids who would otherwise fall through the cracks.  Families are struggling with social and financial challenges.  Mental health is a second pandemic for youth.  We need to serve kids in the places where families turn for help, like primary care.  Complete implementation of a transformation model is not necessary before integrating community health workers into care.  Kids can't wait.  Collaborative care complements the work of health navigators but involves licensed mental health therapists.  This workforce can be stood up quickly.  Our health systems are exponentially more difficult to navigate where there is a linguistic or cultural barrier.  Important health issues are sidelined by pressing mental health concerns.  Making a referral doesn't help families when they don't have extra time or transportation.  Team care is much more efficient.  We want to not just screen for but address the social determinants of health.  One community health worker costs about $70,000.  Most clinics should have two.  The two clinics in the state who provide this service support it through private philanthropy.  We don't have the overall financial system in place to underwrite the services we need.  More should be invested in primary care.  This bill will move the needed Multi-Payer Primary Care Transformation Model forward more quickly by proving the funding and support for implementation.

CON:  We should not limit our problem solving to psychiatric solutions.  Parents need information about alternatives that do not emphasize drugs and coercive treatment. 

OTHER:  Using the existing infrastructure of community health workers makes more sense than creating health navigators.  Please do not restrict Medicaid administrative dollars; care coordination should be funded differently.  Please do not lock in requirements for the Multi-Payer Primary Care Transformation Model because they could be changed following input from stakeholders.

PRO:  Fully half of the patients I see in clinic on any given day are there for mental health needs.  The numbers have exploded during the pandemic.  A community health worker can be the life ring, keeping the family afloat.  Taking care of children and youth is a team sport, and community health workers are a missing critical player.  They help build a bridge of trust between the system and families that allow us to catch kids who would otherwise fall through the cracks.  We have a 4 to 5 month waiting list to see a behavioral health specialist, and a community health worker can fill the gap by helping families fulfill basic needs between visits.  There is very strong evidence that inclusion of community health workers advances health equity.  Parents need more than we provide for them in primary care.  Parents who live at the intersection of racism and poverty need a team to provide for their needs.

CON:  We object to embedding community health workers in the mental health system and guiding families in that direction without adequate protections for parents and youth.  Medicalizing children's distress leads to overprescription of psychiatric drugs.  Please amend the bill to make community health workers an independent position, trained in non-drug, non-coercive forms of diagnosis and treatment.

OTHER:  We support the intent of this legislation.  Please do not structure the bill to couple the community health worker expansion to the Multi-Payer Primary Care Transformation project.  We support these things happening eventually but feel it is premature at this early stage of development.  There is nothing preventing these items from being coupled down the line.