How Tech Company Connects Payers and CBOs Without Medicalizing Social Services

The company Unite Us' Social Care Payments platform provides the tech infrastructure for the health equity ecosystem.

East is east and west is west and ne'er the twain shall meet. This could describe how healthcare payer and social service infrastructures have historically operated. But things are changing and, in a technology-enabled way that supports community-based organizations (CBOs) without "medicalizing" their operations.

"Medicalizing the social" — expecting CBOs to operate like payers and clinical providers — isn’t feasible for health equity initiatives. Melissa Sherry agrees. "That is accurate and spot on," says the PhD and vice president of social care integration for Unite Us, an enterprise technology company connecting health and social care.

Sherry's interview with HealthLeaders included the macro concerns of payer-CBO partnerships and followed the March 2022 introduction of Social Care Payments, which Unite Us describes in its press release as the first integrated social care payments platform "designed to bridge the gap between healthcare funders and [CBOs]” and “the only end-to-end solution for social care that streamlines the implementation and management of paid social care programs."

As these programs increasingly involve public and private payers, Social Care Payments is designed to help funders and CBOs partner, each in their own lane of expertise, to expand community impact.

The coding, claims, and billing conundrum for CBOs

The typical CBO wheelhouse does not include medical coding, claims, billing, or provider contracting. To join payer networks it will have to, but that's not something that most CBOs, if any, have the expertise or resources to build themselves.

"The biggest challenge we solve for community organizations is that we simplify billing," says Sherry, who also discussed the current state of medical coding for social needs.

"Social coding and diagnoses are in its infancy. Z codes are the 'What's going on?’ codes, but they are broad and to date haven’t been used systematically. The same is true for CPT® codes [Current Procedural Terminology] for social care services. Some states, California for example, are assigning HCPCS codes [Healthcare Common Procedure Coding System] for their community supports services, which represents the ‘What’s the solution?’ codes."

Sherry further cites the social coding standardization work by the Gravity Project, of which Unite Us is a sponsor and committee member along with multiple private payers.

Speaking on billing and claims, Sherry notes: "As a tech company, we create bridges, turning CBO services and documentation into claims for the payer so the social service organization can get reimbursed for services and focus on what they do best — again, not medicalizing the social, but enabling the two to do what they each do best."

Health plan medical-social service tech integration

Health plans are taking different approaches to medical-social service alignment.

"Some health plans are telling CBOs, 'If you want to join our network, you have to use our system,'" says Sherry. But if payers are not "thoughtfully and carefully integrating the medical and the social," it won’t be effective.

This group now includes North Carolina Medicaid, which launched a $650 million Healthy Opportunities Pilot program in quarter one 2022 "to test and evaluate the impact of providing select evidence-based, non-medical interventions related to housing, food, transportation and interpersonal safety to high-needs Medicaid enrollees." The pilot is currently using Social Care Payments.

Unite Us created Social Care Payments as an alternative to homegrown systems. "Thoughtful rollouts and integration" — those that solve problems for payers and CBOs alike while protecting their lanes — "are part of our technology goal," says Sherry.

Some payers have already chosen Unite Us offerings over homegrown solutions: Horizon Blue Cross Blue Shield of New Jersey; payvider Kaiser Permanente Northwest; and Aetna, a CVS Health company.

One social IPA's perspective

Without a careful integration strategy, Sherry worries that more disparity could be an unintended consequence if some CBOs are favored over others.

"If only the wealthy CBOs participate because they're more sophisticated, it will put smaller ones even further behind," she states. Noting that smaller CBOs may serve even more disadvantaged populations, Sherry adds that Unite Us works to support small organizations, help them build scale, and practice at the top of their license.

Another organization working to do this is Healthy Alliance, which connects the underserved to a growing network of organizations—big and small—that provide services that are essential for a healthy life. Healthy Alliance is a Unite Us client and understands the importance of not medicalizing the social, while also using components like cost, encounter data, service volume, and prediction to help CBOs scale.

Healthy Alliance created one of the first social independent practice associations (social IPA) in the nation, taking the traditional IPA model—i.e., allowing independent providers to share resources and gain collective contracting power with payers—and applying it to CBOs instead of medical providers.

CFO/CAO Michele Kelly notes: "We're able to provide backbone infrastructure analysis … on individual costs to evolve a new model for system intervention design that allows us to start to projecting volume."

Healthy Alliance VP of strategic partnerships, Kristen Scholl, also notes: "We'll always need encounter data, and we don’t expect a food bank provider to do this. Michele’s team has translated data to an encounter file that managed care understands."

Avoiding medicalization but achieving more

The tech infrastructure that organizations like Healthy Alliance and Unite Us provide can help CBOs achieve something important: attracting new funding via new access to data on spending, services, and outcomes.

"With Social Care Payments, CBOs don’t have to be medicalized while funders get the data they need," says Unite Us' Sherry. "You have all the pieces and the data in one place: who to screen, what services to provide, setting up the interaction and tracking it while bringing the billing component into population health management programs."

Unite Us Senior Vice President of Insights + Growth, Kurt Waltenbaugh, adds that the Social Care Payments platform "identifies and predicts, drives community investment, and connects the dots.

"It's like an easy button for CBOs," says Sherry.