Quick Take
California created enhanced care management to help Medi-Cal patients with complex health and social needs before they reach the emergency room. Community Bridges spent three years building a community-based program that now serves more than 200 people. But, Community Bridges CEO Ray Cancino writes, a shift toward encounter-based reimbursement is making the relationship-building, outreach and coordination that prevention requires increasingly difficult to sustain and Community Bridges will now be forced to close the program. Cancino questions whether the new payment model will actually save money — or simply move the costs downstream.
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For years, California health leaders have talked about the same goal: stop waiting until people are in crisis to help them.
Prevent hospitalization instead of paying for it. Help someone manage their chronic
illness before they land in the emergency room. Address food, housing, and transportation barriers before they become medical emergencies. Give people the most complicated health and social needs one trusted person who can help them navigate an increasingly complicated system.
California created Enhanced Care Management, or ECM, a statewide Medi-Cal benefit for people with complex medical or social needs, to help accomplish exactly that. The idea is simple: instead of making a person with complicated needs navigate a maze of doctors, hospitals, behavioral-health providers and social services on their own, ECM gives them one person responsible for helping coordinate it all.
At Community Bridges, we believed in that vision.
We spent more than three years developing a community-based ECM program. With support through California’s PATH initiatives, we hired and trained staff, developed systems and built relationships with residents facing multiple chronic conditions, unstable housing, behavioral health needs, language barriers and other obstacles that make traditional healthcare difficult to access.
Today, more than 200 people are connected to our program.
And now we are preparing to close it.
Not because preventive care stopped being important.
Not because our participants magically accomplished all their health goals.
But because the way this work is being funded is changing so dramatically that the community-based model California encouraged organizations like ours to build might no longer be financially sustainable.
Consider what ECM looks like in one person’s life.
Celia returned home after months of hospitalization following septic shock and multiple surgeries. She was a farmworker who primarily spoke Mixteco Bajo, had limited Spanish and was trying to manage a serious wound, medications, specialists, transportation and basic needs while recovering from a life-threatening medical crisis.
Her hospitalization had ended. Her needs had not.
Her Community Bridges care manager began meeting with her regularly. She helped coordinate medical appointments and transportation. She connected Celia to food, housing and eviction-prevention resources so she could remain housed while recovering and returning to work. She helped her understand medication and wound- care instructions and navigate programs such as Medi-Cal and CalFresh.
Over time, her wound healed. Her breathing improved. Just as importantly, Celia became more capable of navigating her own healthcare.
That is prevention.
And prevention does not always happen inside a clinic.
Enhanced Care Management is not home healthcare, and it does not replace doctors, nurses or behavioral-health professionals. It is intensive care coordination for Medi-Cal members with some of the most complicated combinations of health and social needs. Sometimes the work means coordinating among several providers. Sometimes it means solving a transportation problem so someone makes a specialist appointment. Sometimes it means helping someone understand why their Medi-Cal paperwork matters.
And sometimes it means making five calls before someone answers because their phone was disconnected, they moved, they are living in a shelter or they are simply overwhelmed by crisis.
That matters because the people ECM was designed to serve are often the people whoare most difficult to reach.
Yet the financing of this work is moving increasingly toward individual billable encounters. That means changing from paying a provider a predictable monthly rate to a variable per encounter-based model.
Community Bridges previously received approximately $625 per enrolled member per month, with requirements for regular engagement. Beginning January 1, the rates most applicable to our existing non-clinical workforce are expected to be approximately $102 per hour for in-person services and $82 per hour for telehealth.
We estimate that the changes will bring reimbursement rates down from approximately $625 per member per month to roughly $166 per member per month.
Under this model, reimbursement increasingly depends on successful direct contact. Much of the indirect work required to make those encounters successful — coordination, documentation, outreach, travel and communication with other providers — must now be absorbed into those rates.
This funding shift represents an estimated 73% decline under our existing service pattern.
That is not a gap that ordinary efficiencies can overcome.
It also does not capture everything required to manage a complicated case: documentation, supervision, travel, case conferences, unsuccessful outreach attempts and the time spent trying to locate someone whose telephone number changed or whose housing collapsed.
This is where the question becomes larger than Community Bridges.
We say we want preventive care. But prevention is often messy.
It does not always fit into a 15-minute appointment or a successful reimbursable phone call.
Sometimes prevention means building trust for months before someone follows through with treatment. Sometimes it means solving a housing or food problem that appears unrelated to health until that problem causes someone to miss appointments, stop taking medication or return to the hospital.
There is certainly a legitimate conversation to have about ensuring ECM reaches people with the highest levels of need and that public dollars are used effectively.
But reducing utilization cannot become the goal by itself.
The question should be whether people are healthier and whether the healthcare system ultimately spends less.
An over-correction carries its own risk. If the people who remain eligible for ECM are those facing the most significant barriers, they are also likely to require the greatest amount of outreach, relationship building and coordination.
A funding structure that primarily rewards successful encounters can unintentionally penalize providers for serving precisely those people and ultimately fall under the weight of its own assumptions.
Community Bridges built ECM as a community-based model with employees who understand the neighborhoods, cultures and languages of the people we serve. We did not create it as a clinical nursing program. Licensed clinicians may qualify for substantially higher reimbursement under the new structure, but replacing community-based care managers with nurses and other licensed professionals fundamentally changes both the economics and character of the service.
We are therefore beginning the process of closing our existing ECM program.
In the coming months, more than 200 people will need to transition from relationships they have developed with Community Bridges. Some may continue receiving ECM through another provider. Others may no longer meet revised eligibility requirements.
Either way, something important can be lost when a trusted relationship disappears.
This comes as California also prepares for significant federal Medicaid changes associated with the federal H.R. 1, including new eligibility, renewal and work-related requirements for portions of the Medi-Cal population.
ECM is not being eliminated by H.R. 1.
But the timing matters.
Just as navigating Medi-Cal may become more complicated for vulnerable residents, organizations that help people navigate complicated systems are facing reductions and restructuring.
We should measure what happens next.
Track emergency-room utilization. Hospitalizations. Gaps in medication. Loss of health coverage. Housing instability. And the total cost of caring for people after ECM support ends.
Because cutting the cost of prevention is not a savings if those costs simply reappear later in an emergency room, hospital bed or shelter system.
Celia’s care manager was not the surgeon who saved her life.
She was the person who helped make sure that, after the surgeon’s work was finished, Celia did not end up right back where she started.
For years, California has said it wants healthcare to move upstream — toward prevention, coordination and community-based support. Enhanced Care Management was one effort to make that promise real.
Before we dismantle the infrastructure built to deliver it, we should make sure we are not saving dollars today only to spend far more tomorrow.
Ray Cancino is the chief executive officer at Community Bridges.
