Executive Office of Health and Human Services, a state-level umbrella organization in Rhode Island that oversees the Department of Health, Population Health, and Human Services; and Tequila Terry, the director of the State and Population Health Group at the Center for Medicare and Medicaid Innovation.

Traylor began the session by inviting each panelist to introduce the work their organization is doing to advance population health and health equity. Hood-Ronick started by introducing Project Access NOW, a community-based nonprofit located in Portland, Oregon, whose mission is to improve community health by making health and social resources accessible to populations in need. Project Access NOW is funded through community benefits and Medicaid managed care fundings from five regional health systems that began collaborating in 2007 to support the many uninsured members of the community.

Yu followed by discussing her involvement with the BUILD Health Challenge, which is a community-driven national awards program and funding collaborative whose mission is to support communities in a cross-sector way and advance health equity. The program started in 2015, Yu said, and to date there have been 55 built communities across three groups of awardees. The communities partner with a public health department, hospital, or health system, and, in the upcoming group of awardees, with payers and health insurers as well. This collaborative, Yu explained, is really bringing forth capacity building and systems-level change to advance health equity and is also using funding in a variety of ways.

Traylor then invited Novais to introduce the work she does in Rhode Island at the Executive Office of Health and Human Services. Novais discussed how the department oversees work related to a variety of issues, including Medicaid, human services, behavioral health, veteran affairs, healthy aging, and children’s care. However, for this discussion Novais wanted to focus on the work surrounding health equity zones and how one department of health began this initiative to elevate the voice of communities and shift from disease-specific interventions toward empowering communities to voice health issues that they feel are most important to address.

Finally, Terry introduced the Centers for Medicare and Medicaid Innovation, which was established in 2010 as a part of the Affordable Care Act and is intended to transition the health system to a value-based care approach. Terry explained that to reach this goal, the innovation center works toward developing testing and evaluating new payment and service delivery models in Medicare, Medicaid, and the Children’s Health Insurance Program. These new payment and delivery models are focused on reducing health care expenditures and delivering cost-efficient and high-quality care. Increased health care spending and lower quality

of care were identified by Congress as two of the most pressing issues in the United States during the time at which the innovation center was established. Terry emphasized that the spending is a growing burden on households, states, and the federal government. Given that the finance system plays a critical role in delivery system reform, the innovation center seeks to identify opportunities to transform health care through testing value-based payment models and partnering with communities and organizations throughout the country. The center, Terry explained, works with state governments, providers, and communities, to examine the role that these partners can play in supplementing the clinical health care system.

The panelists, Traylor noted, represented the federal level and the state level in addition to foundations and community-based organizations, so they could offer a variety of perspectives. Traylor explained that the audience would hear about the challenges and lessons learned within the work of funding population health and said that during the planning discussions for this session, some key themes emerged. These included managing funding streams, blended versus braided funding,¹ challenges in getting buy-in for supporting community-based organizations, managing the work, delivering care to patients, and closing the loop back with providers.

Hood-Ronick provided further insight into the work of Project Access NOW, including the biggest challenges and lessons learned, in addition to the engagement of providers and community payers to drive this work. Project Access NOW² is a “safety net to the safety net” which provides care coordination and premium assistance support for those who are uninsured or unable to access care from a community clinic. Project Access NOW offers access to donated specialty services from five funded health systems and support for enrollment into the state Medicaid plan. For uninsured patients who do not qualify for Medicaid and cannot afford insurance, there is a team to help them navigate the marketplace and pay their premiums. One of the biggest challenges for health systems, Hood-Ronick said, is providing support for communities of undocumented

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¹ For a definition of braiding vs. blending funding, see https://www.tfah.org/wp-content/uploads/2018/01/TFAH-Braiding-Blending-Compendium-FINAL.pdf (accessed August 28, 2023). Braiding refers to coordinating funding and financing from several sources to support a single initiative or portfolio of interventions (usually at the community level). Braiding keeps funding/financing streams in distinguishable strands, so each funder can track resources. On the other hand, blending refers to combining different streams into one pool, under a single set of reporting and other requirements, which makes streams indistinguishable from one another as they are combined to meet needs on the ground that are unexpected or unmet by other sources.

² https://www.projectaccessnow.org/ (accessed August 22, 2023).

immigrants who speak English as a second language and cannot access state-run programs. Emergency room discharge nurses or social workers in a federally qualified health center typically provide care coordination or access for these patients.

Project Access NOW responded to gaps in the safety net system by developing infrastructure and goals targeting improved health outcomes across several systems and in a collaborative nature, Hood-Ronick said. The Project Access NOW team brings together health system partners aligned with a common community health improvement plan, recognizing that health systems are often better resourced than local nonprofits. Many of the community benefit programs within the health systems have recognized the value of Project Access NOW, taking the opportunity to outsource administrative care coordination and enrollment work while supporting community-based outcomes. Project Access NOW, Hood-Ronick said, is a “melting pot of funding” from the founding systems partners that serves to maximize health impact and efficiency in the region.

Traylor asked Novais to discuss her work in Rhode Island and to share lessons learned about blending and braiding funding streams. Novais responded that early in the process of pursuing braided funding, Rhode Island recognized that health promotion strategies that were focused on addressing specific diseases or telling people what to do did not work and that, at the same time, place-based or community-driven approaches to funding did not exist. Rhode Island needed to use the categorical funding received from the federal government (e.g., diabetes funding, tobacco funding) and develop a new approach to health promotion. Health equity zones (HEZs) emerged in this moment; these zones are community-driven collaboratives with a delineated area of intervention to address the social determinants of health.

Rhode Island, Novais said, pursued a braided funding model because “blending is not a word that the feds want to hear.” The federal government seeks to keep the integrity of funding streams intact, Novais said. A braided funding model places the burden on the state to map all funding streams, lead a community-driven process, develop a workplan, and report grant deliverables to the federal government. In this model, she said, the community is provided with “a menu of interventions” that conform to grant requirements. The process of braiding funding from different sources is grounded in identifying community problems, developing solutions, and proposing plans of action by “elevating the voice of the community.” The state serves as a backbone organization for the community-driven collaboratives, Novais said, facilitating “a lot of conversations, a lot of trust that needs to be gained” with partners. Community benefit resources are one example of how HEZs are funded,

she continued, where state and federal partners place conditions of approval (e.g., certificate of need) on investing in these zones and projects. State and federal partners expect accountability, delivery on programs, and engagement with health care systems.

Traylor asked Terry to provide additional insights from the CMS innovation center perspective, including limitations faced in blending and braiding funding. Terry said that the innovation center announced a “strategy refresh” centering equity into existing and future payment models.³ In fall 2021 the Innovation Center set a strategic 10-year goal to transform the health system into a model of high-quality, affordable, person-centered care that achieves equitable outcomes. The strategy refresh had five key objectives, Terry said:

1. Advance health equity across all areas of CMS and the Department of Health and Human Services, including addressing the needs of underserved populations and improving quality of care.
2. Drive accountable care by increasing the number of providers accountable to patient costs and the improvement of care.
3. Support innovation among local communities and organizations that want to play a role in transformation. CMS strategies on this front include, Terry said, “actionable and practice-specific data, technology, dissemination of best practices, fostering opportunities for peer-to-peer learning collaboratives, and payment flexibilities” to ensure the infrastructure exists to support innovation.
4. Improve affordability by reducing expenditures in Medicare and Medicaid, a statutory mandate for these organizations. Terry added that affordability also considers impact on individual people and out-of-pocket costs.
5. Partner to achieve system transformation across CMS and with a broader network of partners (e.g., commercial payers, purchasers, states, community-based organizations, and beneficiaries).

Ultimately, Terry said, the goal was operationalizing multi-payer alignment as part of health care. The innovation center plays an important role in using its resources and authority to foster transformation, particularly by using the finance system. In closing, she emphasized that “the finance system has the ability to act as a catalyst to make really important changes.”

Traylor next asked Yu to explain how the BUILD initiative is maximizing impact, given the position of the foundation and the limits, targets, and goals of funding. Yu began by offering a lesson from the Center for

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³ https://innovation.cms.gov/strategic-direction (accessed October 3, 2022).

Community Investment—that funding and resources tend to flow down the path of least resistance. In the field of community health, addressing large-scale systems or social issues requires cross-sector collaboration, which is often an uphill battle. Yu said that foundations play a unique role in funding population health. As part of BUILD’s fourth cohort fund-raising effort, Yu spoke with various partners to pull together the funds, based on the principle of aggregating collaborative resources to do more together. For the first three groups of awardees, the funders represented national and regional foundations and provided $20 million in support for the program, supporting 55 collaboratives over the last 8 years. Philanthropic dollars are used to incentivize or leverage what the community can raise. In the latest round, a total of 15 partners, including an unprecedented two health systems, supported the overall BUILD effort. This was the first time that health systems had supported BUILD. In the past, hospitals provided match funding for individual communities or individual collaboratives as part of an existing BUILD award.

These types of investments are moving beyond philanthropy. Yu provided the example of Campbell Soups, a private sector group looking for “outsized” opportunities for investment. Over 8 years, 55 communities took $20 million and leveraged over $50 million in other funding and resources (not including ARPA). These investments represent a magnitude of opportunities for BUILD and community health. Yu emphasized that philanthropy alone cannot sustain this type of work, but it plays a critical role in sparking innovation and showing the evidence-based results for others to make the investment. BUILD has already facilitated reimbursement contracts, where community-based organizations are providing services that decrease costs. Yu shared an example of payers seeing data demonstrating decreases in emergency room visits for a given issue area. The community-based organization is reimbursed based on cutting down costs by 50 percent. In some instances, groups can translate the work into other grants or funding. Over time, some BUILD communities have shown they no longer need the leveraged funding.

Traylor then asked Yu if there are windows of opportunity or other areas where philanthropic funding should be used. Yu said that recently over 100 BUILD representatives from across the country met and provided feedback on areas where additional support and work is needed. One point of discussion was the opportunity for foundations to make unrestricted operational grants that assume “the recipient, the community, the community-based organization, really knows best what and how to leverage that money.” Although BUILD did not operate this way until the most recent cohort, Yu said that moving forward it will be the most effective method. Many foundations do not operate in this way, which illustrates the need to shift existing power dynamics between funders

and awardees. Yu highlighted the need to shift towards advocacy and other legislative efforts in some communities, but also noted the tax implications and legal barriers that stunt this type of effort. There is an opportunity, she said, for philanthropy “as a sector to try to change things, change the rules.”

Traylor asked Hood-Ronick to discuss how her project measures impact and return on investment (ROI). Hood-Ronick said measuring ROI in a public health entity is often a challenge because it requires understanding prevention or a “lack of something occurring,” which is well beyond medical visits. In 2021, Project Access NOW helped one health system in the Portland region avoid over 1,400 hospital stays by placing patients in hotels if they were ready to leave an expensive hospital bed. For example, patients might receive a $100 hotel room and taxi ride. Hood Ronick said that these are examples of upstream investments that are simple. However, the sustainable infrastructure does not currently exist to support these “preventive programs” as part of a health system. Project Access NOW can provide an initial, rough idea of how to measure ROI in systems savings, but there is a bigger question about the impact to the bottom line. Philanthropic partners have played an important role in providing the space to spark innovation, exploring what it means to look at ROI differently, and ultimately using evaluation as a tool to better understand impact with client and community-based stories rather than reports.

Continuing the discussion on ROI, Traylor asked Novais to provide her thoughts on how to measure impact, how COVID has affected Rhode Island, and how the state thinks about using funds to maximize health and well-being. Novais noted the importance of states and specifically, the foundations that work in communities, since they have the money and power to influence the requests and proposals for the work being done. “Rhode Island made a commitment to do differently” with HEZs, Novais said. There was an intentional effort by the state to fund environmental and policy change interventions, which also meant accepting a broader definition of health and taking responsibility for making it easier for local communities to advance community well-being. The state also took the time to work with community partners from the beginning of the project to develop core health equity indicators. It took nearly two years for the state, community partners, academia, and out-of-state agencies to come to agreement on the health equity indicators. Novais said that these metrics are now used in HEZs and by state agencies or partners that want to work on equity. The state demonstrated its commitment to leading with evidence-based interventions, Novais said, and while evaluation was one component required by the funding stream, the state also did the work of developing the indicators.

model portfolio and direct grants to providers to test new kinds of service delivery to patients. While engaging the right resources at the state, local, and community levels can spark change, Terry said, a more sustainable alternative to grants is needed. The innovation center designed effective models, but when these ended there was no path forward for continuation. These examples mark an opportunity to consider funding strategies used and alternative payment models as a path for more sustainable programming.

Second, Terry said that funding approaches can greatly affect assets. She explained that the COVID-19 pandemic made a strong case for payment reform by highlighting the flaws with fee-for-service payment models. Some health care providers who were reliant on fee-for-service payment models lacked the necessary patient volumes to maintain their pre-pandemic revenue levels, which created financial strain for providers across the country and threatened access to care for many communities. The innovation center, Terry continued, has tested the effectiveness of state-based models, including alternative payment models such as hospital global budgets, which set fixed amounts for the total number of services that a hospital provides. During the pandemic, she said, this type of alternative payment model created a greater degree of financial stability for hospitals at a time when patient volumes were very volatile and unpredictable and ultimately translated to instability in services for patients. Terry added that the design of finance mechanisms directly affects how communities access care. As such, alternative funding streams allow providers to be creative in how they deliver services (e.g., telehealth or other mechanisms).

Third, Terry said that funding approaches have a direct link to health equity and the reach of both patients and providers around the country. Medicaid beneficiaries, she said, rely heavily on safety net providers, whose participation in health system models has been limited. This presents an opportunity to think creatively about alternative payment models that address the concerns of Medicaid beneficiaries, Terry said, adding that care management tools provide one example of how to ensure protection against the financial implications of high-cost beneficiaries and the infrastructure that needs to be in place.

Traylor added to the discussion by re-elevating Yu’s earlier analogy about “creating smooth pathways for the flow of capital.” Under fee-for-service, Traylor said, there is no smooth pathway to move funds from the health care space to preventative care and the addressing of health equity and social determinants of health. Traylor made a comparison to the health maintenance organization (HMO)/managed care movement of the 1980s and 1990s as a time that soured some to the idea of capitated payment strategies, which are uncommon in alternative payment methods (but include quality measures and guardrails against stint-

ing of care missing from the HMO efforts). At the innovation center, the current focus is on incentives, quality measures, and other components that both sustainably fund health care and create clear incentives for the health care system to invest in upstream work. Terry acknowledged that while this approach makes intuitive sense, the current system is designed in a way that makes it difficult to execute on the ground.

AUDIENCE DISCUSSION

To begin the audience Q&A session, Traylor directed the first question to either Novais or Terry, asking about the progress in reimbursing registered nurse providers in the community. Traylor broadened the question to thinking about reimbursing for a “wider range of providers,” not just the CMS legal definition of providers (e.g., registered nurses, nurse practitioners, and physician assistants), but also community health workers and others who are active in maternity care, doulas, and doula care.

Novais said that in Rhode Island the state reimburses Medicaid for community health work (e.g., community health workers, doulas) and that this is part of the state’s normal reimbursement plan. There is also reimbursement in place for community health teams through both Medicaid and commercial insurance, and the state tried to establish minimum fee-for-service rates. The state operates as a managed care Medicaid program for most of the population. The goal, she said, is to have a system that is easier to navigate and that can be paid through Medicaid, health insurance, or grants. From a payment perspective, the state sees initiatives as investments or seed funding, rather than as grants with a finite end. Therefore, the work with partners includes ongoing implementation funds focused on building infrastructure and long-term sustainability. Rates need to be increased, Novais continued, given the existing workforce crisis exacerbated by COVID, in which the state is having a hard time hiring employees given existing levels of payment. Novais said that conversations about increasing rates will come later, after those about funding infrastructure and sustainability.

Terry added that the mandate of the CMS innovation center is to run model tests and test new ideas. The example of Rhode Island and other creative opportunities informed the thinking of the center and future models for engaging different community-based resources. Terry said she firmly believes that “the community has to work together with the clinical health care system to create longstanding transformation.”

Traylor directed the next audience question to Yu: “What mechanisms do health systems use to reimburse community-based organizations for services that are reducing readmission?” Traylor added a related question of her own: “Are there other ways, in addition to community benefit

funds, alternative payment models, and shared savings arrangements, to reduce downstream usage in spending and improve quality?”

From the BUILD perspective, Yu responded, there have been three groups of awardees, an open call for applications, and over 500 applications for the initiative in the last 8 years. These were applicants with a committed hospital or health system partner that wanted to provide matching funds to unlock the BUILD award. While the Affordable Care Act offers a community benefit dollar opportunity, Yu said, the reality is that obtaining the matching portion from a hospital or health system is still one of the biggest challenges for applicants. Yu said that this example speaks to the challenges that communities, in particular CBOs, are facing in trying to create “smoother, paved pathways that do not already exist” for funding, support, and collaboration with local hospital or health systems. Those 500 applicants are innovators trying to find new ways and philanthropic partners to incentivize matches or other opportunities that unlock those dollars.

There is also in-kind support that does not get as much attention, Yu continued, such as a hospital or health system that can provide staff time, expertise, or a facility. This could also mean collaborating to distribute food or food prescriptions. A more generous interpretation of reimbursement could benefit these types of opportunities and help “elevate community collaborators to a scale that they might not have been able to hit without that sort of support.” While having a hospital or health system as a partner in a community opens doors into policy, funding, and other partnerships, Yu reiterated that in-kind support or resources are just as valuable and, in some cases, even more valuable. In closing, Yu referred to a group working on pediatric asthma as another example of success. The medical–legal partnership reduced emergency room pediatric visits for asthma by about 50 percent. In this example, the insurer worked with the hospital and health system to reimburse the community-based organization.

In addition to thinking creatively about what counts as reimbursement, Traylor said that there are many ways to be a good partner, including lending your voice, political power, respectability, and position in the community. For example, for smaller organizations, not having to pay rent is a helpful contribution to reduce costs.

Before concluding this panel, Traylor directed the final audience question to Terry, asking why federally qualified health centers (FQHCs) cannot share in savings to pay for community health workers. Terry mentioned the work of the Health Care Payment Learning and Action Network,⁴ a public–private entity that brings together CMS government resources and

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⁴ What is the Health Care Payment Learning and Action Network (https://hcp-lan.org/ [accessed October 3, 2022]).

private sector organizations to develop alternative payment models to help achieve person-centered care. One measure of commitment is how well an organization is moving to new models of payment, including creative options such as shared savings approaches. Terry encouraged those from FQHCs who are interested in participating in new payment models to look at the Health Care Payment Learning and Action Network to explore creative payment options.

To close, Traylor invited the panelists to provide any closing remarks. Hood-Ronick emphasized the importance of shifting power dynamics and empowering communities to drive the decisions on which initiatives get funded. Yu followed by encouraging funders and philanthropists to reflect on their current policies, as this could reveal opportunities to center community. These remarks were further supported by Novais, who highlighted the need to put communities at the forefront to improve health for all. Finally, Terry remarked that although the federal government plays a role, the most impactful change to the health care system will come from the efforts of communities.