Pear Suite’s Colby Takeda on the Evolution of CHW Reimbursement

Pear Suite, a tech company focused on empowering community health workers (CHWs), recently announced a partnership with Instacart to bring food-as-medicine solutions to Medicaid members across the country. Not long before that announcement, Pear Suite co-founder and CEO Colby Takeda sat down with Healthcare Innovation to talk about changes in community health worker activity and reimbursement nationwide.

Healthcare Innovation: Hi Colby. The last time we spoke, we talked about Pear Suite’s origins and your business model and and I interviewed one of your customers on Maui. I read that you recently gave a presentation at the National Association of Community Health Workers on cracking the code on Medicaid and Medicare reimbursement for community health workers. Could you share a little bit about what you told that audience?

Takeda: The CHW provider type is completely new, right? For decades, these CHWs have been doing this work for free, and have never been able to partner with health plans or work with health systems to integrate data across these different entities that all speak in claims data and ICD-10 codes. CHWs think about impact and just focus on the needs of their members, so for there to be so much policy change around reimbursement and to provide pathways for CHWs to get paid now is completely new and exciting, but there are obviously a lot of friction points around contracting. Most of the CHWs at this conference have never even started working with health plans, and they don't know where to start. They don't know who to contact or how to get credentialed or what cyber insurance is. So we help them understand the requirements around working with health plans to then get reimbursed for the work and how to operate in a way that allows them to scale their operations.

Many of them just want to keep their staff employed, because a lot of their funding is running out. They're losing a lot of these short-term grants. We’re helping them understand the requirements of staying in compliance, whether it's documentation, getting consent, tracking social needs and then closing those care gaps. Health plans are willing to pay for any provider that will help them save money or provide care. But if CHWs aren't consistent and can't meet the expectations of a health plan, it can be challenging.

HCI: You mentioned conversations about credentials. What's happening in the credentialing space? Is there an agreed upon single credential that people get or are there multiple groups working on credentials for CHWs?

Takeda: That is a hot topic right now in the CHW world. There is no national credentialing pathway right now. It is state by state, because state Medicaid departments have created reimbursement pathways through 1115 waivers or through a state plan amendment. In those state plan amendments or the waivers, they spelled out that if there is a credentialing pathway in the state, you have to follow that. If not, it's up to the health plans to decide. 

The challenge is that the backgrounds of the CHWs are so diverse. They come to this work from different perspectives and backgrounds. Some have college degrees. Some haven't even finished high school. Some come straight out of the prison system, and are becoming CHWs. To have a single expectation around what's required to become a CHW has been challenging for a lot of groups.

HCI: Have training programs been set up? 

Takeda: Yes, there are lots of training programs, some run and funded by the states. Other times, they're run by local community colleges who have found a revenue opportunity for this. There was a lot of funding that went out during the Biden Administration to support training, about $200 million, and in some states, the health plans are paying for training for their CHWs. Some training programs are eight hours total. Some are 80 hours total. Some are all asynchronous and online, and some are in person with hands-on field experience as part of the training. So it's very variable.

HCI: Are there some new CMS rules and/or state-level Medicaid changes impacting CHWs?

Takeda: The good thing is that with the proposed 2026 Physician Fee Schedule, there is actually nothing that would negatively impact CHWs. It seems like CMS is on board with this and hopefully making it easier for groups to utilize this benefit. At the same time, states are actually expanding use of these codes. In the past two months, Arkansas passed a law to allow for community health workers to bill for services. Oklahoma created policy for credentialing CHWs and creating pathways for that. Hawaii passed a policy to create a working group to evaluate credentialing pathways. It is actually a pretty bipartisan thing. It is not seen as something that is very progressive and only in blue states. We're seeing CHWs step up in Alaska, in places where there are no other doctors and no other clinicians. So it's a reminder that this is a topic that we can find consensus around.

HCI: One state we've reported on was North Carolina, where the legislature defunded the Healthy Opportunities Pilot. It seems like that might have a negative impact on community health workers there.

Takeda: Yes, that’s true. But actually North Carolina has a really strong community health worker association that has a lot of sway, so they are stepping up. They also have a really robust credentialing process that's run by the state. I sit on the board of the National Association of Community Health Workers, and we're trying to figure out what is our role in supporting policy state by state.

HCI: Is the work in California’s Cal-AIM Medicaid transformation initiative on track and accelerating?

Takeda: It is, although the CHW benefit is actually not part of Cal-AIM. But Cal-AIM, of course, utilizes quite a few community health workers with their Enhanced Care Management program. And certainly a lot of the community supports utilize community health workers.

HCI: I recently had a chance to interview two executives from Health Net, a Medi-Cal health plan, about their work with Pear Suite to support community health workers (CHWs) with billing, documentation, and training, enabling sustainable integration into healthcare teams.

Takeda: Yes. Health Net is on the front edge of working with CHWs through our platform, but also through their other pop health solutions. What’s interesting, though, is we started off with a lot of Medicaid plans, and now the commercial plans are interested. And this is on the Medicare side, the duals side. We are seeing a lot more health plans pay for this out of pocket and not waiting for a reimbursement pathway, because they recognize the value of CHWs to support their membership. 

And for employers, CHWs are like the new EAP [Employee Assistance Program]. It's like a person-centered approach to solving employees’ health and social challenges.

HCI: Does this effort require working closely with the payers on APIs or interfaces, depending on what kind of system they have, to make sure that the data all flows properly?

Takeda: Yes, absolutely. And starting with claims, we do integrate with the claims clearinghouses, so we can submit claims from our platform. We are also integrating with the HIEs to being able to share data and pull in data around who has recently been to the hospital for an ER visit, and what kind of challenges or diagnoses they have. 

HCI: In working with an HIE, does the data have to be segmented so that the community health worker only sees the aspect that's important to their work?

Takeda: You’re right, because if a CHW saw all the EHR data, they would get confused by 90% of that. They don’t need to know medications and doses, right? The HIEs have worked with us to decide how we collect the right data that is impactful not just for the CHW to track, but also for the healthcare system to see about social needs. We can capture the Z codes right now. But beyond Z codes, there was nothing else in the platform or in the HIE that allowed them to see anything about health and social needs. What goals are we creating with the CHWs?  What progress are we making to see if someone’s food insecurity is being addressed?

Doctors don't want to see all of that information, so how do we present the information in a way that the doctor feels it’s helpful for them and not causing more pain by having to read through a multi-page document? They want a quick and easy snapshot into the health and social needs of a member, and as long as they feel that someone's working on these social care challenges, they're happy.

HCI: Can you give an example of an HIE that you work with?

Takeda: In California, there are two that we're integrating with: LANES, which is big in the Los Angeles area, and SCHIO in Santa Cruz. 

We are also working with health plans, which are focused on HEDIS and stars. They have their population health platforms where they can see who has care gaps. Their whole goal now is to ask: how do we get this data to the people who can address these challenges, like the CHWs, and how do we get the feedback loop to say, this member  didn't have an annual visit this year, hasn't been vaccinated and is due for their annual visit and their cancer screening hasn't been addressed? So we are working on that now, both technically and with integrations, but also  a process workflow — how do we take in referrals and then get that feedback back to the health plan?

Instacart partnership

Here is some more information Pear Suite provided about its deal with Instacart Health, Instacart’s initiative to improve nutrition security:
 
The collaboration builds on a six-month pilot where CHWs integrated nutrition education, SNAP enrollment support, and online grocery and delivery services via Instacart and Instacart Health Fresh Funds into their outreach to engage over 3,000 Medicaid members. 

Pear Suite said CHWs using its digital platform can now connect individuals and families with Instacart Health’s technology – including Instacart Health Fresh Funds grocery stipends – directly within their workflows. Since the partnership launched earlier this year, Pear Suite has seen that by addressing food insecurity, individuals are more likely to engage and discuss their needs with their CHW.

The pilot also revealed that one in five SNAP-eligible community members were not enrolled in SNAP.