Building a Payment Model for Health Coaching in Primary Care: Lessons From Tennessee

ABSTRACT

Objectives: To describe Tennessee’s process for convening key stakeholders to develop uniform payment guidelines that encourage increased preventive service delivery and provide lessons learned that can inform similar work in other states.

Study Design: Descriptive case study.

Methods: Observational.

Results: Tennessee’s statewide multistakeholder health care extension cooperative, the Tennessee Heart Health Network, was instrumental in convening major stakeholders, including Medicaid, health plan, and safety-net provider representatives. Stakeholders reached consensus and developed and implemented common guidelines for reimbursement of health coaching services focused on cardiovascular health in the context of team-based primary care.

Conclusions: Tennessee’s experience suggests that statewide multistakeholder health care extension cooperatives can facilitate Medicaid and Medicare payment policy alignment and delivery system improvement. they have potential to yield important benefits in state-based efforts to improve access and quality of care.

Am J Manag Care. 2025;31(Spec. No. 10):SP709-SP720. https://doi.org/10.37765/ajmc.2025.89797

CMS has recognized the need to increase utilization of preventive services in primary care¹ and has developed payment policies to support delivery of these services by auxiliary personnel such as health coaches working “incident to” qualified billing providers,² but few states have adopted aligned Medicaid payment policies. Experts recognize that “psychosocial support, health behavior coaching, [and] health-promoting resources” are essential for realizing the person-centered, family-centered, and community-oriented primary care that people want and deserve.³ Likewise, evidence-based guidelines recommend increased delivery of preventive cardiovascular services, including regular screening for obesity, hypertension, and diabetes; diabetes prevention program⁴ and diabetes self-management education services⁵; intensive behavioral therapy for obesity and cardiovascular disease; intensive multicomponent behavioral weight loss interventions⁶; and tobacco use cessation counseling.¹ These essential population health services are infrequently delivered, and available billing codes are seldom utilized despite CMS authorization for Medicare reimbursement for these services. The need for increased delivery of preventive services is particularly acute in low-income, medically underserved areas.^7,8

Historically, preventive services have not been delivered at scale to Medicaid beneficiaries because of provider and payer uncertainty about Medicaid coverage, lack of clear guidance regarding proper coding for reimbursement,⁹ and substantially lower payment rates for preventive services than for evaluation and management or procedural services. As a result, preventive service codes are rarely billed and seldom paid in most state Medicaid programs, including Tennessee’s, contributing to low utilization by vulnerable populations. Central problems facing Tennessee providers wanting to increase preventive service delivery for Tennessee Medicaid enrollees in early 2020 included a lack of clear guidance from the state Medicaid organization (TennCare) on whether they could bill for incident to provider preventive services and from state Medicaid managed care organizations (MCOs) on how to ensure payment. Providers identified the following as major contributors to provider inertia: opaque and unclear rules regarding Medicaid payment for preventive services, a focus on sickness rather than preventive care, and lack of interest in taking the risk of developing the infrastructure necessary to reliably deliver preventive services.

This article describes lessons learned from Tennessee’s process for convening key stakeholders to develop uniform payment guidelines and encourage increased preventive service delivery that can inform similar work in other states. Specifically, this article seeks to demonstrate how a state-based multistakeholder health care extension cooperative can help states build consensus and achieve Medicaid/Medicare payment policy alignment in support of evidence-based integration of health coaches into the primary care team.

Evidence for Health Coaches Extending Primary Care

Strong evidence attests to the benefits of employing health coaches (HCs) and other types of community health workers (CHWs) to improve delivery of essential services in primary care settings. HCs support team-based, person-centered care for chronic disease and lifestyle-related conditions¹⁰ by engaging patients in self-management and treatment adherence, assisting patient navigation to improve access to essential care,¹¹ and providing referrals or resources to address social determinants of health.

Employing HCs and CHWs in primary care has been shown to improve adherence to medical recommendations, increase trust in the health care system, and reduce the need for emergency and specialty services.¹² For example, findings of the PROPEL study (NCT02561221) demonstrated the effectiveness of HCs in supporting weight loss among low-income people with obesity.¹³ Similarly, our team’s MODEL study (NCT02957513) findings demonstrated improvements in self-efficacy, diet, exercise, body mass index, and hemoglobin A_1c levels among African American participants with uncontrolled diabetes receiving personal health coaching.¹⁴ Likewise, a New Mexico CHW program targeting high-need individuals reduced emergency department and inpatient utilization.¹² Recent systematic reviews have found that HCs can help patients with hypertension reduce blood pressure, improve dietary and exercise behaviors,¹⁵ and increase self-efficacy.¹⁶

In light of this evidence, some states have begun to adopt approaches for Medicaid coverage of some CHW services.¹⁷ Yet despite this extensive evidence base and Medicare payment policies supporting payment for HCs in the context of team-based care,¹⁸ most state Medicaid programs do not explicitly support payment for HC services.

Multistakeholder Engagement in Tennessee

Population health leadership at the University of Tennessee Health Science Center (UTHSC) established the Tennessee Heart Health Network (TN-HHN) as Tennessee’s statewide health care extension collaborative in early 2020 (Table).^19,20 Promoting reimbursement of HC services in primary care was an early goal of the TN-HHN. Tennessee’s selection as 1 of 4 states (the others being Alabama, Ohio, and Michigan) to participate in the Agency for Healthcare Research and Quality (AHRQ) EvidenceNOW: Building State Capacity (ENOW BSC) initiative gave UTHSC the opportunity to engage payers, providers, and other stakeholders in statewide efforts to incorporate patient-centered approaches to improve the health of people with cardiovascular disease.^21,22 As part of a large land grant university (University of Tennessee) with 4 health science center campuses and affiliated health systems spanning the state, UTHSC was ideally positioned to organize, host, and support a statewide health care extension collaborative and serve as a trusted mediator to bring together key stakeholders across Tennessee.

From the outset, key partners across the state recognized strong potential benefits to patients, providers, and plans from HC services in the context of team-based care, but they expressed concern over the lack of clear and consistent payment mechanisms to support delivery of these new services. Tennessee safety-net primary care providers expressed support for implementing evidence-based lifestyle interventions for blood pressure control and smoking cessation, but they reported needing to better understand how to implement team-based care using HCs from a business perspective.²³ Providers particularly expressed interest in joining forces in collaborative quality improvement efforts to increase statewide impact on patient outcomes. Providers with high proportions of Medicaid patients also sought to improve their performance in the state Medicaid value-based purchasing program.

Likewise, TennCare’s MCO leadership reported needing more clarity from the state Medicaid program regarding expectations for MCO reimbursement of preventive services. Even though TennCare MCOs already had the ability to implement payment for preventive services, they reported concern that lack of clarity prior to implementation could jeopardize their relationship with TennCare if new payment policies were implemented without direct TennCare guidance. Furthermore, the TennCare MCOs had not previously come together in a formal way to establish uniform guidance regarding coverage of preventive services delivered by auxiliary personnel working under the supervision of qualified billing providers. All 3 MCOs recognized the need to seek the input of TennCare leadership in this process. Thus, the TN-HHN overcame competition among MCOs by bringing together high-level payer, provider, and TennCare leadership, with the UTHSC serving as a trusted neutral convener.

TN-HHN was envisioned from the outset as a self-governing multistakeholder group supported by high-level representatives of partner organizations who served as the 21 founding members of its Executive Council²² (Figure). TennCare and TennCare MCOs, community health centers (CHCs), and other safety-net providers were highly engaged from the outset. The TN-HHN Executive Council adopted formal bylaws in November 2022, at which time the Founding Council nominated and elected its chair and 10 high-level representatives of the Tennessee Department of Health (n = 1), TennCare (n = 1), TennCare MCOs (n = 3), other health insurance plans (n = 1), CHCs (n = 1), other safety-net providers (n = 2), and primary care professional organizations (n = 1) to serve as members. The TN-HHN developed governance and engaged payers through its Executive Council, which formed the Population Health Subcommittee as its only subcommittee (which included representatives of Medicaid MCOs, commercial insurance, and federally qualified health center representatives) to develop and help implement common reimbursement guidelines for HC services and set certification standards.²² The TN-HHN was fortunate that the MCOs agreed to help champion this work, given their reported challenges committing the time required to develop, adopt, and educate providers in a uniform approach to reimbursement of HC services consistent with state guidelines for billing and payment.

As shown in the Table, all major stakeholders reached consensus by mid-2021 on the value of expanding TennCare reimbursement of HC services for preventive cardiovascular services. Work to reach full consensus on detailed guidelines took more than 2 years. TN-HHN served as a neutral convener and used this effort as part of a broader approach to improve heart health in Tennessee. In January 2024, the TN-HHN Executive Council approved the following voluntary standards:

HC training and certification standards (eAppendix 1 [eAppendices available at ajmc.com])²⁴: These standards provided the foundation of the proposed reimbursement approach and detailed the required qualifications for HCs to deliver services in primary care. There was broad agreement for general consistency with Medicare requirements and no requirement for licensure.

Service codes for use by HCs in team-based care (eAppendix 2)²⁵: These service codes represented almost the exact same list of billing codes initially proposed by the UTHSC population health research leadership in January 2022, soon after the formation of the Executive Council and its Population Health Subcommittee. The subcommittee, with guidance from the TennCare Division, rejected a proposal to add coverage of additional behavioral health service codes, limiting the initial list of approved service codes to those focused directly on cardiometabolic health.

Frequently asked questions (FAQs) regarding service codes for use by HCs in team-based care (eAppendix 3)²⁶: The subcommittee agreed to continually update FAQs to address additional provider/payer questions and concerns as they arose. The subcommittee had lengthy discussions regarding preferred dissemination approaches for the information referenced above, and it was unanimously recommended that the TN-HHN serve as the primary dissemination vehicle through its website and learning collaborative sessions.

Lessons Learned

Working with state Medicaid agencies and MCOs to establish new payment policies requires multi­stakeholder organization, patience, and persistence. Tennessee’s process began with clear shared vision of the end goal and then required an iterative process organized and facilitated by the TN-HHN, driven by the TennCare MCOs, and overseen and approved by TennCare administration. This process required goodwill and shared vision among providers, payers, and government representatives, with iterative work to achieve consensus on details. Medicare and TennCare alignment on a new payment model for HC services in team-based primary care was ultimately a 3-year endeavor. Thus, for other state health care extension cooperatives seeking to facilitate delivery system improvement, it is important to recognize that Medicaid/Medicare payment policy alignment requires high-level leadership and substantial commitment of time and effort.

State-level payment policy change also requires vocal payer and provider champions. State engagement, representation, and high-level payer and government leadership, including chief medical officers (CMOs) for all 3 TennCare MCOs and key TennCare directors, were essential to align Medicare and Medicaid payment policies. Payer and provider champions who understood and cared about the mission of the ENOW BSC–supported state-based health care extension cooperative were nominated to lead critical TN-HHN committees and then were given strong university management, administrative, and faculty expert support to empower them in their roles. The vice president and CMO for population health services of a major Tennessee health system and a well-respected CMO of a TennCare MCO accepted nominations to chair the TN-HHN Executive Council and its Population Health Subcommittee, respectively. Together, these chairs and university management of the TN-HHN worked together to continually remind collaborative members of common interest related to improving the health care of Tennesseans and effectively resolved tensions among organizations that typically compete with each other. Leadership at all levels modeled a primary focus on service to health plan members that was contagious and helped plan and provider leadership justify their involvement in the cooperative. The TennCare administration’s contractual requirements for MCO cooperation on key program aspects and TennCare leadership’s presence at TN-HHN meetings also assisted in keeping MCO representatives accountable to common goals.

Keeping key collaborative members engaged in the Population Health Subcommittee of the TN-HHN Executive Council was critical to successful payment policy change. Two factors contributed most to long-term partner engagement in the subcommittee. First, the subcommittee chair was highly respected and collaborated well with other MCO leaders and TennCare leadership. He played a critical role by keeping his fellow CMOs and their staff engaged by encouraging attendance at regular meetings and keeping TennCare administration leadership informed and engaged at each step. Second, university management and administrative support of the TN-HHN ensured that meetings were scheduled well in advance at times convenient for members, agendas with clear deliverables were circulated prior to meetings, a regular meeting cadence was established, and meetings stayed on task.

Rising health care costs, a competitive health care marketplace, provider burnout, increased reporting metrics, privacy concerns, and care complexity are among the many powerful payer/provider incentives favoring the status quo in primary care billing and payment. However, the AHRQ ENOW BSC–supported state-based health care extension cooperative agreement, together with the support of TennCare, TennCare MCOs, and safety-net providers, created shared goodwill and opportunity for change. Specifically, ENOW BSC provided the framework for engagement of multistakeholder payers and providers in TN-HHN collaborative governance. Then the TN-HHN Executive Council developed a shared vision for aligning state and federal payment policy to strengthen the primary care sector and expand its capacity to improve patient outcomes.

With the support and framework of the new collaborative governance provided by the ENOW BSC–supported TN-HHN, Tennessee stakeholders were able to achieve consensus by identifying a strategic area for a win-win-win for patients, providers, and payers by focusing on high-burden, high-cost chronic cardiometabolic conditions for which critical preventive services were underutilized. Tennessee’s health care collaborative governance approach has laid a strong foundation for future quality improvement efforts and has strong potential for replication nationwide.

Future Directions and Policy Recommendations

Although many authors have called for increased Medicare-Medicaid coverage integration for those dually eligible,²⁷ less attention has been placed on the need for Medicare-Medicaid payment policy alignment for all recipients. Although national consensus on Medicare-Medicaid alignment is unlikely without legislation, Tennessee’s experience demonstrates that state efforts supported by strong multistakeholder health care extension cooperatives can be successful in achieving statewide consensus among payers, providers, and government leadership for reimbursement of HCs in the context of team-based care. The TN-HHN governance model for high-level engagement of payer, provider, and government leadership has the potential to be deployed in states across the US to expand access to essential population health services among Medicaid enrollees nationwide.

Expanding fee-for-service (FFS) payment for preventive health services delivered by HCs and other CHWs in the context of team-based care is a critical first step to expanding access to essential services. But FFS payment must be supplemented by value- and outcomes-based payment to support the low-cost personnel needed to deliver these services long-term. Evidence suggests that incorporating value-based payment into state-directed payment arrangements can improve outcomes for dually eligible individuals.²⁸ Value-based payments have potential to bring similar benefits to nondual Medicaid enrollees as well.²⁹ In Tennessee, it remains to be seen whether increased availability of FFS billing opportunities for HCs in the context of team-based care will translate into increased delivery of essential preventive services. Further efforts are needed to assess the effectiveness of Tennessee’s payment policy change in improving clinical outcomes.

Tennessee’s experience suggests that building state capacity to support delivery system and payment policy improvements through statewide multistakeholder health care extension services, such as the TN-HHN, can yield important benefits in state efforts to align Medicaid and Medicare payment policy and improve access and quality of care.

Acknowledgments

The authors gratefully acknowledge the invaluable support provided by TennCare and the TennCare managed care organizations, whose general assistance was instrumental in the completion of this work. Their collaboration and resources significantly contributed to the success of this research. The authors also thank Deborah Ogunsanmi for editorial assistance.

Author Affiliations: Division of General Internal Medicine, Department of Medicine (JEB, SWB), Tennessee Population Health Consortium (JEB, SWB, AE), Center for Health System Improvement, College of Medicine (JEB, SWB, AE), Department of Preventive Medicine (JEB), and Department of Clinical Pharmacy and Translational Science, College of Pharmacy (AE), University of Tennessee Health Science Center, Memphis, TN; Center for Financing, Access, and Cost Trends, Division of Healthcare Delivery and Systems Research, Agency for Healthcare Research and Quality (JCC), Rockville, MD; BlueCare Tennessee (CH), Chattanooga, TN.

Source of Funding: This work was supported by the Agency for Healthcare Research and Quality (AHRQ EvidenceNOW: Building State Capacity Award 1U18 HS27952-01). The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Author Disclosures: Dr Butterworth reports work for a consulting service that provides training and quality improvement services for health coaches unrelated to this work. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JEB, SWB, JCC, CH); acquisition of data (JEB); analysis and interpretation of data (JEB); drafting of the manuscript (JEB, SWB, AE, JCC, CH); critical revision of the manuscript for important intellectual content (JEB, SWB, AE, JCC, CH); provision of study materials or patients (JEB); obtaining funding (JEB); and administrative, technical, or logistic support (JEB, SWB, AE).

Send Correspondence to: James E. Bailey, MD, MPH, Center for Health System Improvement, University of Tennessee Health Science Center, 956 Court Ave, Coleman D222, Memphis, TN 38163. Email: jeb@uthsc.edu.

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