This week’s article comes to from HMA Principals Meggan Schilkie, Joshua Rubin, and Heidi Arthur in our New York City office and the HMA national behavioral health team. On December 21, 2016, the U.S. Department of Health and Human Services (HHS) announced the selection of eight states for participation in a two-year Certified Community Behavioral Health Clinic (CCBHC) demonstration program “designed to improve behavioral health services in their communities.” The eight states are Minnesota, Missouri, New York, New Jersey, Nevada, Oklahoma, Oregon, and Pennsylvania. The demonstration projects are slated to begin on July 1, 2017. They build on a total of 24 state planning grants issued by HHS in 2015 to support states in designing their certification process. Nineteen of the 24 states submitted applications to participate in the demonstration program, and the eight awardees were selected from this pool of 19 applicants.
CCBHCs were created through Section 223 of the Protecting Access to Medicare Act (PAMA), which established a demonstration program based on the Excellence in Mental Health Act. The Excellence in Mental Health Act demonstration program, or the “Excellence Act,” is a two-year initiative with the stated goal of expanding access to mental health and substance use services in community-based settings, including in rural areas, with a particular focus on veterans, services to Native American tribes, and other underserved populations.
Some estimates have placed the investment of funds associated with this project at more than $1 billion, which would make it the largest investment in mental health and substance use services in recent history. Behavioral health stakeholders around the country have identified this as a parallel construct to Federally Qualified Health Centers (FQHCs), allowing behavioral health providers to access similar levels of reimbursement for community-based care to high-need underserved populations and communities.
The Excellence Act established a federal definition and criteria for Certified Community Behavioral Health Clinics (CCBHCs) and established that these centers would receive an enhanced Medicaid prospective payment rate based on projected costs. States must certify that each CCBHC offers the following services either directly or through a formal contract with a designated collaborating organization (DCO) with an emphasis on the provision of 24-hour crisis care, utilization of evidence-based practices, care coordination, and integration with physical health care.
| Must be Provided Directly by CCBHC |
|---|
| Crisis mental health services including 24-hour mobile crisis teams, emergency crisis intervention, and crisis stabilization |
| Screening, assessment, and diagnosis including risk management |
| Patient-centered treatment planning |
| Outpatient mental health and substance use services |
| May be Provided by CCBHC and/or DCO |
|---|
| Primary care screening and monitoring |
| Targeted case management |
| Psychiatric rehabilitation services |
| Peer support, counseling services, and family support services |
| Services for members of the armed services and veterans |
| Connections with other providers and systems (criminal justice, foster care, child welfare, education, primary care, hospitals, etc.) |
All states were allowed to select one of two reimbursement models to evaluate as part of the demonstration project: PPS 1 or PPS 2. (a cost-based, per clinic rate that is paid through a fixed, daily rate for all CCBHC services provided to a Medicaid beneficiary or a cost-based, per clinic rate that is paid through a fixed, monthly rate for all CCBHC services provided to a Medicaid beneficiary. Under this option, the monthly rate varies according to clients’ clinical conditions, and states had flexibility to decide how exactly PPS rates would vary based on their local needs. In addition, states who chose this option were required to make a QBP to CCBHCs who achieve the CMS- and state-specified measures. Only 2 of the 8 states selected a PPS 2 (NJ and OK) and only one (OR) of the 8 states did NOT opt to utilize quality bonus payments which were optional for PPS 1 and required for PPS 2.
Throughout the development and planning phases of the CCBHCs, many stakeholders and policymakers have raised questions about the possible tension between a Prospective Payment System (PPS) and the principles and goals of accountable care and value-based payments. Supporters of the CCBHC model conclude that the compatibility lies in the establishment of a continuum of mental health and substance use treatment services for individuals of all ages and an emphasis on needs assessment, population management, quality monitoring, and evaluation of outcomes, as well as an emphasis on open access, crisis intervention and diversion, care coordination, and follow-up post-discharge. Accessibility is promoted via peer, recovery, and clinical supports in the community and increased access through the use of telehealth/telemedicine, online treatment services, and mobile in-home supports (SAMHSA, Section 223 Demonstration Program for Certified Community Behavioral Health Clinics, 2016). All of these requirements enhance the ability of behavioral health providers to ultimately participate in pay-for-performance and value-based payment arrangements as critical partners in reducing the costs and improving health outcomes for individuals with serious behavioral health needs.
Even providers who are not certified under the official demonstration can seek to build out their continuum via partnerships and affiliations that mirror the CCBHC model, while also leveraging available housing resources and other social services linkages necessary to promote health, wellness, and sustained recovery. These networks can have substantial effects on the social determinants of health, which are proven to improve health outcomes and lower costs. Such networks will be well positioned to partner with accountable provider-led entities including accountable care organizations (ACOs), performing providers systems (PPSs), independent practice associations (IPAs) and integrated delivery systems led by hospitals, and FQHCs, in preparation for value-based arrangements.
The selected states’ demonstration programs will be evaluated based on data from 21 quality measures collected through sources such as program records, Medicaid claims, managed care encounter data, and clinic cost reports. Qualitative data also will be obtained from interviews with state officials and clinic staff. HHS will report on the access, quality, and financial performance of the demonstration programs annually beginning December 2017, using data from the evaluation.
For more information on the Section 223 Demonstration Program for CCBHCs visit: http://www.samhsa.gov/section-223
Potential Impact of Federal Healthcare Changes on CCBHCs
It does not currently appear as though the Trump administration will move to repeal or amend Section 223 of the Protecting Access to Medicare Act (P.L. 113-93), at least not in the near term. However, expansion beyond the initial eight states based on a successful demonstration project may be less likely. Other factors that would appear to provide some protection for the demonstration include:
- Budget neutrality: CCBHC demonstration state applications incented the establishment of budget neutral demonstrations. Budget neutrality means the demonstration cannot cost the federal government more than what would have otherwise been spent absent the demonstration. To demonstrate this, the state must provide its explanation of how the demonstration program will achieve savings sufficient to cover any additional cost of the program.
- CBO scoring: The Congressional Budget Office scored the Protecting Access to Medicare Act (PAMA) as having a net savings of $1.2 billion between 2014 and 2024. However, the cost of the bill between 2014 and 2019 had an overall cost of $17.7 billion, whereas from 2020-2024, the bill is scored with a savings of $18.9 billion, so repealing it would mean that the upfront spending happened, but the back-end savings did not.
- Section 223 (which established the CCBHC demonstration) is scored with a total cost of only $1.1 billion, so it seems unlikely that it would rise to the level of attention required to single it out for repeal.
- The Protecting Access to Medicare Act was a politically essential piece of legislation, support for which was built over a significant time. Repeal of the whole bill would be problematic politically, and repeal of Section 223 alone would not generate a significant advantage.
HMA worked with many providers and states throughout the CCBHC development and planning process as well as with providers seeking to be certified as community behavioral health centers (CBHCs) and is pleased to see the demonstration projects proceeding around the country.