Across the nation, states are delivering higher quality care, reimbursing providers based on value rather than volume, and testing delivery system and payment reforms aimed at lowering health care costs. In the behavioral health care arena, Medicaid and mental health agencies have not been moving as quickly to transition to value-based payment, given important differences in system capacity between physical and behavioral health delivery settings. For example, clinical standards and quality measurement are less well established in behavioral health, and provider capacity to assume risk for outcomes-based payments is significantly weaker, given the generally recognized under-funding of our community mental health system.
Introducing Certified Community Behavioral Health Centers
Certified Community Behavioral Health Centers (CCBHCs) offer states a new opportunity for improving behavioral health care delivery. Authorized under Section 223 of the Protecting Access to Medicare Act, this new model standardizes expectations for quality and service delivery in community mental health centers, and provides opportunities for linking payment to outcomes. The goal of CCBHCs is to strengthen community-based mental health and addiction treatment services, integrate behavioral health care with physical health care, and use evidence-based care more consistently.
CCBHCs are required to provide a comprehensive range of mental health and substance use disorder services to vulnerable individuals with serious behavioral health needs. CCBHCs serve adults with serious mental illness, severe substance use disorders, and/or co-occurring mental, substance use, or physical health disorders. They will also focus on children and adolescents with serious emotional disturbance. To become certified, clinics must demonstrate: (1) appropriate staffing; (2) availability and accessibility of services; (3) care coordination across providers and settings; (4) comprehensive scope of services reflecting patient-centered care; (5) quality and other reporting; and (6) organizational governance and capacity.
What is the Payment Strategy for CCBHCs?
CCBHCs will be reimbursed under a prospective payment system (PPS), similar to that used by federally qualified health centers (FQHC). Compared to current Medicaid funding mechanisms, CCBHCs are expected to benefit from enhanced reimbursement under PPS, infusing an estimated $1.1 billion into community-based behavioral health services.
States can select one of two PPS rate methodologies, one in which the state has the option to make quality bonus payments and the other which requires the incorporation of quality-based payments. Quality payments are tied to: post-hospitalization follow up; medication adherence for individuals with schizophrenia; substance use disorder treatment engagement; and suicide risk assessments. The introduction of standardized data collection and quality reporting into the behavioral health care setting through CCBHCs is a key step in the evolution toward value-based reimbursement.
As states move to adopt value based purchasing strategies (VBP), CCBHCs offer an incremental approach to drive accountability in behavioral health service delivery. Additionally, the certification of behavioral health centers creates a national standard of care similar to the FQHC model of primary care and patient-centered medical homes, raising the bar on quality of care delivery within the behavioral health arena.
CCBHC Demonstration Sites Coming Soon
Section 223 authorized SAMHSA to establish a two-year demonstration program for eight competitively selected states to implement the CCBHC model. In 2015, 24 states received planning grants to develop applications for the demonstration program, which have supported states’ efforts to:
(1) certify CCBHCs; (2) establish PPS methodologies; (3) improve data collection and reporting systems; and (4) engage stakeholders in program implementation. In April 2016, the Center for Health Care Strategies convened the planning grant states, through support from the California Health Care Foundation and the New York State Health Foundation, to discuss the opportunities and challenges for implementing and aligning CCHBCs with other delivery system and payment reform initiatives. In January 2017, SAMHSA is expected to announce the eight states selected for the two-year demonstration projects (Update: The eight states selected to participate in the demonstration include: Minnesota, Missouri, New York, New Jersey, Nevada, Oklahoma, Oregon and Pennsylvania).
Proposed State CCBHC Models
The planning grant states have generally proposed CCBHC models that align with other VBP and physical/behavioral health integration initiatives already underway, both at the federal and state level. For example:
- Missouri is looking to leverage the CCBHC demonstration to drive more comprehensive payment reform for its existing behavioral health home model. Through CCBHCs, the state would test whether bundled payment rates can drive better quality and cost outcomes than through health homes alone, which are generally reimbursed fee-for-service and with monthly care management fees.
- Texas is using the CCBHC PPS framework to standardize its approach to VBP contracting with behavioral health care providers through managed care. Given the relative newness of quality-based payments in behavioral health settings, the CCBHC parameters have enabled the MCOs to align their VBP approaches with network providers across plans.
CCBHCs offer the potential to expand access to behavioral health care services, improve the quality of behavioral health care delivery, and serve as a starting point for providers to adopt a payment methodology that rewards value rather than volume. The certification and reporting requirements lay the groundwork for the inclusion of VBP within behavioral health, and also raise the bar on the expected quality of service delivery and outcomes, positioning CCBHCs as an important step on the value-based continuum. Federal partners, states, and providers should look forward to the work of the eight demonstration states starting in early 2017.