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Chuck Ingoglia

Senior Vice President, Public Policy & Practice Improvement

CMMI: Look to CCBHCS – They are a Building Block

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The Center for Medicare and Medicaid Innovation (CMMI) is interested in developing and deploying an alternative payment model for people living with behavioral health conditions. To do this, they convened the Behavioral Health Payment and Care Delivery Innovation Summit. It is encouraging to see CMMI’s attention on this important issue.

A model already exists that, with adjustments, would meet CMMI’s goals – Certified Community Behavioral Health Clinics (CCBHC).

In 2014, Congress approved the demonstration program that created CCBHCs to improve community mental health and addictions services. Subsequently, the Centers for Medicare and Medicaid Services, the Substance Abuse and Mental Health Services Administration and the Assistant Secretary for Planning and Evaluation developed the demonstration design, bundled payment methodology and evaluation plan.  Twenty-four states received planning grants and eight states are currently in the early implementation stages of this demonstration.

The components of CCBHCs that align with CMMI’s goals are:

  • Evidence-based services: The fundamental elements of the demonstration are to improve the breadth, depth and quality of evidence-based services available in communities.  CCBHCs must meet federally mandated criteria regarding breadth of services, timely access to care and care coordination.
  • Integrated care: CCBHCs must provide a full range of outpatient mental health and substance use services, including medication-assisted treatment.
  • Alternative payment methodologies: CCBHCs receive a bundled payment calculated either daily or monthly. The bundled payment, like managed care payments, is calculated to be adequate to cover the actual cost of services. The CCBHC does not get any additional payments if a person requires mores services and must manage the risk for providing additional services. Participating states are also able to provide quality bonus payments, aligning this demonstration with most current alternative payment methodologies.
  • Care coordination: CCBHCs must have care coordination relationships with Federally Qualified Health Centers, emergency departments, residential substance use centers, adult and juvenile justice, schools and other entities.
  • Access: CCBHCs are required to offer evening and weekend hours and 24/7 crisis services. They also must serve everyone, regardless of ability to pay.
  • Measurement-based care: CCBHCs must use the PHQ-9 to measure severity of depression and are encouraged to use other standardized tools at the consumer level to improve care. These measures make CCBHCs accountable for the quality of care delivered.
  • Care transition: CCBHCs must improve the transition of care between hospitals and clinics for patients to meet care engagement standards and hospital readmission measures.
  • Technology:  Due to the payment methodology, CCBHCs can implement new technologies such as telemedicine, remote patient monitoring and online treatment supports.
  • Payment: The payment methodology addresses the historical and pervasive under-payment issues that have limited access to behavioral health services.
  • Expansion: Currently, only eight states are participating in the demonstration, but several states and providers are ready to participate in an expansion.

Several modifications are necessary to make this model work for CMMI’s purposes, including:

  • The current demonstration period is only two years. It needs to be longer to make the extensive service and care coordination requirements fully operational and allow enough time for patient change to demonstrate effectiveness and cost-savings.
  • While the federal government developed the overall criteria, states participating in the demonstration had flexibility with some elements of the demonstration design.  For CMMI purposes, it may be necessary to standardize elements of the model, including range of evidence-based practices, inclusion of technology in the bundled payment and use of quality-based payments.

CCBHCs can dramatically improve the lives of individuals with behavioral health conditions and increase the quality of care. CCBHCs could be the building block CMMI needs to advance an alternative payment model for people living with behavioral health conditions.