A Game Plan for Building a Sustainable Certified Community Behavioral Health Clinic (CCBHC)

The goal of the Certified Community Behavioral Health Clinics (CCBHC) is to improve patient care across the healthcare spectrum, serving highly complex patients while avoiding the use of high-cost, low-return care models though community-based alternatives that improve care management. Based on the success of the first wave of CCHBC’s, Congress has acted five times to extend the demonstration project and has allocated $450 million (to date) for CCBHC expansion grants. The number of CCBHC’s have expanded from 66 in 2015, to 166 in 2020.  The Substance Abuse and Mental Health Services Administration (SAMHSA) has embraced the CCBHC concept of integrated care and behavioral health providers, who have long supported integrated care, are now looking to the CCBHC model as an economically viable way to support this model of care.

Indeed, CCBHC’s have an excellent opportunity to be leaders in the new integrated healthcare system if they can display the following specific values:

  1. Accessibility: All needed services – mental health, substance abuse treatment, and physical health care – are provided in-house or quickly, in proximity, within the community.
  2. Efficiency: Multiple services can be provided daily, with one patient visit instead of multiple visits.
  3. Connection: Electronic Health Records (EHR) are used across service lines to produce and track clinical and quality metrics.
  4. Accountability: A commitment to producing the array of quality metrics required for quarterly reporting, in nearly real time.
  5. Adaptability: A commitment to using bundled payment arrangements that help clinics adopt and utilize alternative payment models instead of fee-for-service.

To meet these core values, provider organizations, in many cases, have had to update their organization’s service lines, hire new staff, and implement or update Electronic Health Record systems (EHRs). These changes represent substantial economic and human resource expenses. While enhanced reimbursement and up-front grant dollars have helped to offset the expense, it still begs the question: “How does an organization sustain the model beyond the grant period?” (https://vbcforbh.com/are-you-really-ready-for-value-based-payment/)

Thinking Beyond Grant Funding

The recipients of the 2020 CCBHC Expansion Grant the funding stream are only guaranteed funding for two years. A few considerations are important. The first is that funding may not be renewed. Considering potential fiscal deficits expected from the COVID epidemic, there is a distinct possibility that additional funding will not be there. A second possibility is that state funding may supplant federal funding. As states grapple with the aftermath of a pandemic, fewer state dollars will be available.  Already, Nevada has made a 6% cut to Medicaid dollars (https://vbcforbh.com/nevada-moves-forward-with-6-medicaid-fee-for-service-rate-cut/).

SAMSHA was abundantly clear that grant participants should not expect more federal support. The newest round of grantees were given the task to: “Develop and implement plans for sustainability to ensure delivery of services once federal funding ends. Recipients should not anticipate the continued renewal of federal funding to support this effort. Federal funding is subject to funding availability and is also subject to a competitive grant award process. Recipients must develop and implement sustainability plans to ensure continued service once the grant ends. Recipients will be asked to report on sustainability plans” (https://www.samhsa.gov/sites/default/files/grants/pdf/fy-2020-ccbhc-foa.pdf).

The long-term sustainability of CCBHC programming requires a strategic response.

Community Behavioral Health Clinic (CCBHC) Sustainability and Value-Based Reimbursement

The CCBHC’s with an eye toward a future will be looking for alternative revenue streams immediately. The good news is that the CCBHC infrastructure of data driven health care focused on improved outcomes and diminished costs is an ideal match for payers who are looking for lower cost interventions and improved population health, and are using Value Based Reimbursement (VBR) to meet these goals.

The organizational readiness for CCBHC implementation has laid the groundwork for Value Based Programming.  The development of Evidenced Based Practices, addition of service lines, hiring new staff, affiliations with emergency care, adoption enhanced payment processes, and implementing and updating you Electronic Health Records (EHR) to capture clinical and quality data has positioned CCBHC to think about working with both private and public payers.

A Growing Value Based Culture

The OPEN MINDS 2019 State-By-State Update found that 28 of the 40 states with Medicaid managed care require health plans to implement alternative payment arrangements (APMs) with provider organizations. This is up from 22 states out of 39 states in 2017. And Value-Based processes are at the center of the trend. Organizational readiness for VBR follows a defined path:

(See OPEN MINDS Are You Really Ready for Value-Based Payment?)

The CCBHC is already this path, developing a VBR infrastructure. The next step is to define the unique value proposition of the CCBHC.

Defining the Unique Value Proposition to New Payors

A successful sustainability plan keeps the following goals in mind:

  • Have the Data: Understand internal unit costs and key performance indicators (KPI). Fortunately, the data needed to do this can be found in your CCBHC data. Use this to data to develop a picture of what the CCBHC does well, and where there are opportunities for improvement. Knowing strengths and possible risks will be important guides in rate negotiations.
  • Know the Customer: Research the payers in the market. For the health plans and accountable care organizations, know their structure and customers, their current service delivery network, executive teams, and their enrollment in your service areas. A CCBHC plan has flexibility to meet the changing needs of the marketplace. Alignment with those needs will make a CCBHC more attractive to payers that need services.  (See What Are Health Plans Actually Doing? and Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System).
  • Prepare for the End-Game. Think about future meetings with health plan executives to discuss current contracts and proposed services as the CCBHC plan is developed. Be prepared with a proposal and assess readiness for newer payment models (Use the Value-Based Reimbursement Readiness Assessment).

Build Relationships Now

Avoid scrambling at the last moment for new funding streams. Remember, payers know that mental health and substance use disorders are the leading causes of disease burden in America.  This is further exacerbated by co-morbidities faced by people with mental health and substance use disorders who also suffer from cardiovascular disease, and diabetes, and other chronic diseases. The CCBHC is addressing this issue head on and that needs to be highlighted. To do this you can start by doing the following:

  • Build relationships with payers immediately: Reach as high into the payer organization as possible to develop those relationships. Then attempt to establish formal touchpoints. A scorecard with quarterly data will provide updates on key points that may be of value to the health plan. These interactions need to be succinct and to the point.
  • Develop a Pitch Deck: Prepare a brief (one or two slide) value story that describes how the CCBHC’s programs are differentiated in terms of quality and costs, and how they contribute to health care cost savings for the payer.
  • Leverage Informal Meetings: Attend conferences and industry meetings with target payers. These less formal venues allow for additional touchpoints to reiterate the value the CCBHC brings to the table, and the differentiating strengths.

Finally, connecting with health plans comes down to persistence.  Provider organizations need to find the right contact in network management, or whoever is leading their local plan and continue to reach out. In the end, relationship-building is still based on quality communication. The CCBHC model is the perfect framework to build relationships with payer organizations.

Nevada Cuts Medicaid Fee-For-Service Rate By 6%; Expects Annual Savings Of $53 Million

On August 15, 2020, the Nevada Medicaid program implemented a 6% rate cut to fee-for-service (FFS) rates. The Medicaid rate reduction is expected to save the state about $53 million over the coming fiscal year. The rate cut was directed by Assembly Bill 3 enacted by the Nevada Legislature during a Special Session to address a budget shortfall due to the coronavirus disease 2019 (COVID-19) pandemic and its subsequent economic impact. The state was facing a budget shortfall of nearly $1 billion. Assembly Bill 3 made a total of $130 million in cuts to the Medicaid program.

The state’s Medicaid managed care capitation rates will be amended by Nevada’s Actuary to include the impact of the 6% reduction to the FFS Fee Schedules, with an effective date of August 15, 2020. The total Medicaid caseload as of July 2020 is 716,981. About 27% (196,256 people) of these recipients are served through the fee-for-service program.

The 6% rate reduction affects behavioral health outpatient treatment, special clinic-addiction treatment agency model, psychologist, behavioral health rehabilitative treatment, applied behavior analysis, and inpatient psychiatric/substance abuse treatment services provided by a general acute hospital. However, rates will not be cut for the following behavioral health provider types and services:

  • Freestanding psychiatric hospital
  • Certified community behavioral health center
  • Residential treatment center
  • Federally Qualified Health Center

On August 14, 2020, the Nevada Department of Health and Human Services (DHHS) Division of Health Care Financing and Policy (DHCFP) notified provider organizations that it was also amending the application for the Home- and Community-Based (HCBS) Frail Elderly (FE) and Physical Disability (PD) Waiver to reflect the rate reduction. All FE and PD Waiver services will remain the same. The amendment must be submitted to the Center for Medicare and Medicaid Services (CMS) for approval. Comments will be accepted through September 14, 2020.

A link to the full text of “Nevada Medicaid Draft Home- and Community-Based Frail Elderly Waiver Amendment” may be found in the OPEN MINDS Circle Library at www.openminds.com/market-intelligence/resources/081520nvdrafthcbsfewaiveramend.htm.

A link to the full text of “Nevada Medicaid Draft Amendment For Home &Community Based Waiver For Persons With Physical Disabilities” may be found in the OPEN MINDS Circle Library at www.openminds.com/market-intelligence/resources/081520nvdrafthcbspdwaiveramend.htm

A link to the full text of “Nevada Assembly Bill #3: An Act Relating To State  Financial Administration” may be found in the OPEN MINDS Circle Library at www.openminds.com/market-intelligence/resources/071920nvassemblybill3.htm.

For more information, contact:

  • Division of Health Care Financing and Policy, Nevada Department of Health and Human Services, 1100 East William Street, Suite 101, Carson City, Nevada 89701; 775-684-3676; Fax: 775-687-3893; Email: dhcfp@dhcfp.nv.gov; Website: http://dhcfp.nv.gov/Contact/Contact_Home/
  • Submit comments on the draft waiver amendment to: Nevada Division of Health Care Financing and Policy, ATTN: LTSS – FE/PD Waiver Amendment, 1050 E William Street, Suite 435, Carson City, Nevada 89701; Fax: 775-687-8724; Email: hcbs@dhcfp.nv.gov

The Business Model Transition To Value-Based Care

Hello again from sunny Clearwater, where we are wrapping up The 2016 OPEN MINDS Performance Management Institute. It’s been a power-packed three days – with a focus on the evolution of pay-for-performance and value-based contracting. The discussion has left me with some new thoughts about the strategies needed for success in the decade ahead. Managed care and integrated service delivery models are definitely causing a “reordering” of the market value chain for the financing and delivering services for consumers with complex care needs. More specialty services are being delivered, and will be delivered, in primary care settings. The current role served by targeted case management will likely be assumed by new programs and players. To respond to the many new opportunities, provider organizations need more entrepreneurial service line development – and the access to capital to make that happen. And, all of this brings big advantages to organizations that have scale.

The fundamental change for health plans and provider organizations alike is the emergence of a new business model in this new value-focused environment. The traditional role of optimizing the volume of services delivered is being gradually replaced by a model that aligns organizational success with giving the consumer (and their payer) what they want and need (see Will Good, Cheap & Easy Win the Day?). This shift to consumer sovereignty as the driver of success (see Consumer Sovereignty As Success Strategy and The Key To Success With Integrated Service Delivery? A Seamless Consumer Experience) creates a new leadership and management challenge – making performance management a core competency.

Are You Really Ready For Value-Based Payment? Planning Your Move

So how do organizations accelerate their path to performance management excellence? There are three key steps:  measurement, metrics-based management, and developing a performance-driven culture.

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Decide what to measure and measure it – The first step on the path is deciding on the measures that your executive team needs to navigate their way to performance excellence. There are the customer-facing metrics (HEDIS and SMS Stars measures for payers and consumer experience and web site analytics for consumers). And, there are the metrics you need to manage the enterprise – from cash on hand to productivity. Automate your measurements and measure routinely.

Establish a metrics-based management system – Metrics-based management is the path from information to action. It’s the system for knowing both your current performance on every measure and the performance you’re looking for – and the actions needed to bridge the gap.

Build a performance-driven culture – Performance measurement is only part of the equation. Using the data to change the organization is the key – and this requires a performance-driven culture. In short, an executive team and a management style that actually improves performance through talent management, goal alignment, and employee engagement.

So the question for most executives teams – is your culture a performance-driven culture? Can your organization thrive in the market environment where performance and value are the determinants of success? For more, check out my presentation, Are You Really Ready For Value-Based Payment?, from today’s institute. And, tomorrow, we’ll review the characteristics and competencies of the organization that is ready for results. And, in the meantime, check out our archived coverage of The 2016 OPEN MINDS Performance Management Institute on Twitter @openmindscircle#OMPerformance.