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.

How To Build Value-Based Payer Partnerships: An OPEN MINDS Executive Seminar On Best Practices In Marketing, Negotiating & Contracting With Health Plans — Best Practices in Contracting With Health Plans

OPEN MINDS Senior Associate Paul Duck delivered this seminar at The 2020 OPEN MINDS Performance Management Institute in Clearwater Beach, FL on February 12th, 2020. In this seminar, we discussed how to start strategic conversations with health plans, how to demonstrate your organization’s value in way that will capture health plan’s interest, and how to secure and optimize service agreements with health plans. The presentation has been broken into four parts, this page contains Part 3: Best Practices in Contracting With Health Plans.

Presentation Download (PDF)

Click here for related resources:

Part 1 — Context of Behavioral Health

Part 2 — Best Practices in Marketing

Part 4 — Best Practices in Payer Negotiating

How To Build Value-Based Payer Partnerships: An OPEN MINDS Executive Seminar On Best Practices In Marketing, Negotiating & Contracting With Health Plans — Best Practices in Marketing

OPEN MINDS Senior Associate Paul Duck delivered this seminar at The 2020 OPEN MINDS Performance Management Institute in Clearwater Beach, FL on February 12th, 2020. In this seminar, we discussed how to start strategic conversations with health plans, how to demonstrate your organization’s value in way that will capture health plan’s interest, and how to secure and optimize service agreements with health plans. The presentation has been broken into four parts, this page contains Part 2: Best Practices in Marketing.

Presentation Download (PDF)

Click here for related resources:

Part 1 — Context of Behavioral Health

Part 3 — Best Practices in Contracting With Health Plans

Part 4 — Best Practices in Payer Negotiating

What Are Health Plans Doing About VBR?

It’s hard to get a snapshot of where the specialty health care market is with value-based reimbursement (VBR). Our recent surveys of provider organizations and health plans provide an interesting view. Generally, while specialty organizations that serve consumers with complex health needs lag behind acute health care in their adoption of VBR, we see use and effects of these payment models continuing to increase.

Our provider organization survey found that 69% of specialty provider organizations participate in some form of VBR arrangement (see Where Are We On The Road To Value?: The 2019 OPEN MINDS Performance Management Executive Survey). Participation varied by market with 85% of primary care provider organizations in VBR arrangements compared with 72% behavioral health organizations, 58% of child service organizations, and 55% of intellectual and development disability or long-term services and supports organizations participating in the models.

Contrast this with the health plan perspective: 93% of health plans are tying fee-for-service payment to performance and, from 2017 to 2019, the number of health plans using some form of bundled payment or case rate rose from 39% to 59% (see Trends in Behavioral Health: A Population Health Manager’s Reference Guide on the U.S. Behavioral Health Financing and Delivery System).

Use of pay-for-performance increased from 86% in 2017 to 93% of all health plans in 2019, and bundled payments increased from 39% to 59%. For 2019, pay-for-performance was used consistently across all plans: 98% of commercial plans, 96% for Medicaid, and 89% for Medicare. And while 40% of commercial plans used bundled payments, 71% and 88% of Medicare and Medicaid plans use the model, respectively.

Increased use of bundled payments among commercial payers in particular indicates success for health care professionals as well as consumers, says OPEN MINDS Senior Associate Deb Adler:

The advantage for the consumer is fewer co-pays. With bundles a consumer pays once instead of one copay for each visit. For example, with a bundled payment for medication-assisted treatment, an evidence-based, increasingly common practice for substance use disorders, a bundled payment includes all services including medication management, individual and group therapy, peer counseling, and labs. The medication is frequently paid outside of the bundle. Bundled payments are becoming a more popular approach for payers to better align incentives because they are a win-win-win…”

How much of the health care spend is tied to VBR? Our survey of specialty provider organizations provides a few interesting insights. While 69% of specialty provider organizations are participating in VBR contracts, only 58% have seen revenue from these arrangements. There was one important change in the data: 16% of those organizations reported receiving 20% or more of their revenues from VBR, which speaks to a growing consolidation of the contracts and income among provider organizations. Ms. Adler notes:

Low revenue from VBR arrangements indicates that we need to increase medical expenditures tied to value-based incentives. It also reflects the fact that rewards are still rather low in performance-based incentives and often range from 3% to 6% in enhanced payments for performance-based contracts. In comparison, pay-for-performance is easier to administer through rewards or disincentives based on outcomes, which could explain why it’s penetrated all books of business.

Learn more about VBR with these resources from the OPEN MINDS Circle Library:

  1. There Is No “Plan B” Alternative To Value Creating A Value-Focused Competitive Strategy In A Changing Market
  2. How To Develop Alternative Payment Models: A Guide To Building Effective Bundled Payment Models
  3. The State of Value-based Care in 2018: 10 Key Trends to Know
  4. Care Delivery In A Value-Based Era – Evidence-Based, Practice-Based, Standardized & Measurement-Based
  5. The Management Lessons Driving Strategy In 2019
  6. Developing Case Rates? Better Find Your ‘Single Source Of Truth’
  7. Adjust Your Strategic Sails!
  8. When The Competition Succeeds At Pay-For-Performance, What Will You Do?
  9. Options For Alternative Payment Models For Behavioral Health
  10. Using Your Performance Metrics To Build A Value Proposition For Health Plans

And join me February 12 for the “How To Build Value-Based Payer Partnerships: An OPEN MINDS Executive Seminar On Best Practices In Marketing, Negotiating & Contracting With Health Plans” during the 2020 OPEN MINDS Performance Management Institute.

Addiction By The Numbers

How should addiction treatment programs be evaluated? That was the focus of the session, Quality Measurement In Addiction Treatment: Advancing Adoption Of Best Practices, at The 2019 OPEN MINDS Management Best Practices Institute, featuring Samantha Arsenault, MA, Vice President of National Treatment Quality Initiatives, Shatterproof; Eric Bailly, LPC, LADC, Business Solutions Director, Anthem, Inc.; and Doug Nemecek, M.D., MBA, Chief Medical Officer – Behavioral Health, Cigna.

Shatterproof, with a coalition of payers and other interested stakeholders, is taking on the challenge of quantifying the effectiveness of addiction treatment programs. Why? There is large variation in the use of evidence-based practices in addiction treatment programs and currently, provider organizations don’t have a standardized research tool to assess and benchmark themselves. Consequently, individuals don’t have reliable or unbiased sources to identify addiction treatment options.

To address these issues, Shatterproof is creating ATLAS (Addiction Treatment Locator, Analysis, and Standards Tool) an online tool available to the public, provider organizations, and payers to identify high quality addiction treatment provider organizations. (For more on ATLAS see, Are You Ready For The Shatterproof Addiction Treatment ATLAS?) This initiative will take addiction treatment program evaluation beyond its current state through  claims data and data provided by the treatment facility and patient experience surveys in order to present a more complete picture of treatment program effectiveness.

Both Cigna and Anthem are moving toward value-based reimbursement for addiction treatment and both are using claims data as the initial framework. The collaboration with Shatterproof will likely add to the data available for the evaluation of the cost and effectiveness of treatment – and this will improve the VBR models.

Mr. Bailly explained that Anthem’s value-based initiatives for substance use disorder (SUD) treatment are influenced by the work of The Alliance for Addiction Payment Reform (Alliance), and have helped to shape Anthem’s SUD strategy outlined in three pillars focused on improving access to high quality SUD treatment services which are efficient and cost effective, and lead to improved health outcomes. Anthem has successfully launched value-based incentives with numerous provider organizations across the country, and is currently developing Addiction Recovery Medical Home Alternative Payment Model proof of concept pilots in several markets, with a goal to launch one of these pilots by the end of 2019.

Dr. Nemecek presented Cigna’s behavioral health network strategy – a strategy that also includes value-based reimbursement elements. The network strategy includes improving access to care through virtual solutions and network growth, promotion of affordability and quality, integration via accountable care organization support, creating provider organizations of choice with differentiated service models, and preferred provider organization network alignment.

To promote affordability and quality, Cigna has already begun selecting Centers of Excellence (COEs) for addiction treatment. The network currently consists of 302 behavioral health provider programs – 133 inpatient and residential facilities and 169 partial hospitalization/intensive outpatient programs. These programs were found to have lower costs for admissions and per customer than both other in-network provider organizations and out-of-network provider organizations. Readmission rates at COEs were also 24% lower than other in-network provider organizations and 87% lower than out-of-network provider organizations.

The collaboration of 21 health and human service stakeholders with Shatterproof on standardizing performance measurement is a significant step forward in creating an improved national approach to addiction treatment program evaluation. For more on the state of metrics-based performance evaluation, join us at The 2019 Technology & Informatics Institute in Philadelphia on October 29 for the session, Data Makes The Difference: Using Data To Manage Care Coordination & Value-Based Arrangements featuring Ken Carr, Senior Associate, OPEN MINDS.

Health Plan Relationship Building Skills Key To VBR Success

As executive teams of specialty provider organizations look ahead to 2019, it appears that the shift to performance-based reimbursement will continue. The most recent change has been the new CMS rules that will move accountable care organizations (ACO) to full-risk reimbursement contracts (see CMS ‘Pathways To Success’ Medicare ACO Overhaul Limits ACO Time Without Risk). This is going to generate new and different relationships between health plans and provider organizations, as I discussed in Health System/Insurer Combos Gain Steam-& More To Come With ACO Changes. As a result, the OPEN MINDS senior team views value-based reimbursement (VBR) strategy as a key sustainability issue for provider organizations in 2019—The 2019 Health & Human Service Landscape: 2018 Legacy Sets Stage For Opportunities & Challenges and The Three Trends That Are ‘Top Of Mind’ In 2019 For The OPEN MINDS Team.

Deb Adler

If that is the case, the strategic question for executive teams is: How do you seize the opportunities and avoid market challenges in this landscape? That question will be the focus of the upcoming 2019 OPEN MINDS Health Plan Partnership Summit on February 13, 2019 at the Sheraton Sand Key Resort, in Clearwater Beach. The summit is led by my colleague and OPEN MINDS Senior Associate Deb Adler. Ms. Adler’s overarching advice for provider organization executive teams struggling with this question is focused on enhancing their skills with building relationships (and new programming) for health plans.

What is involved in that relationship building? Ms. Adler outlined four key items:

  1. Develop a brief (one or two slide) value story that describes how your organization’s programs are differentiated in terms of quality and costs, and how you contribute to health care cost savings for the payer
  2. Know the payer’s pain points and needs, as well as important performance metrics
  3. Know thyself and plan a formal negotiation strategy that identifies your “walk-away” position on pricing and service model elements
  4. Develop the relationship, at the highest level possible, and sustain that relationship intentionally

Develop a brief value story—When contact is made, and executives of a provider organization have gotten “in the door” for their initial meeting, the conversation needs to get to the point promptly. What value is your organization bringing to the table, and what are the strengths that differentiate you from the competition. Ms. Adler noted:

Provider organizations should have a short, one or two-slide value story presentation that illustrates what they bring to the health plan that is a cost and quality differentiator. Ideally it would include measurable results for the measures that the plan cares about—measures like ambulatory follow-up, readmission rates, health care cost savings, reduced emergency room visits, etc.

Know the payer’s pain points—It’s a mistake to walk in and attempt to describe the problem when the payer knows exactly what their problems already are. The key is for the provider organization’s executive team is to understand the problem from the health plans perspective and how they will measure success. Ms. Adler explained:

There is a high probability that the payer’s pain points largely center around three key areas: access to psychiatry services, addiction costs, and autism service access and costs. While I wouldn’t assume that any individual health plan has all three or even any of these pain points, the best approach is to ask. Get to know the health plan’s specific problems and devise a proposal that makes the health plan management team successful in terms of the quality or cost issues they have identified. Presenting a proposal that ultimately solves the health plan’s current challenge is the key—with a focus on the service, the cost, and measures of performance.

Know thyself and plan—When developing a relationship, and hopefully a contract, a provider organization’s executive team need to know when to compromise and when to hold firm. Walking that fine line is the focus of your negotiations, and requires an understanding of the market, the competition, and your organization’s capabilities and cost structure. Ms. Adler explained.

Provider organizations need to have a formal negotiation strategy-knowing what they want and how to negotiate towards that end. You need to understand your internal unit costs and key performance indicators (KPI) and your ability to manage risks and alternative reimbursement models. You should spend time preparing (and role playing if possible) all key contract terms (both language and reimbursement), thinking through various payer reactions and how you will respond. You need a clear idea of what things you will bend on, as well as those that would result in walking away.

Develop the relationship—Finally, Ms. Adler stressed the importance of pull-through on the new relationship. After the contract is in place, the executive team must be involved in maintaining and continuing to build the relationship to ensure that the partnership remains mutually beneficial. She noted:

Like any relationship, you need to find ways to develop and sustain it. I always recommend reaching as high into the payer organization as possible to develop those relationships—and the more relationships, the better. Then implement formal touchpoints (e.g., monthly or quarter scorecard reviews) or informal touchpoints (watch for conferences where the health plan leader is attending, and you can interact), where you can share industry updates that you think will be valuable to the health plan.

In summary, Ms. Adler explained that connecting with health plans on these (and other) topics comes down to persistence more times than not. Provider organizations need to find the right contact in network management, or whoever is leading their local plan and continue to reach out.

For more, be sure to mark your calendar for The 2019 OPEN MINDS Health Plan Partnership Summit on February 13, featuring Ms. Adler along with Kelly J. Champ, Vice President, Network Strategy & Innovation, Optum; Matt Miller, Senior Vice President, Public Sector, Magellan Healthcare; Charles Gross, Ph.D., Vice President, Behavioral Health, Anthem, Inc.; and Beth Rath, PMP, Vice President Network Operations, New Directions.