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

Making VBR A Success: What Health Plans Can Do

Adoption of value-based reimbursement (VBR) models is glacial—slow to occur but changing the delivery system in its wake. It’s an issue we’ve written about before—4 Lessons From ACOs For Managing Downside Financial Risk, VBR @ Scale—Changes Required, and Preparing For The Very Glacial VBR Rollout In Some Markets and will continue to help health and human service organizations find their footing. In the field, what I find interesting is that two different conversations are happening: Health plan executives talk about the lack of readiness of provider organizations while managers of provider organizations talk about the difficulty in moving VBR proposals forward with health plan customers. How do we make these partnerships evolve more smoothly? I think observations and advice from Alyna T. Chien, M.D., MS, Harvard Medical School, and Professor Meredith B. Rosenthal, Harvard T.H. Chan School of Public Health in the report, A 3D Model For Value-Based Care: The Next Frontier In Financial incentives And Relationship Support) provide a great foundation for that discussion.

The authors present a three-part framework for considering the health plan shift to VBR – financial incentives for reduced spending, financial incentives for improving quality, and infrastructure support for their partner provider organizations. Their infrastructure support includes performance management information (both access to raw data and analyzed data), limitations on financial exposure from risk contracts, care coordination tools, technical assistance, and infrastructure payments.

What is interesting is that these were the very issues brought up by provider organization executives during my session at our 2019 OPEN MINDS Executive Leadership Retreat. Access to data and limitation on financial downside were high on the list.

To make this three-dimensional model for VBR a reality, there are some specific actions that managers in health plans, accountable care organizations, and state and county government can take. Two key issues stood out for me as potentially having the greatest impact: Increasing the amount of revenue tied to VBR and aligning performance measures across payer contracts.

One of the common concerns I hear from provider organization executives is that the upside in the value-based contracts is not enough to justify infrastructure expenses. This is a fiscal reality at two levels in any individual payer contract. Is the incremental increased revenue of quality-based performance bonuses or shared financial savings enough to justify new operating infrastructure? Second is the volume of consumers served great enough to warrant dedicated service capacity (it’s addressing that ‘one foot in two canoes’ issue that provider organization managers face).

In our recent survey of specialty provider organizations, we found that 16% had 20% or more of their revenue coming from VBR contracts (see Where Are We On The Road To Value?: The 2019 OPEN MINDS Performance Management Executive Survey). While these numbers represent growth, they still illustrate the challenge of scale.

OPEN MINDS Senior Associate Drew Digiovanni urges industry members to walk before they run with VBR contracts that include financial risk:

Establish a pathway for providers who are entering into VBR agreements for the first time. Assess their abilities and offer limited performance measures in the first year to help them ramp up for success, before entering into more robust risk contracts.

The other issue is one that comes up every year during the OPEN MINDS Performance Management Institute – can’t health plans get together and agree on the same performance measures? From the provider organization perspective, almost every VBR-based contract is a ‘one off’ with different measures that have different definitions.

Admittedly, the adoption of NCQA HEDIS and CMS STARS are starting to create some “standardization” of measures, but provider organization managers need very flexible (and very expensive to maintain) performance reporting tools that can be customized for each contract. Almost any initiative to standardize measures would be welcome on the service delivery side of this equation.

Moving forward, how do health plan executives make their provider partnerships a success, sooner rather than later? OPEN MINDS Senior Associate Paul M. Duck suggests that transparency and investments in technology need to be front and center in VBR discussions:

Provider and payer organizations benefit from technology implementation. If a tool like a telepsychiatry platform is implemented, the payer benefits by increasing access to care, which lowers costs and prevents emergency room admissions. Provider organizations benefit by delivering a new service, which opens the door for additional revenue. It expands access for a larger population and delivers services in places where a group might not have a physical presence, such as rural communities. In other words, it’s a win-win.

Tomorrow, we’ll look more specifically at the provider organization side of the VBR equation. But for now, for more on the path to VBR, check out:

  1. The OPEN MINDS Value-Based Reimbursement Readiness Assessment
  2. How To Build Value-Based Payer Partnerships
  3. Implementing Value-Based Care Through The Certified Community Behavioral Health Model
  4. Does Your Strategy Prepare You For Success In A Value-Based Market?
  5. Current Insights Into Population Health Management Value-Based Models In Managing High-Risk, High-Cost Patients
  6. Using Data To Follow The Money & Stay True To The Mission
  7. Structuring (& Budgeting For) Analytics
  8. Technology & Reporting Requirements For Population Health Management: Preparing For Value-Based Reimbursement
  9. Planning & Budgeting For Technology: How Much Is Enough?
  10. From Pain Point To Revenue

And for a deep dive, join us 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.