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National demo aims to update clinic pay scale

August 12, 2015
by Brian Albright
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As many as two dozen states are preparing to launch a new approach for delivering and reimbursing comprehensive behavioral health services through specially certified clinics. At $1.1 billion, the program marks the largest federal investment in community-based mental health in decades.

Planning grants are already in place for the Demonstration Program to Improve Community Mental Health Services. The Substance Abuse and Mental Health Services Administration (SAMHSA) and various offices in the Department of Health and Human Services (HHS) are overseeing the project, which was established under the Protecting Access to Medicare Act (PAMA) of 2014.

SAMHSA will award up to $24.6 million in initial planning grants for up to 25 grantees to lay the groundwork to ultimately participate in the practical phase of the two-year demonstration program. Awards will be announced in October. In the project, states will establish Certified Community Behavioral Health Clinics (CCBHCs) and a Prospective Payment System (PPS) for those clinics that will reimburse the full cost of services provided.

“The goal here is to see if we can provide these comprehensive services, increase access to those services, and are able to provide them earlier, so we can reduce overall system expenditures,” says Chuck Ingoglia, senior vice president of public policy and practice improvement at the National Council for Behavioral Health. “Can we stop people from using the emergency room or having expensive inpatient psychiatric hospitalization? At the end of the day, we want to improve access to quality care.”

The demo is based on language originally found in the Excellence in Mental Health Act.

Provider criteria

To become a CCBHC, providers must meet a lengthy list of criteria that include primary health screenings, the ability to coordinate with primary care providers, the use of evidence-based mental health and substance abuse treatment services, and other best practices.

The planning grant phase of the project will provide funds for one year to develop processes to certify CCBHCs, establish a PPS for Medicaid-reimbursable behavioral health services and to prepare applications. Applications for participation in the practical demonstration program are due in October 2016. Eight of the applicants will be selected in January 2017.

“This will take a lot of work for the states,” says David Morrissette, senior program manager at SAMHSA. “Under those one-year grants, the states are going to be working hard to prepare to participate in the demonstration program. The challenges are going to vary by state.”

Once the demonstration is up and running, SAMHSA and the Centers for Medicare and Medicaid Services (CMS) will evaluate how the program is affecting both outcomes and costs.

“The evaluation process will examine the impact of the demonstration on several things, including access to community-based behavioral health services, the quality and scope of those services, and the federal and state cost for a range of services, including inpatient and ambulatory services,” says Cynthia Kemp, chief of the community support programs branch at SAMHSA.

Sufficient payments

Populations served by the CCBHCs under the project will be adults and children with series mental illness or emotional disturbance, and those with long-term and serious substance abuse disorders. Once the practical demonstration project starts, participating states will be paid with federal matching funds equivalent to the Children’s Health Insurance Program (CHIP) matching rate for services.

The prospective payment system is one element that has a lot of states and providers excited.

Under the program, payment is derived from the actual cost of providing services. Providers who qualify as CCBHCs can implement evidence-based practices and be assured a payment stream that can effectively compensate for those efforts.

“In general, when we have looked at the spread between what it costs a mental health center to deliver services and what they get reimbursed, generally there is a 35-cent gap on every dollar,” Ingoglia says. “This program moves us closer to actual costs.”

States will select one of two PPS rate methodologies for use in the demonstration:

  •  The first option provides reimbursement of cost on a daily basis with the addition of a state option to provide quality bonus payments to CCBHCs that meet defined quality metrics.
  •  The second option would use a monthly unit of payment, and provides for quality bonuses and for rates that vary, depending on the populations served by the certified clinic. Under the second option the state is required to incorporate quality bonus payments.

The program will also reimburse some services that prove challenging under current Medicaid rules.

“What we’ve found is that there are a lot of evidence-based practices that sometimes are hard to pay for in a traditional Medicaid model,” Ingoglia says. “So states will be able to do that through the prospective payment system based on actual costs. It doesn’t need to have a corresponding CPT code.”