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Podcast Library > NextGen Advisors Podcasts > How Certified Community Behavioral Health Centers are Leading the Integration of Whole Person Care

June 25, 2021

How Certified Community Behavioral Health Centers are Leading the Integration of Whole Person Care

Ambulatory practices continue to advance the integration of physical and mental health services.  In this episode, NextGen® Advisors Graham Brown and Dr. Marty Lustick speak with NextGen Healthcare’s government affairs Advisor, Chris Emper to discuss the important role played by Certified Community Behavioral Health Centers and detail recently announced $3B in grant programs from Health and Human Services to advance the integration of these programs at the community level.

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Transcript

Graham Brown:

Hello, this is Graham Brown, principal with NextGen Advisors. Welcome to our podcast. Today, I'm joined by my colleagues, Chris Emper, NextGen's government affairs advisor, and Dr. Marty Lustick, a principal with the advisers. Good morning gentlemen, and welcome.

Marty Lustick:

Hey Graham, it's great to be here.

Chris Emper:

Hey Graham.

Graham Brown:

We've each been working for many years with provider organizations around the United States who provide physical health and primary care services as well as services for behavioral and mental health needs. On prior podcast episodes and via the NextGen advisors blog, we've explored the historical differences in how behavioral and physical health have been separated from a payment, regulatory, staffing, and even government's perspective. As a result of this history, many provider groups find themselves operating what may feel like and function like two parallel businesses, each subject to very complex operating needs. Yet over the past decade, there's been a focus and traction on the integration of these two practice areas. And we want to explore that topic today as well as the recent announcement from health and human services regarding grants to behavioral health provider organizations. So Marty why don't you start us off by describing what's happened via demonstration projects that the centers for Medicare and Medicaid services have initiative?

Marty Lustick:

Yeah. So I was actually interested to learn more about this. It started back in 2014 when Congress passed a set of rules, requiring demonstration products be developed by CMS to be tested across several states. So they put the initial pilot descriptions and requirements starting in 2014. The first eight states that were part of this pilot, I think were up and running by the beginning of 2017. And within this is the concept of a certified community-based behavioral health clinics. CCBHC for short, and there's a variety of requirements for those organizations to qualify to be part of them. Those requirements were delineated in the legislation in terms of being patient centered and having a scope of services that met the needs, mostly focused on the needs of those, the serious mental illness and substance use disorders, and also had a particular focus on those issues as it relates to the needs of veterans. And so those pilots got started in 2017 with an enhanced payment. And then of course the states, because it was through Medicaid, had some leeway in how they built and organized to those pilots.

Graham Brown:

And so talk a little bit about what the results of some of these demonstration projects were and did that lead CMS to broaden the program? And if so, how?

Marty Lustick:

Well it's interesting because it all happened, it's happened fairly quickly by government standards is that there really wasn't enough time to see impact on outcomes so much for patients, but clearly the pilots demonstrated significantly improved access to services for those with serious mental illness and substance use disorder. So as a result of that in 2018, Congress actually appropriated significant funding for other states to begin to get planning grants, to begin to scope out how they would build the same capabilities there. And so that by, by this past year, there were, there's now up to 40 states that have over about 340 CCBHCs now established. So went from a pilot to being pretty pervasive pretty quickly.

Graham Brown:

Chris, the, you know, the health and human services has kind of continued on this theme and continuing to invest in this area. There's some significant grant opportunities that were announced recently just for behavioral health services. Talk a little bit about those grants and what goals and objectives they're meant to achieve.

Chris Emper:

Absolutely. So this actually ties in with the federal government's response to the COVID 19 pandemic and tracing back to last year that the Covid aid laws that were passed specifically allocated funding for several behavioral health programs, as well as for rural communities, community health centers, and other programs that Congress felt could reach the more underserved communities that have been more heavily impacted by the pandemic and some of the secondary effects of the lockdown from the pandemic as well.

Chris Emper:

Most recently in the American Rescue Plan Act that was passed and signed into law in March, there was $3.5 billion for behavioral health programs and $3 billion specifically allocated to the two largest block grant programs run by SAMHSA, the Substance Abuse and Mental Health Services Administration, another acronym for us to learn under the banner of the HHS Department of Health and Human Services. The two big grant programs, which each were given $1.5 billion where the Substance Abuse Prevention and Treatment Block Grant Program, similar to as Marty was just talking about focused on substance abuse disorders and the like, and providing preventative services for them. And the other program is the Community Mental Health Services Block Grant Program. So each of these programs is given $1.5 billion, which is actually initially given to the states, and then from there, the states have pretty broad authority with some federal purse strings attached to it, and some rules to make grants, to be able to help providers, non government, nonprofit agencies and local health departments that run some of these programs.

Chris Emper:

This is actually record funding for these programs. As a comparison, you know, you're looking at a $6 billion dollar annual budget for the entire department. The entire SAMHSA department across all of these behavioral health programs. And there was actually 5.5 billion, 2.5 billion included in a December, 2020 end of year law for these block grant programs and then 3 billion in the most recent program. So five and a half billion, almost as much as the annual budget for SAMHSA appropriated through these programs with pretty flexible distribution options for providers. So similar to what we talked about in previous podcasts and over the last few months with community health centers, this is a time of record investment from the federal government into behavioral health programs.

Graham Brown:

You know, it's, it's really fascinating to see this level of recognition at the federal government level of this area that's really been underfunded and kind of ignored sitting on the periphery in terms of overall healthcare. According to the Mental Health America, which is an advocacy group, promoting mental health as a critical part of overall wellness, almost one in five Americans, or 19%, experienced a mental illness in 2017 and 2018. And that's before COVID-19 pandemic, which saw a major increase in the use of mental and behavioral health services, increase in suicidal ideation, increase in recreational and drug use. So if, you know, community health centers and these organizations that have been certified or providing this integrated care, it sounds like they're really bridging the gap between services that the population needs in mental health and physical health under one organization. To me that integrated care model may be appropriate for value based contracting approaches and alternate payment methods and Marty, I'd be interested in your thoughts on what are some of the opportunities that you've seen these organizations undertake related to value based contracting?

Marty Lustick:

Yeah, so I, think that to start with these pilots in the CCBHCs looked at somewhat of a case rate that spanned, you know, in general a kind of a six month period. So it began to look at the concept of an episode of care in behavioral health and provide the lead organization in these CCBHCs with a monthly set of funds to manage those patients. So from the beginning, I think there was an attempt to align the way the payment's structured with giving the providers the financial tools and the flexibility to figure out how to take a sort of global payment, for lack of a better word, and figure out how to most effectively and efficiently use those funds to meet the needs of that individual that they were serving. So I think it was a great place to start. We've already begun to see, I was reading about in Baltimore where they've piloted actually a capitation arrangement for these patients.

Marty Lustick:

So to your point, where if you have an organization that can take accountability for the overall care, it's worth noting, you mentioned, you know, the prevalence of mental health disease, but reading a statistic that over two thirds of people with a chronic mental illness have a comorbid physical condition. So the need to have integrated care to meet the needs of this population is enormous. So I think we're moving in the right direction. And these ideas with case rates and capitation, I think are going to make a big difference, if we can work out the details.

Graham Brown:

Are there any unique challenges you think that providers in this space are facing?

Marty Lustick:

Yeah. So I said, if we can work out the details and that's kind of what I was alluding to, even if you look at the way the CCBHC is defined and they're required to have a set of a scope of services and care coordination capabilities that are intended to meet the overall needs of the patients they serve. But for example, one of the requirements is that there's an ability to screen for the risk of physical illness and in the needs on the physical medicine side of it, but it doesn't require a fully integrated system of care that meets both sets of needs. And there's a lot of work to be done in that space. Likewise, it doesn't, for example, require that inpatient psychiatric and substance use services are formally included in the CCBHC. So in order for these organizations to really fully take accountability and take financial risk, they need to have integration with the whole continuum of services that these patients are going to require and to be if they don't own them, at least influence that care so that they can be accountable for the outcomes and the cost and so on.

Graham Brown:

Yeah. So still operational silos there, when we think about it at a community level. Chris, so what given this, you know, really kind of historic funding that's in place now and going to be rolled out over the next several months. What would you anticipate the overall impact is going to be for behavioral health providers and maybe a little glass balling about the future outlook?

Chris Emper:

Yeah, great question. It's always interesting after these programs are rolled out and the funding has been kind of pushed out the door to see what, you know, what happens and what comes next. Next, I think a lot of that and a lot of the impact needs to be determined based on how providers, you know, choose to use the funds, whether they're used in a, for lack of a better word, sustainable fashion, to build some of the capacities they'd need to participate in some of these advanced risk based models that Dr. Marty was talking about. And, you know, just in, in general, where you look at behavioral health, and right now these programs should be viewed as incentive programs, similar to what we saw maybe 10 years ago for the broader healthcare community, with meaningful use in PQRS and different states demonstration programs that were trying to play around with primary care models, and PCMH, and medical homes, and trying to build the capacity and provide some financial resources for practices to build the capacity they might need to enter into these advanced risk-based models that can provide, you know, higher quality, lower cost care.

Chris Emper:

I think that's where the behavioral health world is right now from the federal government's perspective. And with that, there's going to be a little bit of leeway to start, but I think the quicker that the provider community can find a way to appropriately measure and demonstrate back to the government, the success of these programs and of these investments, they'll have a big part to play in shaping that future. And I think one of the exciting things about the behavioral health space, it is a unique space in that as Dr. Marty mentioned, there are a lot of costs dollars in healthcare, as you consider these value-based care models that are associated with the patients who are in this space. So I think the providers have a unique ability to shape the future of these models with commercial payers, with the government, and especially in the states with the state governments and the Medicaid agencies where a lot of these patients are allocated towards.

Graham Brown:

It will be really interesting to watch because, to your point, there could be, you know, really 50 different models of innovation that occur at a state level, and there could be many different approaches tested. Marty, what do you anticipate, a thought that comes to mind as we think about Chris referencing the transformation in primary care over the past decade, should behavioral health organization start thinking about accountable care organizations and how they look at that full continuum of care and managing it in a different way. Do you anticipate that? Or what else might you foresee?

Marty Lustick:

I hope for that, I do think that the CCBHC model sort of represents a potentially really good foundation for building the equivalent of a clinically integrated network that it focuses on behavioral health needs. I would pile on Chris's comment or use of the word sustainability. I think if the organizations that are getting this extra funding use the money strategically to position themselves in the long run, to be able to improve the value and the outcome of care for the population they serve. The good thing is there's enormous amounts of excess spending because of the lack of infrastructure to support that population historically. So if they can use the money strategically, there's a huge opportunity to make this a cost-effective long-term sustainable solution.

Marty Lustick:

If they, if they use the money to dig themselves out of the holes that they've been in, because they've been so underfunded and they don't take a strategic approach, this could just be a flash in the pan kind of thing that we're seeing right now. So I think it's going to be really important, both to support organizations that are trying to move forward in this space to help them take a strategic approach and to measure and track the outcomes so that as we see where there are successes, we work on replicating and scaling those.

Graham Brown:

Well excellent insights and great, great expertise from each of you to inform this conversation. Thank you very much for joining Chris Emper and Marty Lustick and to our listeners as well for tuning in. For more episodes from the NextGen Advisors hit the subscribe button. This is Graham Brown with NextGen Healthcare. Thanks for listening and have a great day.