December 20, 2015
On Monday, December 7th, I participated in the National Council for Behavioral Health’s second all day training for state associations to support state planning to develop proposal under the Excellence in Mental Health Act Certified Community Behavioral Health Centers program which will significantly increase funding and significantly reduce documentation requirements for outpatient behavioral healthcare. See my paper documenting that the value of this is about $1 Billion statewide in the first year and growing.
A centerpiece of that training was the review of a new and expanded “Integrated CCBHC Certification Criteria Feasibility and Readiness Tool (I-CCFRT)”.
In studying that tool and discussions with other state association representatives I learned that the structure of county mental health in California (not yet the case for substance use disorders- but should eventually be with the implementation of the Organized Delivery System) is well aligned with the requirements for CCBHC certification, management and establishment of a prospective payment system.
Among our strengths are the following:
- Counties currently manage and direct all levels and types of care. This does not exist in states where most care is provided through fee for service.
- Counties also have good cost information since we already have cost based rates.
- Through the coordinated care initiative for dual eligibles with Medicare and MediCal; seven counties now also have care coordination and MOUs with health plans to create the bidirectional integration with physical health that is also expected. Many other counties and providers have pilot programs. Moreover the pending Section 1115 Waiver that includes the whole person health care pilots (described in more detail in last month’s blog) creates $1.5 Billion in funding for counties and plans that creates incentives for all counties to create these relationships.
- Most counties also have relationships with child welfare and other systems to provide for the care coordination that is required.
- California has programs (largely suspended) to do outreach to homeless individuals and other groups (some in prevention and early intervention) which not only helps provide better integration and achieve goals but also represents a type of expense that is eligible for federal financial participation under this program in a way in which it is not under our current billing system. This also could cover the behavioral health staff components of law enforcement related crisis intervention teams as well as the planning and continuity of care to serve people transitioning in and out of jail and prison.
- Well established recovery and resilience oriented services that comply with the trauma informed care requirement including many evidence based practices.
- Requirement of performance metrics some of which are already in place in the coordinated care initiative models and are consistent with those that must be developed for the Section 1915 B (mental health carve out) federal waiver and which we have already started to put in place.
There are others but the fact is that our county based system gives counties the centralized management and knowledge of costs that the provider entities who are funded as mental health centers directly by other states generally do not have. Note that this positions counties for certification as CCBHCs – not CCCBHA members. It now seems settled that none of our member CCCBHA agencies are likely to be certified. Counties may extend the daily or monthly payment model to pay providers but that is not something that directly affects state or federal funds and is something for agencies (and CCCBHA) to work out with counties.
I also learned that there is the ability to do this through a regional or broader joint powers authority of counties so that smaller counties and others that might not feel they have the capacity to take on this certification and new responsibility on their own may have an easier way to participate.
On the National Scene Only the National Council is Focused on This Program.
Others seem to not recognize the value of it and have not made any effort to educate their membership about what it can do- that includes NAMI, the associations of state mental health directors and the association of county behavioral health directors. Perhaps that is because it was enacted so quietly as part of a Medicare bill through an amendment added at the last minute or perhaps because of the nature of Washington DC advocacy competition and not wanting to bring attention to something that they can’t take any credit for.
So while the National Council is offering extensive technical assistance and also working on Capitol Hill to expand this to more states and more years (something that they are cautiously very optimistic about) other groups seem to ignore it and are talking about big complicated controversial bills introduced by Congressman Murphy of Pennsylvania (HR 2646) and Senator Murphy of Connecticut (S 1945. However, neither of those bills provide any meaningful funding compared to the Excellence Act.
The National Council has also indicated that state Medicaid directors believe that everything except the higher federal share of costs could be done through a Medicaid waiver – once the initial pilots show that this investment in outpatient behavioral health will pay for itself with savings in behavioral health and physical health inpatient costs.
The bottom line is that this is probably the future of community behavioral health. California counties are well positioned to become CCBHCs but our membership is way ahead of counties (and all other stakeholder interests) in studying it and preparing for it. Counties will likely need your leadership to get them to invest high level staff time in learning about this program and designating a qualified person to promote it and lead their efforts.