Implementation Findings from the National Evaluation of the Certified Community Behavioral Health Clinic Demonstration. I. BACKGROUND


A. Description of the CCBHC Demonstration

In April 2014, Section 223 of the Protecting Access to Medicare Act (PAMA) authorized the Certified Community Behavioral Health Clinic (CCBHC) demonstration to allow states to test new strategies for delivering and reimbursing services provided in community mental health centers (CMHCs). The CCBHC demonstration aims to improve the availability, quality, and outcomes of ambulatory services provided in CMHCs by establishing a standard definition and criteria for CCBHCs and developing a new payment system that accounts for the total cost of providing comprehensive services to all individuals who seek care. The demonstration also aims to provide coordinated care that addresses both behavioral and physical health conditions.

In October 2015, the U.S. Department of Health and Human Services (HHS) awarded planning grants to 24 states to begin certifying CMHCs to become CCBHCs, develop new prospective payment systems (PPS), and plan for the demonstration's implementation. To support the demonstration's first phase, HHS, as required by PAMA, developed criteria for use in certifying CCBHCs in six important areas: (1) staffing; (2) availability and accessibility of services; (3) care coordination; (4) scope of services; (5) quality and reporting; and (6) organizational authority.[5] The criteria established a minimum threshold for the structures and processes that CCBHCs should have in place to provide high-quality care, although states may exercise some discretion in implementing the criteria to reflect their particular needs.

States used the planning grants to develop infrastructure to support the CCBHC demonstration, and to select a PPS model and develop PPS rates. States chose between two broad PPS models developed by the HHS Centers for Medicare & Medicaid Services (CMS) (although they may exercise some flexibility in operationalizing the models). The first model (PPS-1) is similar to the PPS model used by federally qualified health centers (FHQCs)--it reimburses costs by using a fixed daily rate for all services rendered to a Medicaid beneficiary. If a state elected the PPS-1 model, CMS reimburses participating CCBHCs at a fixed daily rate for all services provided to a Medicaid beneficiary. The PPS-1 model also includes a state option to provide quality bonus payments (QBPs) to CCBHCs that meet defined quality metrics. The second model (PPS-2) reimburses costs by using a standard monthly rate per person served, with separate monthly rates that vary with beneficiaries' clinical conditions. Under the PPS-2 model, CMS reimburses participating CCBHCs at a fixed monthly rate for all services provided to a Medicaid beneficiary. The PPS-2 also includes outlier payments for costs above and beyond a specific threshold (that is, payment adjustments for extremely costly Medicaid beneficiaries). The PPS-2 model also requires bonus payments for clinics that meet defined quality metrics. Both PPS models aim to enhance Medicaid reimbursement by ensuring that reimbursement rates more closely reflect the cost of providing an enhanced scope of services. The use of a PPS provides a unique opportunity for states and CCBHCs to develop rates based on the expected cost of care that accounted for total costs associated with delivering the nine required services to Medicaid beneficiaries. This included the ability to use a mix of staffing models, as well as pay for services that were allowed under the demonstration, but might not have been traditionally covered under Medicaid, such as those that do not involve face-to-face contact with the consumer. These PPS reflect HHS's broader strategy of encouraging the development of a health care system that results in better care, smarter spending, and healthier people. While clinics cannot reject or limit services on the basis of a client's ability to pay, CCBHCs can, however, only bill Medicaid for services provided to Medicaid beneficiaries. In addition, states must establish and publish a sliding fee discount schedule for clients.

In December 2016, HHS selected eight states from among the 24 that received planning grants to implement their PPS models and provide services that align with the CCBHC certification criteria. Consistent with PAMA requirements, HHS selected Minnesota, Missouri, Nevada, New Jersey, New York, Oklahoma, Oregon, and Pennsylvania based on the completeness of the scope of services their CCBHCs will offer; the CCBHCs' ability to improve the availability of, access to, and engagement with a range of services (including assisted outpatient treatment [AOT]); and their potential to expand mental health services without increasing federal spending. CCBHCs participating in the demonstration must also provide coordinated care and make available a comprehensive range of nine types of services[6] to all who seek help, including but not limited to those with serious mental illness (SMI), serious emotional disturbance (SED), and substance use disorder (SUD). Services must be person-centered and family-centered, trauma-informed, and recovery-oriented, and the integration of physical and behavioral health care must serve the "whole person." To ensure the availability of the full scope of CCBHC services, service delivery could involve the participation of other Designated Collaborating Organizations (DCO), which are entities not under the direct supervision of a CCBHC but that are engaged in a formal relationship with a CCBHC to provide selected services. DCOs provide services under the same requirements as CCBHCs. CCBHCs that engage DCOs maintain clinical and financial responsibility for services provided by a DCO to CCBHC consumers, and directly reimburse DCOs for provided services. CCBHCs and participating states must be able to collect, track, and report on a wide range of encounter, outcome, cost, and quality data. As summarized in Table I.1, 66 CCBHCs are participating across eight states; only two states elected the PPS-2 model. As of August 2019, the demonstration will end on September 13, 2019.

TABLE I.1. Number of CCBHCs, Demonstration Start Date, and PPS
State Number of CCBHCs Demonstration Start Date PPS
Minnesota 6 July 1, 2017 PPS-1*
Missouri 15 July 1, 2017 PPS-1*
Nevada 3a July 1, 2017 PPS-1*
New Jersey 7 July 1, 2017 PPS-2
New York 13 July 1, 2017 PPS-1*
Oklahoma 3 April 1, 2017 PPS-2
Oregon 12 April 1, 2017 PPS-1
Pennsylvania 7 July 1, 2017 PPS-1*
SOURCE: Mathematica/RAND review of CCBHC demonstration applications and telephone consultations with state officials.
  1. Nevada initially certified 4 clinics; however, 1 is no longer participating in the demonstration. In March 2018, this CCBHC withdrew from the demonstration after Nevada revoked its certification. The total in the table reflects the number of participating CCBHCs in May 2019.

* = PPS-1 with QBPs.

1. Goals of the National Evaluation

In September 2016, the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) contracted with Mathematica and its subcontractor, the RAND Corporation, to conduct a comprehensive national evaluation of the demonstration. ASPE is overseeing the evaluation in collaboration with CMS.

Working with these federal partners, Mathematica and RAND designed a mixed-methods evaluation to examine the implementation and outcomes of the demonstration and to provide information for HHS to include in its reports to Congress. Specifically, Section 223 of PAMA mandates HHS's reports to Congress to include: (1) an assessment of access to community-based mental health services under Medicaid in the area or areas of a state targeted by a demonstration program as compared to other areas of the state; (2) an assessment of the quality and scope of services provided by CCBHCs as compared to community-based mental health services provided in states not participating in a demonstration program and in areas of a demonstration state not participating in the demonstration; and (3) an assessment of the impact of the demonstration on the federal and state costs of a full range of mental health services (including inpatient, emergency, and ambulatory services). To date, the evaluation has focused on providing critical information to Congress and the larger behavioral health community about the strategies that CCBHCs employ to improve care. As more data become available, the evaluation will describe the effects of the demonstration on consumer outcomes and costs.

2. Purpose of Report

In June 2018, Mathematica and RAND submitted to ASPE a report titled "Interim Implementation Findings from the National Evaluation of the Certified Community Behavioral Health Clinic Demonstration," which described--through April 2018--the progress that states and CCBHCs made in implementing the demonstration and their successes and challenges. The current report provides updated information on the implementation of the demonstration through April 2019 (approximately the first 22 months of the demonstration for six states and 24 months for the remaining two states). The findings in this report draw on data collected from interviews with state Medicaid and behavioral health agency officials and progress reports submitted by all participating CCBHCs (hereafter referred to as clinics). The clinic profiles in the report are based on site visits to CCBHCs in four states. Chapter II of the report describes the data collection and analytic methods. Chapter III provides updated findings on implementation progress, successes, and challenges with respect to CCBHCs' staffing (Chapter III.A), access to care (Chapter III.B), scope of services (Chapter III.C), and care coordination (Chapter III.D). The final chapter summarizes overarching themes that emerged from our analysis and briefly describes next steps for the evaluation. In future reports, we will examine the impact of the demonstration on health care utilization, quality, and costs, using claims data and information submitted by CCBHCs and states. In August 2019, we will submit a separate report that summarizes states' and clinics' experiences with the required quality measures (based on interview and site visit data) and costs (using data from the CCBHC cost-reporting template).[7]