ccbhc ta initiative virtual launch party ta initiative virtual launch party june 28, 2017 rebecca...

CCBHC TA Initiative

Virtual Launch Party

June 28, 2017

Rebecca Farley David

VP, Policy and Advocacy

Xavior Robinson

Senior Advisor, Practice Improvement

Welcome!

Presentation Staff

Rebecca Farley DavidVP, Policy and Advocacy

• CCBHC Policy Pro• 10+ years in health system policy &

financing

Xavior RobinsonSenior Advisor, Practice Improvement

• CCBHC Learning Initiative Project Lead• Public and Behavioral Health Financing Expert

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Why CCBHCs?

BH Safety Net Providers vs. FQHCs

Topic BH Safety Net Providers FQHCsFi

nan

cin

g &

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mb

urs

emen

t Low payment rates that don’t cover cost of doing business

Cost-based reimbursement with enhanced payments on Medicaid and Medicare claims.

Categorized as an optional benefit under Medicaid

Services are mandatory under Medicaid

Latest evidence-based practices may not be covered in a rigid FFS

Cost-based reimbursement allowsflexibility and payment for innovative service delivery

Difficulty investing in services at federal level due to lack of defined category of provider

Cost-based reimbursement mitigates investment risks. Special grants exclusive to FQHCs.

FFS payment drives staffing mix instead of clinical staff mix being driven by needs of patients

Staffing mix covered on a cost-basis.

BH Safety Net Providers vs. FQHCsTopic BH Safety Net Providers FQHCs

Fin

anci

ng

Most BH providers have underdeveloped cost reporting and therefore usually do not have an accurate understanding of the return on investment (ROI) of each treatment modality that includes all cost inputs such as infrastructure and IT.

Cost-based reimburses incentivizes FQHCs to take a nuanced look at the extent to which infrastructure impacts patient outcomes.

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Challenges psychologists, nurses and psychiatrists. Overreliance on LCSW’s, licensed professional counselors, and non-licensed staff

Preferential treatment under the National Health Service Corps program

Other Organizational AdvantagesType Advantages

Hospitals Prospective payment or diagnostic related group (DRG) payment that is a diagnosis specific prospective payment methodology, price to cover the cost of the average patient at the average length of stay.

Disproportionate Share Hospitals (DSH)

Receive supplemental payments based on the number of Medicaid beneficiaries or other low-income persons who receive services.

Healthcare for the Homeless Projects

PPS (cost-based) reimbursement finances innovative staffing models to provide services to high intensity clients.

Skilled Nursing Facilities Payments adjusted based on the intensity of the facility’s client mix and geographic variation.

Safety Net Behavioral Health Providers

Deserve a Level Playing Field

The Vision for CCBHCs

Why is this important?

Data

Data analytics will drive outcomes and a nuanced

understanding the exact costs of all components of

the care and supports we provide.

Recognition

Federally-recognized and supported provider type in

Medicaid with expanded array of services, improved

access to care, and increased quality of care.

Innovation

provides an opportunity for behavioral health

organizations to demonstrate that we can

successfully implement alternative payment

methodologies that include value-based purchasing.

CCBHCs: A Foundation for the Future

CCBHC 2-Year Demonstration

Alte

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tive

Pa

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Valu

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ased

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erv

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ay A

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Evolving health care ecosystem built on value, quality and impact

CCBHC Paradigm Shift

What is a CCBHC?• A non-profit or governmental organization

• Serving a specific geographic area

• Employing evidence-based, best and promising practices

• Coordinating care and providing a comprehensive array of community behavioral health services

• To the residents of the area and specific populations of focus

• Regardless of their ability to pay

• Across the lifespan: children, adolescents and adults

• Measuring and reporting specific outcomes regarding efficiency, effectiveness and health status

CCBHC Scope of Services

Must be delivered directly by CCBHC

Delivered by CCBHC or a Designated Collaborating Organization (DCO)

Care CoordinationThe Linchpin of CCBHCs

Partnerships or care coordination agreements required with:

– FQHCs/rural health clinics

– Inpatient psychiatry and detoxification

– Post-detoxification step-down services

– Residential programs

– Other social services providers, including

• Schools

• Child welfare agencies

• Juvenile and criminal justice agencies and facilities

• Indian Health Service youth regional treatment centers

• Child placing agencies for therapeutic foster care service

– Department of Veterans Affairs facilities

– Inpatient acute care hospitals and hospital outpatient clinics

CCBHC Data & Quality Measures

1. Number/Percent of New Clients with Initial Evaluation Provided within 10

Business Days, & Mean Number of Days until Initial Evaluation

2. Preventive Care & Screening: Adult Body Mass Index (BMI)

3. Weight Assessment & Counseling for Nutrition & Physical Activity for

Children/Adolescents

4. Preventive Care & Screening: Tobacco Use: Screening & Cessation

Intervention

5. Preventive Care & Screening: Unhealthy Alcohol Use: Screening & Brief

Counseling

6. Child & Adolescent Major Depressive Disorder (MDD): Suicide Risk

Assessment

7. Adult Major Depressive Disorder (MDD): Suicide risk assessment

8. Screening for Clinical Depression & Follow-Up Plan

9. Depression Remission at 12 months

17

CCBHC Financing

The Past and Present

The Future

Traditional BH FFS Payment

• Psychiatrist is typically the loss leader

– Difficult to give patients as much access to

psychiatrists as needed

• Case management, services by mid-level

professionals tend to have a better margin (or

less loss)

– Rely more heavily on these services in the treatment

plan

• Service mix often driven by financial constraints

CCBHC Payment InnovationEstablishment of a Prospective Payment

System

Prospective Payment System

(PPS)

• Reimbursement is based on the cost of providing the array of services required by the typical consumer for a specific period of time

• Implications compared to Fee-for-Service model

– No financial incentive to provide lots of units of service

– Does not require that all services be translated into units

– Does not incentivize one service over another

– Reimbursement is tied to the cost of providing services

What goes into the numerator?

• “Allowable costs” for the entire year

– Direct costs related to anticipated CCBHC services and

activities (e.g. staff salaries, care coordination activities, costs of

services provided under agreement/contract, medical supplies,

professional liability insurance, etc.)

– Overhead, indirect costs

– Does NOT include non-CCBHC services

Total number of daily or monthly visits each year

Payment rate for each daily

or monthly visit

What goes into the denominator?

• Important note for CCBHCs: your state defines what

constitutes a “visit”

– E.g. in-person encounter with clinician,

– Telehealth encounter? Call to crisis line? Other?

Total number of daily or monthly visits each year

Payment rate for each daily

or monthly visit

When is a payment triggered?

• In a Medicaid PPS, payment is only received for patients

who are covered under Medicaid…

• …When that patient has a qualifying visit (incl. at DCO)

• Note distinction between allowable costs and

qualifying visits!

Total number of daily or monthly visits each year

Payment rate for each daily

or monthly visit

Qualifying Visit or Not?

Phone call from nurse care manager to

primary care doctor to discuss patient’s

increased blood pressure?

• Yes

• No

• Unsure

45-minute counseling session with

licensed clinical social worker?

• Yes

• No

• Unsure

Traditional Services

• Difficult to finance care coordination

• Services delivered in units within the 4 walls of

clinic

• Service delivery constrained by rates

• Difficulty financing innovation

CCBHC Services Innovation• Patient needs drive level of care

• Payment supports non-4-walls approach &

greater use of technology to support care

• Payment rates inclusive of care coordination

costs

What could this look like?Date & type of service FFS $ Actual cost CCBHC visit

triggered?PPS-1 $ PPS-2 $

March 24: Diagnostic assessment with LCSW

$123 $127 Yes $344 $516

March 30: 60-minpsychotherapy for crisis with psychiatrist

$102 $300 Yes $344 n/a

April 7: 45-minpsychotherapy by LCSW

$102 $150 Yes $344 $516

April 7: 15-min. clinical care consultation by psychiatrist

$30 $75 Yes n/a n/a

April 7: Face-to-face case management

$416 (permonth)

$380 (per month)

No n/a n/a

Total $773 $1,032 $1,032 $1,032

The Innovation

Possibilities are Endless

Breaking through old

limitations…

Think creatively!

? In-home services for

newly placed foster

youth

? Post-booking

assessment in jails

? Outreach to homeless

populations

Services are not confined to delivery within the

4 walls of a clinic

Innovation AlertAdd web or app-based self-help and social connection support services (such as those offered by 7 Cups and MyStrength, among many others) to support your patients when they are not directly engaged with your staff.

Innovation AlertAdd Peer Specialists if your current Medicaid FFS or MCOs doesn’t already support them.

Innovation AlertAdd a case manager specifically assigned to local law enforcement and court staff to understand their needs better, respond more promptly and gain their support in your community.

Innovation AlertAdd nurse support to your medication clinics to increase the efficiency of your

psychiatrists.

Innovation AlertUse psychiatrists for more than diagnosis and medication visits, case reviews with other staff, curbside consultation to selected outside PCPs to support referral of stable patients to them for refills, planning and developing new program and treatment interventions.

Take-home Strategies for

CCBHCs

Checklist✓Reorient your thinking about billing: from service

units (volume) to qualifying encounters (value).

✓Unleash your big ideas about where, when and

by whom to deliver services.

✓Start planning what you’ll do to increase access

✓Build continuous quality improvement into

clinical & financial operations

✓Do a frank assessment of your change

management strengths and weaknesses

Reorient Your Thinking About Billing

• Understand your flexibilities under the PPS

system vs. FFS or pre-CCBHC MCO contracts

• Understand the difference between qualifying

encounters and nonbillable activities

• Orient staff to these changes and the

opportunities they present

• Be aware of any special state requirements

From service units (volume)

Qualifying encounters (value)

Under PPS…

• Cost-related rate captures actual cost of staff salaries– Psychiatry, etc. no longer loss leader

– The revenue supports clinical care decisions driven by patient need

• Key services (care coordination, case management) typically no longer billable– Wrapped into daily or monthly rate

– CCBHCs should beware of “business as usual” when it comes to service mix

• PPS-2 states should monitor monthly service utilization for alignment with predictions; consider whether rebasing is needed

• What will have biggest impact on increased access to care?

• What will have biggest impact on consumer outcomes?

• What services are consumers demanding when they seek access to care?

• Will improved use of technology to support evidence based practice & care management tools?

Unleash your big ideas about where,

when and by whom to deliver services

Enhanced Access• Quicker Access means more value to the consumer in

distress and increases probability of visit

• Offer same day if they cannot schedule within 7 days

• For hospital discharges utilized assertive outreach and

engagement

• Time versus Value

• Functional Assessment & Screens versus exhaustive

Psychosocial Report

Enhancing EfficiencySCHEDULING PERFORMANCE INDICATORS—

• Scheduling Days Out: Count of days between the date on which an appointment was made and the date for which it is scheduled

• No-Show Rate: % of scheduled appointments for which a patient does not present, or that a patient cancels within 24 hours

• OPEN SLOTS ARE WHAT

COUNTS !!

• YOU CANT TREAT A SEAT !!!!!

Build CQI into clinical and financial

operations

Assess your change management

strengths and weaknesses

https://www.nationalcouncildocs.net/ccbhc-learning-

community

Get Help: CCBHC Launch Pad

https://www.nationalcouncildocs.net/ccbhc-learning-community

Get Help: CCBHC Launch Pad

Register for our July 12 webinar at 2:00pm EDT

Questions?

Register for our next webinar on Leveraging PPS to Innovate Service Delivery:https://attendee.gotowebinar.com/register/636559341890253571

ResourcesFlannery PetersonSenior Project ManagerFlanneryP@thenationalcouncil.org

Chayla Lyon Project ManagerChaylaL@thenationalcouncil.org202-629-5797