Uncertainty about the future state of publicly-funded health care is widespread following the presidential election. However, the design of accountable delivery systems committed to comprehensive, cost effective care continues to have bipartisan support. Such systems demand a full array of health, behavioral health, and social services supports, yet behavioral health and human services providers must be strategic in order to ensure effective engagement in the transformation.
Behavioral Health is Not Yet Fully Integrated within Accountable Care Efforts
An accountable delivery system is comprised of a wide array of providers that agree to share responsibility for care delivery and outcomes for a defined population (Kaiser Family Foundation, Medicaid delivery system and payment reform, 2015). Within the accountable care network, funding for health care is capitated and providers ultimately share in both risk and savings, with the goal of promoting value by improving care and reducing costs. Such systems bear financial risk for health care quality and outcomes, and are thus incentivized to more effectively—and efficiently—use the full array of social services and supports that will maximize the impact of interventions on patients (Mahadevan, R., & Houston, R., Supporting Social Service Delivery through Medicaid Accountable Care Organizations, 2015).
Too often the role of behavioral health is limited within these accountable delivery systems. Although most Accountable Care Organizations (ACOs) hold responsibility for some behavioral health care costs, integration of behavioral health and primary care remains low, with most ACOs pursuing traditional fragmented approaches to physical and behavioral health care (Lewis, V.A., Colla, C.H., Tierney, K., Van Citters, A.D., Fisher, E.S., & Meara, E., Few ACOs Pursue Innovative Models That Integrate Care For Mental Illness And Substance Abuse With Primary Care, 2016). Often, behavioral health providers are considered clinical, non-network “specialty providers,” resulting in siloed care planning limited to subcontracts with external behavioral health vendors (Kathol, R.G., Patel, K., Sacks, L., Sargent, S., & Melek, S.P., The Role of Behavioral Health Services in Accountable Care Organizations, 2015). Indeed, the majority of metrics to which payment and incentives are tied relate to primary care, and many ACOs are focused on addressing primary care referrals and patient behavior first, concentrating more on influencing rather than integrating behavioral health (Korenda, L., & Thomas, S., Integrating Specialty Care Into Accountable Care Organizations, 2016).
Examples of the Delivery System Evolution
To ensure robust participation in the delivery system of the future, including accountable systems that evolve from entities like health homes and DSRIP PPSs, behavioral health leaders are wisely seeking to expand their volume, enhance their service continuum, and increase their value by actively partnering. The following examples offer a preview for how systems are converging.
In New York City, NYC Health + Hospitals is the largest health care system. OneCity Health Services is its subsidiary Performing Provider System, comprised of 220 different health care and social services organizations with responsibility for almost 660,000 attributed Medicaid lives. As its next step toward building its integrated delivery system (IDS), OneCity Health Services will facilitate care management and conduct the administrative contracting and coordination necessary with community providers. Its recent Request for Expressions of Interest from venders to support its planned infrastructure described a vision for managing risk-based service arrangements on behalf of over one million members—80% of whom are expected to be Medicaid Managed Care recipients throughout all five boroughs.
In the Hudson Valley, the Coordinated Behavioral Health Services (CBHS) IPA is a behavioral health provider-led independent practice association (IPA) that has formed a comprehensive behavioral health network designed to enter into accountable care arrangements. Services across the network include a broad range of clinical, housing, supportive, and recovery-oriented behavioral health services (Anderson-Winchell, A., Kocsis, A., Kohn, A., Madison, S., & Trager, A., One Group’s Pathway toward Preparing for Managed Care, 2014). Among other initiatives, the CBHS IPA has established a partnership with the area’s largest Federally Qualified Heath Center (FQHC), creating a delivery system able to offer integrated care to attributed individuals within value-based payment (VBP) arrangements. Currently, this integrated IPA, CBHCare, is leading a number of integration initiatives across the Hudson Valley as an active partner within Delivery System Reform Incentive Payment (DSRIP) program Performing Provider Systems (PPS’) and health home networks, and they have successfully established a phased VBP contract with an managed care organization, which, beginning January 1, 2017, will incorporate total cost of care payments, as well as upside and downside risk (Hardesty, M. Advancing Value-Based Care in New York’s Hudson Valley, 2016).
Certified Community Behavioral Health Centers: A Model upon which Behavioral Health Providers can Build
The CCBHC structure can offer a valuable roadmap for behavioral health providers seeking to take action. New York was recently selected as one of eight demonstration states and is implementing CCBHC pilots designed to “strengthen payment for behavioral health services for Medicaid and CHIP beneficiaries, and…help individuals with mental and substance use disorders obtain the health care they need to maintain their health and well-being” (HHS, HHS selects eight states for new demonstration program, 2016). Though designed for funding under a Prospective Payment System (PPS), the CCBHC model fully aligns with the principles and goals of accountable care and CMS’ Triple Aim, and offers a template for a comprehensive behavioral health system that can successfully be integrated into an accountable care network.
Each CCBHC offers both mental health and substance use treatment services for individuals of all ages and holds responsibility for the behavioral health of the population within their designated geographic area. They have open access, offer mobile crisis, and maintain established relationships with local emergency departments to facilitate care coordination and follow-up post-discharge. Accessibility is promoted via peer, recovery, and clinical supports in the community and increased access through the use of telehealth/telemedicine, online treatment services and mobile in-home supports (SAMHSA, Section 223 Demonstration Program for Certified Community Behavioral Health Clinics, 2016).
Even providers who are not certified under the official demonstration can seek to build out their continuum via partnership and affiliations that mirror the CCBHC model, while also leveraging available housing resources and other social service linkages necessary to promote health, wellness, and sustained recovery. Such networks will be well positioned to partner with accountable provider-led entities, like hospital systems and FQHCs, in preparation for value-based arrangements. Should the demonstration be successful, the PPS financing mechanism may be federally adopted, which also makes this model worthy of early attention.
The success of accountable care demands thorough attention to behavioral health, but proactive leadership and well considered partnerships are critical. Models are available and means for adoption are currently at hand. Providers planning to survive within the new healthcare economy must be actively building their continuums, expanding their reach, and evolving toward value-based payment.
Health Management Associates is a consulting firm with deep expertise across all domains of publicly funded health care, including behavioral health practice transformation. Founded in 1985, Health Management Associates has 19 offices across the country, including Albany and New York City. For more information, call (212)575-5929 or visit www.healthmanagement.com.