Coordinated Behavioral Health Services, Inc. (CBHS) – One Group’s Pathway Toward Preparing for Managed Care

Coordinated Behavioral Health Services (CBHS), incorporated in 2012, is comprised of eight leading behavioral health and developmental disability nonprofit community-based agencies serving the Lower/Mid-Hudson River Region of New York State, and providing services in Westchester, Putnam, Rockland, Orange, Sullivan, Dutchess, Ulster, Greene and Columbia Counties. CBHS has an invaluable partnership with New York Integrated Network (NYIN), a group of leading providers in the Developmental and Intellectual Disability field who are creating myriad innovative products and services. This article, however, will only focus on CBHS in the behavioral health space.

The five Behavioral Health agencies—Human Development Services of Westchester (HDSW), Mental Health Association of Rockland County, Mental Health Association of Westchester County, Occupations, Inc., and Westchester Jewish Community Services (WJCS)–are now forming an Independent Practice Association (IPA) to build a Multi-County Model to deliver the Triple Aim for people with behavioral health needs: improve patients’ experience of care while improving their health and reducing the per capita cost of care.

The Context

Just a few years ago New York State announced it planned to move all Medicaid-funded services to managed care—which had potentially seismic implications for the people receiving services as well as for providers. Agencies needed to rapidly contemplate how to shift our focus and business model. For decades, these providers had developed valuable relationships and contracted with the “O’s”—Office of Mental Health (OMH), Office of Alcohol and Substance Abuse Services (OASAS) and Office for People with Developmental Disabilities (OPWDD) – and we were now faced with the prospect of our primary business being delivered through contracts with managed care companies (MCO’s). This move to managed care was a cost cutting/cost control effort. Many questions were raised for all providers: did the new rates established in the multi-year roll out of clinic transformation get marginalized; how do we market to the MCO’s, and if we are successful, how would our agencies stay in business with even lower rates than under clinic restructuring; will this transition to managed care really give us more flexibility and allow us to be creative and more responsive to the people we serve, or will this simply boil down to needed cost-cutting; was this effort to reign in unsustainable Medicaid costs going to totally disrupt the delivery of services as we know it—and who among us would survive?

New York was also creating “Health Homes,” a fundamental and important new service that would explicitly provide care management to all its customers…and potentially play an important role in what services were used (and what providers were utilized).

On the heels of the 2008 Great Recession, the government would likely have little if any funds available to facilitate this transition, and this transformation was occurring at a time when there was an expanded pool of people needing services.

On the federal level, The Affordable Care Act was now being implemented with its goals to improve access to quality care and to reform a stagnant system. The Institute for Healthcare Improvement called for health care systems to simultaneously address the “Triple Aim.” Noble goals that we should all embrace—but how to do it under a new and unfamiliar system! At the same time, and not unrelated, there was increasing attention to improving the overall health care in the United States by paying for outcomes and not procedures. The concept of providers sharing risk – benefiting financially from achieving a defined set of quality outcomes but also being penalized for failing to achieve those goals—was a very new and challenging prospect for behavioral health providers.

Our Response

As providers, we had absorbed many challenges and changes over the past decades, but this was different – radically and disruptively different. The usual tweaks and tools would no longer suffice. Each agency tackling the challenges in their habitual way would no longer work.

The five behavioral health agencies decided to meet and assess whether as a group we could address these challenges, changes and opportunities. Partly driven by concerns about self-preservation, we also wanted to address the opportunity to implement the federal strategy to identify the heavy users of more expensive inpatient and emergency department services and connect them proactively to those that are less expensive, and often more clinically appropriate, and create more person-centered services (perhaps less burdened by traditional regulations).

In 2012, the five organizations provided behavioral health services to an unduplicated 10,000 individuals. Services include a broad range of clinical, housing, supportive and recovery-oriented behavioral health services.

Although the group was convened based on some familiarity with each other and with our respective agencies, we did not all know each other well. We needed to confirm that we shared values, were mission-based and could trust each other. Two years into the process we continue to build trust and strengthen our partnership.

This group quickly became a robust learning collaborative: to identify the areas about which we needed to educate ourselves, to quickly develop expertise in those areas and to remain scrupulously on top of information.

With our increasing knowledge, we recognized that in the managed care world of “covered lives” and “depth and breadth of services” this group needed to become more than a learning collaborative. Guided by expert consultation, this informal group created a strategic alliance…and then formed a legal not-for-profit corporation in August 2012.

Organizations that were applying to be Health Homes approached our individual agencies to be providers in their Health Home. We responded as CBHS, underscoring our presence in the market.

As a consequence of our significant role in the local health homes, we tasked ourselves to become experts in care management. As CBHS providers, we will insure that our staff utilize best practices and adhere to the highest standards, regardless of “agency of origin.”

With Health Homes ‘launched’ and our care management services active, we continued to do business in the current environment while preparing for the world-to-come. We are actively meeting with MCO’s and health care providers to gain a better understanding of their needs and what CBHS and they can bring to the table

While remaining mission-centric and keeping our eyes on the needs of the people we serve, attention is required to implement leaner, more efficient work processes, establish a competitive advantage, and solidify reputations as go-to service providers of high-quality efficient services. We created an extensive committee structure to dive deeper into metrics, care management, new products, financial models, and information technology.

In order to plan for negotiating with MCO’s and other funders, we have created an IPA. As we write this article, we are in the midst of addressing the issues of clinical and financial integration. Integration as an IPA will allow us to negotiate as one organization—an organization that provides a broader array of services to more people than any one of us could offer individually. We have also developed a CBHS brand that compels us to maintain the highest standards, deliver quality care, and do it efficiently.

The Process…and the Future

As a group of individual providers coming together we have had to address the issues of different corporate cultures, different management styles, different services and fidelity to one’s own agency and doing things “that way”…not to mention 5 CEO’s used to running their own shops finding a way to make this work.

As a collective, learning to manage risk, create new business models, and partner with folks “on the other side of the counter” brings its own challenges, including addressing the need to consider business partners that bring deep pockets—and different lenses—to better compete in the new world.

We have engaged with each other and consultants to learn about healthcare policy and finance, and the complexity of business models that are now shaping our industry. We are poised to partner with managed care organizations and other providers to implement our concepts to deliver the outcomes of the triple aim. There is risk in these initiatives for accomplishment and for failure. We have jumped in with perhaps equal doses of commitment, hubris, humility and fear. We recognize how much we do not know – but hold onto a steady, even renewed determination to play an active role in this transformation. We are certain that we will continue to learn from our experience and will utilize this learning to inform our practice of the future.

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