Leaders of mental health centers in eight states are sweating over the looming loss of federal funding for a Medicaid demonstration that enables them to offer a broad array of coordinated services for people with serious mental illness and substance use disorders.
Funding cutoff looms for model mental health clinics
Certified community behavioral health clinics, or CCBHCs, in Oklahoma and Oregon will have to start notifying staff and patients later this month about layoffs and service cuts, while centers in Minnesota, Missouri, Nevada, New Jersey, New York and Pennsylvania will have to do so in April.
Sens. Roy Blunt (R-Mo.) and Debbie Stabenow (D-Mich.), the original sponsors of the CCBHC demonstration program, say they plan to reintroduce a bill to renew it for one year and expand it to 11 additional states, including California and Texas. That funding, estimated at $520 million, was left out of the opioid treatment bill signed by President Donald Trump in October due to concerns about the opioid package's $8.4 billion price tag.
The CCBHC program is "helping more people get the mental and behavioral health treatment they need and moving us closer to treating mental health like all other health," Blunt said.
But unless the deeply polarized Congress takes action in the next few weeks, nearly 3,000 staff at 67 CCBHCs could lose their jobs, and more than 9,000 patients receiving medication-assisted treatment for substance abuse could lose access to that treatment, the National Council for Behavioral Health estimates.
"We're very nervous," said Larry Smith, COO of Grand Lake Mental Health Centers, which serves more than 10,000 clients a year in seven counties in rural northeast Oklahoma, nearly double the previous caseload. "If it's not funded, we'll have to start dismantling, and it will be pretty devastating."
The CCBHC demonstration, created by the Excellence in Mental Health Act of 2014, is the biggest federal investment in many years in improving community-based mental healthcare.
The $1 billion, two-year demonstration is testing a new, multidisciplinary model for delivering community-based mental health and addiction treatment. Participating clinics are required to provide nine types of evidence-based services, including 24-hour crisis care, substance abuse services such as medication-assisted treatment and detox, care coordination, and integration with physical healthcare.
CCBHCs receive enhanced, cost-based reimbursement from Medicaid through a global payment per patient model, while reporting 22 quality measures.
The enhanced funding enables the clinics to cover the costs of support services such as outreach, case management, housing, legal and employment services. The Substance Abuse and Mental Health Services Administration projected that the current 67 CCBHCs would serve more than 380,000 people at 372 sites.
Experts say it's critical to expand and strengthen community-based behavioral and addiction services as a proactive alternative to the current patchwork of treating patients with advanced serious mental illness in hospital emergency departments, jails or prisons. There's also a stark shortage of psychiatrists and other mental health professionals willing to serve Medicaid patients due to low payment rates.
A key benefit of the CCBHC model is offering a broad range of services in a single setting, so patients with disabling disorders don't have to navigate the system on their own.
"The goal is to provide integrated care for people with complex mental health, substance use and medical problems, reducing costs by reducing hospitalizations and emergency department visits," said Dr. Elinore McCance-Katz, HHS' assistant secretary for mental health and substance use, who supports extending the demonstration. "There's a lot of evidence for integrated care, and we need to provide the resources to pay for it."
McCance-Katz said HHS is evaluating the demonstration, and will release data on the program's health outcomes and costs later this year.
Surveys of the clinics conducted last year by the National Council for Behavioral Health found that the program had enabled them to hike their patient caseload by an average of 25%. Two-thirds of the clinics had seen a decrease in patient wait times, and all had launched or expanded addiction treatment services, including hiring or training clinicians who can prescribe buprenorphine.
Many reported partnering with police departments, jails and hospitals to better serve people with behavioral health and addiction problems. Grand Lake's Smith said his agency has opened two 24/7 crisis response units which save police officers the time required to take people to inpatient facilities. The agency also provides officers easy access to therapists who can perform mental health assessments on the spot for people they pick up.
Critics argue CCBHCs are receiving higher payment rates for providing the same services other clinics provide.
But Rebecca Farley David, vice president for policy at the National Council for Behavioral Health, said CCBHCs offer services that are fundamentally different in terms of coordination with hospitals, primary-care clinics, law enforcement and schools, plus they cannot turn patients away for inability to pay.
"You are paying for more services and more access," she said.
David said her organization is watching for possible legislation in Congress to attach the CCBHC extension and expansion bill to. She's worried, however, about the sharp partisan divisions and the increasing focus on the 2020 presidential race that could make bipartisan deals difficult.
Smith, who traveled to Washington twice last month to lobby Congress for funding, fears having to lay off 320 employees, nearly half his agency's staff, and cut services sharply. He worries that lawmakers don't know about or understand the CCBHC program.
"I have a lot of faith that people will see the value of it," he said. "I can't imagine legislators not funding this if they knew what it's doing for communities."
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