February 18, Dear Ms. Hyde:

Transcription

1 February 18, 2015 Ms. Pamela Hyde Administrator Substance Abuse and Mental Health Services Administration 1 Choke Cherry Road Rockville, MD Attn: Draft Criteria to Certify Community Behavioral Health Clinics Dear Ms. Hyde: On behalf of the nation s Medicaid Directors, we appreciate the opportunity to comment on the draft criteria for the state-certified community behavioral health clinic (CCBHC) demonstration enacted under Sec. 223 of the Protecting Access to Medicare Act of Our comments focus on the need to finalize a CCBHC framework that is flexible enough to support states and clinics in enhancing care for those with behavioral health conditions, regardless of their starting place. NAMD is a bipartisan, professional, nonprofit organization representing the nation s 56 state and territorial Medicaid agencies, including the District of Colombia, whose mission is to represent and serve state Medicaid Directors. NAMD works closely with our members to provide a focused, coordinated voice for the Medicaid program in national policy discussion and to effectively meet the needs of our member states now and in the future. We appreciate SAMHSA s work on this demonstration and your agency s commitment to advance improvements in the delivery of timely, coordinated behavioral health services for Medicaid enrollees. However, we are concerned that the framework presented by the draft criteria does not reflect the range of state and clinic readiness, nor is appropriate for the two-year timeframe authorized for this demonstration. Medicaid Directors across the country are advancing efforts to improve quality and deliver person-centered care to those with behavioral health needs, and are closely partnering with providers and sister state agencies to do so. While some states and clinics have progressed farther in this journey, others are in the earlier phases of their initiatives. Recognizing that reform occurs along a continuum, the CCBHC demonstration should support states and providers in taking behavioral health care to the next level, regardless of state and clinics starting points.

2 Therefore, we urge you to revise the framework for the criteria. Specifically, we ask that states have the authority to select applicable CCBHC criteria from a menu of options laid out by SAMHSA. States would propose their selected set of criteria as part of their application to participate in the demonstration, giving SAMHSA an opportunity to analyze and assess its sufficiency to achieve the goals of the demonstration. This approach would help to ensure that any interested state is able to avail themselves of this opportunity. Further, it would ensure that the demonstration reflects the diversity in population, health care marketplaces, and geographic regions, which states are best positioned to understand. A flexible framework could also allow states to build upon and enhance their existing behavioral health initiatives. In particular, many states are approaching behavioral health improvement through bi-directional, large scale initiatives that aim to facilitate a more rational, accessible and cost-effective delivery system for those with behavioral health diagnoses. We believe successful, sustainable demonstration programs will be those that align with emerging and effective state models. An overly prescriptive framework, as proposed under the draft criteria, could compel states to create a distinct system of care that bifurcates services for those with behavioral health needs and would be a step backwards. In addition, we urge SAMHSA and the Centers for Medicare and Medicaid Services (CMS) to enhance their partnership to develop this demonstration. We are concerned that the proposed CCBHC criteria and PPS methodology appear to be developing along distinct paths. Because of the strong link between delivery and payment, these aspects of the CCBHCs cannot be developed or assessed in isolation. In particular, we are concerned that the draft CCBHC criteria do not align with statutory requirements around the PPS, which we discuss in more depth in our comments that follow. We ask that SAMHSA and CMS address this concern. The federal agencies must align the criteria with the payment methodology such that they accommodate the delivery of appropriate, integrated care and mandatory services while also promoting efficiency and value. Finally, without additional flexibility, we believe many states and CCBHCs could be stymied by certain data sharing requirements in the proposed criteria. We recognize that SAMHSA is currently evaluating existing policy in this area. In the meantime, we ask that SAMHSA allow demonstration states to pilot data sharing across physical and behavioral health providers, including substance use disorder data. We appreciate the opportunity to comment on the draft CCBHC criteria. Enclosed please find detailed comments on specific sections of the criteria below, which supplement our primary

3 request for a more flexible CCBHC framework. We look forward to continuing to work with you around the implementation of this demonstration to ensure it improves care and drives value for individuals with behavioral health needs in Medicaid. Sincerely, Matt Salo Executive Director Enc. Comments on draft criteria to certify CCBHCs Cc: Vikki Wachino, MPP, Acting Director, Center for Medicaid and CHIP Services, Centers for Medicare and Medicaid Services Richard Frank, PhD, Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services

4 Comments on Draft Criteria to Certify Community Behavioral Health Clinics Care Coordination 1. SAMHSA should allow states to define care coordination and determine the essential elements of care coordination applicable to their state in addition to those specified in statute. We are concerned that the draft criteria define care coordination and add unreasonable prescriptive detail to the requirements around this. This is problematic, given the variation that exists between state Medicaid programs and the diversity of the population with behavioral health conditions. Care coordination is already a central tenant of state efforts to advance behavioral health reforms and other care delivery improvements across their programs, whether in health homes, community integration transformations, Medicare-Medicaid integration efforts, or managed care initiatives. States have significant experience in outlining and structuring care coordination approaches, including approaches to coordinate social services and supports, and tailoring care linkages to meet the needs of the population. SAMHSA should revisit these overly-prescriptive criteria and provide for state flexibility to define the elements of care coordination as part of their application to participate in the demonstration. At a minimum, the agency should allow states to select criteria around care coordination from among an optional menu of criteria as part of the application to participate. 2. SAMHSA should permit CCBHCs to provide care coordination activities through broadly defined partnerships, not just formal arrangements, with the entities outlined in statute (Criteria 3.C). Requiring formal arrangements, such as MOUs or MOAs, with the wide range of care coordination providers listed in the draft criteria may not be feasible in the timeframe allotted for providers, nor is it necessary in all communities. Under the proposed criteria, the time and the sheer number of entities involved could create an insurmountable barrier for CCBHCs to develop agreements, especially in certain geographic regions and health care marketplaces. Some states have found that there are many more organizations willing to develop good working relationships than are willing to enter into formal agreements. Further, developing a good working relationship with a wide range of community organizations takes time and is not necessarily enhanced by formal contracts.

5 Rather, the option for states to require MOUs, MOAs or demonstrate partnerships would offer the flexibility needed for CCBHCs to build linkages between services. This option also would help to minimize the administrative burden of developing MOUs or MOAs, and will ensure CCBHCs have linkages with the broadest scope of providers. In addition, SAMHSA should define partnerships to allow states to demonstrate a variety of ways that they have established relationships with the providers listed in statute. For example, CCBHCs could submit letters of support from a wide array of health care, social service (including vocational rehabilitation), and community organizations as part of the certification process to demonstrate the existence of partnerships. The criteria should also allow exceptions to this requirement when a CCBHC can demonstrate a good faith effort to obtain a letter of support and, of course, when no such organization exists that directly serves the CCBHC s area. 3. SAMHSA should remove or make optional the requirements that CCBHCs coordinate care for patients served by other facilities and that care is delivered in accordance with the CCBHC-developed active treatment plan (Criteria 4.b.2 and 3.d.3). The draft criteria require CCBHCs to enter into a formal arrangement with local emergency departments, urgent care centers, inpatient facilities, and other providers to permit the CCBHC to coordinate care provided in these locations. A separate criteria requires care provided by these entities be delivered in accordance with the CCBHC-developed treatment plan. States are concerned that this criteria may not feasible to operationalize. While CCBHCs and these facilities may agree to work together in the coordination of care for shared patients, there may be challenges in developing an agreement in which a hospital would allow an outside entity to coordinate care provided by the hospital. Likewise, these providers may not readily agree to give the CCBHC the authority to ensure that the care and services they provide are in accordance with another organization s treatment plan. Again, while such formal relationships may be possible over the longer term, states believe it could be challenging to do so within the parameters of the demonstration period. Quality Metrics 4. States should be permitted to select from among a menu of measures on which CCBHCs would report under the demonstration which are also consistent with existing Medicaid reporting requirements (Criteria 5.C and Appendix A). The 30 quality metrics required under the proposed CCBHC criteria are expansive, and many of them have not been

6 endorsed by a body such as the National Quality Forum (NQF) or included in the National Behavioral Health Quality Framework (NBHQF). States recognize the need for appropriate measures for the population to be served in this demonstration. However, this is a time-limited demonstration and it is not feasible to implement a plethora of untested measures. As noted in our initial comments to SAMHSA, the agency should provide a menu of measures and determine a minimum number on which states would report, while also providing states the option to report on additional measures pertinent to the state. The selected measures (and any additional state identified measures) would be identified as part of the application to participate in the demonstration, giving SAMHSA an opportunity to confirm their comprehensiveness. Further, to the greatest extent possible, these measures in SAMHSA s menu set should be consistent with other measure requirements in Medicaid and other federal programs. Such alignment is necessary to bring coherence with other innovative delivery models and behavioral health care improvements in Medicaid, and minimize administrative burden on states and providers. We urge SAMHSA to revisit the proposed measures and draw greater alignment with the quality measures for other Medicaid initiatives, such as health homes, the electronic health records meaningful use incentive program, federally qualified health centers, Medicare-Medicaid demonstrations, and other key efforts. Scope of Services 5. The CCBHC criteria and payment requirements must be aligned to ensure the PPS covers the cost of any required services. The criteria, as proposed, are not aligned with the requirements for the PPS. This raises major concerns about the sustainability and success of the demonstration. Statute establishing this demonstration requires that payments only be made for mental health services for which payment is available under the state Medicaid plan. Some of the service requirements for CCBHCs in the draft criteria include services for which payment is not provided under state Medicaid plans. For example, some states do not reimburse for service components specified under psychiatric rehabilitation services (criterion 4.h.1). SAMHSA should work with CMS to ensure that payment can be appropriately made available, and if payment cannot be made available for these services, the relevant CCBHC service requirements should be removed or amended.

7 6. States should specify the services that must be directly provided by CCBHCs and those that can be provided through formal arrangements (Criteria 4). The statute does not require any service to be directly provided by a CCBHC; rather, it explicitly recognizes that such services may be directly provided or referred through formal relationships. As such, it takes into account the fact that the diversity of state delivery systems and statutory authorities will necessitate a variety of approaches to meet the objectives of the demonstration. The draft criteria, however, require that almost every service in the statute be directly provided by a CCBHC. Consequently, it fails to recognize critical differences that exist between state delivery systems, populations and health care marketplaces. States are best positioned to assess the landscape of their health care marketplace in order to determine the approach that will meet the objectives of the demonstration. Thus, states should identify what CCBHCs services should be provided directly or through relationships with other providers. In selecting states to participate in the demonstration program, SAMHSA and CMS will have the opportunity to assess the extent to which the CCBHCs meet the goals of the demonstration and provide a comprehensive array of services according to the statutory requirements. 7. Any additional services outside of those described in statute should be encouraged but not required. The underlying statute requires that the Secretary give preference to selecting demonstration programs where CCBHCs provide the most complete scope of services outlined in statute. Some of the draft criteria (i.e., elements of draft criteria 4.e.1 and 4.e.3) identify additional services beyond those included in the scope of services in statute. To ensure the feasibility of this demonstration, we recommend that any additional services beyond those outlined in statute be encouraged, but not required. States should be permitted to select from among these additional services, as appropriate, as part of their application to participate in the demonstration. 8. SAMHSA should clearly indicate that states may apply service areas to a CCBHC demonstration and only require CCBHCs to deliver crisis response/emergency and stabilization services to individuals residing outside its service area (Criteria 2.E). From criteria 2.E, it is unclear whether states with defined service areas for their behavioral health delivery system will be able to have CCBHCs only deliver care to individuals within a given region or catchment area. As noted in our comments to CMS regarding the PPS methodology, states should have the option to establish CCBHC service areas, in consultation with providers. States should also be permitted to require that the CCBHCs deliver crisis response/emergency and stabilization services to individuals residing outside of their service area.

8 Many states currently rely on catchment or service areas for community mental health service providers and have a delivery system structured around this model. To reflect this catchment or service area structure, this demonstration should allow state flexibility to define service areas that would apply to the PPS. This approach would require CCBHCs to provide crisis services to all individuals regardless of place of residence, while the CCBHC from a given individual s region would be responsible for providing all required services on an ongoing basis. 9. SAMHSA should clarify that states are permitted to require CCBHCs to directly provide primary care services and coordinate primary care with an array of primary care providers. It is important that CCBHCs are able to seamlessly connect beneficiaries with physical health services as appropriate. As some states pursue a model where the primary care provider is embedded in the clinic, it is equally important that states have the option to require the provision of primary care services as part of the CCBHC. It is unclear from the draft CCBHC criteria if states have this option. Additionally, partnerships with large provider delivery systems are critical in addressing patient transitions and access to appropriate levels of care. As such, we request that as part of this demonstration SAMHSA allow states to require that CCBHCs coordinate with a diverse array of physical health providers, extending beyond federally-qualified health centers. This is necessary to ensure the CCBHC model effectively treats the whole person, including both their physical and behavioral health needs. 10. States should be permitted to partner with CCBHCs to assess evidence-based practices and propose how they can be delivered within the structure of the organization and the population they serve (Criteria 4.e.1, 4.e.2, 4.e.3, and 4.e.4). The requirement to provide certain evidence-based treatments, as specified in the draft criteria, are not feasible as proposed. Many of the evidence-based treatments mentioned lack sufficient scientific support and others are for specific conditions that may not have sufficient volume in some clinics, or both. The models of delivery for the treatments also vary greatly and thus would not be appropriate to require in this demonstration. In addition, the implementation of many of these treatments is very costly. States further indicate that it would not be feasible to implement them in the timeframe allotted. Few, if any, community behavioral health providers nationally are currently directly providing with fidelity all of the evidence-based practices listed in the draft criteria, and truly integrating an evidence-based practice takes time beyond that allotted for this demonstration.

9 Staffing We believe the criteria should be revised to promote the adoption of evidence-based practice and allow state flexibility in this area. This will balance the desired goal of moving towards evidence-based practice with the need to ensure that the demonstration is feasible for states and providers. 11. Staffing criteria should provide for state flexibility to address shortages and other capacity concerns. States have identified some of the requirements in the draft criteria as unfeasible due to variations between health care marketplaces and the availability of providers. For instance, some required practitioners may be limited in certain regions or available practitioners may not have the required subject matter expertise required by the draft criteria. Another concern centers around proposed training requirements. Some states indicate a lack of subject matter experts who are available to render the trainings each year, as well as the added cost of such frequent trainings. SAMHSA should provide allowances for geographic variations and marketplace differences, which would make certain staffing requirements unachievable. One example of the flexibility states might consider is to allow CCBHCs to contract for certain providers services only on an as needed basis. Accessibility/Availability 12. Updates to the patient assessment should only be required when changes occur in the consumer s status (Criterion 2.b.4). Requiring patient assessments every 30 days, regardless of his/her change in status, is burdensome and outside of the bounds of standard practice. Rather, an assessment should only be required when there is a change in status, responses to treatment, or goal achievement. If this alternative requirement is not feasible, the minimum timeframe within which a comprehensive evaluation must be updated should be no less frequent than 90 days. 13. The initial and comprehensive evaluation criteria should be revised to ensure it meets member needs (Criteria 2.b.2 and 2.b.3). The criteria should ensure that the comprehensive evaluation is related to member strengths and aspirations, as well as recovery needs, which should be noted in criterion 2.b.2. In addition, to ensure that the evaluation reflect member needs, criterion 2.b.3 should be amended to identify member's natural

10 community supports" in addition to current social health care support systems. 14. The emergency crisis intervention criteria should be amended to allow states to require a Wellness Recovery Action Plan for adults and safety plan for members under 21 (Criteria 2.C). The addition of these sections would be consistent with the reference to member "strengths" in treatment planning identified in criterion 4.d.4. Data Sharing 15. SAMHSA should allow demonstration states to pilot data sharing across physical and behavioral health providers, including substance use disorder data. Many states have identified major concerns with the ability to deliver a cohesive, coordinated set of services due to separate health information privacy requirements for substance use disorder treatment. As a result, it is significantly less likely that people with substance use disorders, including Medicaid beneficiaries, receive the attention and time to support continuing remission. It also makes it less likely that these individuals have early recurrence identified, which is routinely provided to those with other chronic medical conditions. We believe this demonstration offers an ideal vehicle for the federal agencies to pilot an approach through which states could exchange data across providers and would align with the objectives of this federal demonstration. We believe our request is particularly necessary in light of the proposed criteria that would require significant information sharing. Such information sharing is not feasible under the current federal regulations governing substance use health information. These criteria include that: 1) those who prescribe medication for CCBHC clients must be aware of any medications prescribed by other providers (criterion 3.a.5), and 2) CCBHCs must have a formal arrangement with programs that can provide certain SUD services and the CCHBC must be able to track when consumers are admitted to facilities providing these services, as well as when they are discharged (criterion 3.c.2). States should have the option to pilot data sharing approaches under this demonstration. But if data sharing cannot be piloted, the above requirements should be removed or amended to recognize limitations that result from federal data sharing regulations for substance use disorder information which would be difficult for states to overcome during the demonstration period.