Rates may be lower in clinics with more visits due to economies of scale. Mathematica and RAND asked state officials to provide the rates that they paid each of the CCBHCs. 200 Independence Avenue, S.W. In this context, quality measurement provides an alternative form of accountability, ensuring that quality of care does not suffer. For both PPS-1 and PPS-2, payment rates were lower for clinics that served a higher number of clients versus those that served a smaller number. The state average visit-day cost ranged from $167 in Nevada to $336 in Minnesota. (DY2) activities (the 2018 and 2019 progress report templates appears in Appendix B). Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. CCBHC cost report rate methodology using either data from Medicare cost reports or collected from providers. However, it is notable that CCBHCs often reported providing a required service and contracting with a DCO for the service, and therefore it seems likely that DCOs may have only served a subset of CCBHC consumers. To assist CCBHCs in providing accurate cost report information, states reported providing extensive technical assistance to clinic financial and administrative staff during DY1. Across all PPS-1 clinics, the average DY1 visit-day cost was $234 and ranged from $132 to $639. In addition, crisis behavioral health services may be provided by a DCO if the DCO is an existing state-sanctioned, certified, or licensed system or network. In Spring 2018 (DY1) and Spring 2019 (DY2), CCBHCs submitted online progress reports to Mathematica that gathered information about their staffing, training, accessibility of services, scope of services, HIT capabilities, care coordination activities, and relationships with other providers. In both cases, the differences would tend to lead to the rates exceeding the costs, for reasons described below. However, the states differed with respect to other special populations: New Jersey included individuals with post-traumatic stress disorder (PTSD) and SED as special populations whereas Oklahoma designated individuals into special populations based on age, homelessness, and the presence of first-episode psychosis. This chapter describes the PPS, rates, and costs of CCBHCs, drawing on data from interviews with state officials and the DY1 cost reports. Consistent with reports from state officials, data from CCBHC progress reports indicated that a majority of clinics utilized CCBHC quality measures to inform clinical practice. Audits of SAMHSA's Certified Community Behavioral Health Clinic The T-CCBHC model is based on federal principles with specific features designed to meet the needs of Texas' delivery system. CCBHC-reported measures were generally seen as more challenging to implement than state-reported measures, largely due to technical issues associated with EHR/HIT buildout that impacted clinics' ability to generate data to support these metrics. The demonstration aims to improve the availability, quality, and outcomes of ambulatory services provided in CMHCs by establishing a standard definition and criteria for CCBHCs and developing new prospective payment systems (PPS) that account for the total cost of providing comprehensive services to all individuals who seek care. At the time of the last interviews with state officials, threshold details were still being finalized. They do not reflect the views of the Department of Health and Human Services, the contractor or any other funding organization. In addition to the six required measures, Minnesota also used the CMS-optional measure Screening for Clinical Depression and Follow-Up Plan (CDF-A) in determining QBPs, and New York added two state-specific measures based on state data regarding suicide attempts and deaths from suicide. Proportion of Clinic Costs Allocated to Direct Labor in DY1 by State, FIGURE III.7. As a result, states and CCBHCs had to project the costs and number of visits for these new services based on very limited information or uncertain assumptions. In June 2018, Mathematica and RAND submitted to ASPE the report "Interim Implementation Findings from the National Evaluation of the Certified Community Behavioral Health Clinic Demonstration. (2016). Pennsylvania planned to use prior year data to determine DY1 performance thresholds for four of the six required measures. As shown in Figure III.2, the average blended rates in New Jersey and Oklahoma were similar to each other, $714 and $704 respectively. In February and March of 2019 (DY2), we conducted site visits to clinics in four demonstration states (Missouri, Oklahoma, Oregon, and Pennsylvania). However, state officials indicated in our interviews that they were aware of these data limitations and expected the rates to be inaccurate to a certain degree during DY1. Based on the DY1 CCBHC progress reports, roughly one-third of CCBHCs provided emergency crisis intervention or 24-hour mobile crisis teams through a DCO relationship, and only 21 percent provided crisis stabilization through a DCO. During site visits, many CCBHC staff reported that similar screening tools had been used prior to the demonstration, but virtually all sites reported implementing changes to screening protocols (for example, the frequency with which screenings were conducted) and how screening data were used in clinical practice, including how and where results were displayed in a consumer's chart. For PPS-2 states, for which there are separate rates for each population category, we calculated a blended rate by weighting the category specific rates by the actual distribution of consumers across the rate categories (based on information contained in the cost reports, described below). Therefore, the rates could differ from the actual DY1 costs if either the anticipated costs or the anticipated visit-days or visit-months differed from the actual DY1 total costs or total visit-days or visit-months. Although state officials recognized that not all CCBHCs would be fully staffed at the outset of the demonstration, it was important to set the rates under this assumption in order to avoid constraining hiring. Considerations for the Design of Payment Systems and Implementation of Certified Community Behavioral Health Centers. As required by PAMA, HHS selected the states based on the ability of their CCBHCs to: (1) provide the complete scope of services described in the certification criteria; and (2) improve the availability of, access to, and engagement with a range of services (including assisted outpatient treatment). States set the PPS rates for each CCBHC by dividing projected total allowable costs by the projected number of visit-days (for PPS-1) or visit-months (for PPS-2). States were able to raise or lower the payment rates for some or all their CCBHCs for DY2 to bring rates into closer alignment with costs. The second round of interviews gathered information on interim successes and challenges since the time of the initial interview, success in implementing demonstration cost-reporting procedures and quality measures, and early experiences with the PPS systems and QBPs (if applicable). The operating costs include both direct costs, such as labor and medical supplies, and indirect costs, such as rent payments. We conducted several types of analyses using the cost report data: Total cost per visit-day or visit-month calculations and cost component analyses. What were the DY1 rates? For example, one clinic in Oregon reported zero indirect costs, but it is likely that they had at least some allowable indirect costs in DY1. Figure III.4 shows the distribution of visit-month costs across clinics and the average visit-month costs for each state. Federal government websites often end in .gov or .mil. In Oregon and New Jersey, the rates were similar to costs on average, but the rate to cost ratio varied widely across clinics. Description of the Certified Community Behavioral Health Clinic Demonstration While interpreting the cost report information, we found some limitations of the data. Some states used different methods to allocate and present direct and indirect costs, and in some cases the costs cover different time periods. Health Affairs 35(6): 1106-1113. Interview topics included: successes and barriers related to CCBHC staffing, steps clinics have taken to improve access to care and expand their scope of services, the CCBHCs' experience with payments and the PPS, and quality and other reporting practices. MEDICAID COST REPORT for Certified Community Behavioral Health Clinics Line Comments Description Total Hours Provider Information Daily Visits Monthly Visits REPORTING PERIOD: CC PPS-1 Rate WORKSHEET: Days Name 1 ** Transfer to Trial Balance worksheet, column 6 as appropriate Explanation of Entry From: PDF CCBHC Planning Grant - Illinois Department of Human Services These state officials explained that their decisions to adjust rates, not re-base, were related to not feeling comfortable with the length of time and the availability of cost, utilization, and staff hiring data to appropriately inform re-basing the rates. How have CCBHCs and states used their performance on the quality measures to improve the care they provide? 3. Changes in the Number of Clients Served by CCBHCs Over Time 9 EXHIBIT IV.1. The percentage of costs allocated for direct labor, indirect, other direct, and DCO costs were similar for PPS-1 and PPS-2 states. CMS required the use of six quality measures to trigger bonus payments to CCBHCs (two of the CCBHC-reported measures and four of the state-reported measures; see Table IV.4). In the early stages of the demonstration, many clinics relied upon ad hoc strategies to overcome these challenges and facilitate data collection and reporting. Ashwood, J.S., K.C. During the demonstration, some CCBHCs and states not only reported quality measure data to CMS, but also used the data to improve care in a variety of ways. The structure of the PPS-1 was relatively simple, with a single rate for each day on which a service was provided to a consumer, regardless of the services provided on that day. What were the total costs and main cost components in CCBHCs per visit or per month in DY1? As reported by one official in Pennsylvania: "The state began group meetings very early in the planning and DY1 and built a culture of group support. The first model (PPS-1) is a daily rate, similar to the PPS model used by Federally Qualified Health Centers. Nearly all clinics (97 percent) across all states made changes to their EHRs or HIT systems to meet certification criteria and support quality measure and other reporting for the CCBHC demonstration. In some cases, this was done when a clinic had zero cases in one of the categories during the year prior to DY1 (the year on which the rates were based). In October 2015, the U.S. Department of Health and Human Services (HHS) awarded planning grants to 24 states to begin certifying CMHCs to become CCBHCs, develop new prospective payment systems (PPS), and plan for the demonstration's implementation. This is not surprising, as data on symptoms of depression (for example, the PHQ-9) are used for the depression remission at 12 months quality measure. DY1 Visit-Day Rates for PPS-1 Clinics by State, TABLE III.1. To sign up for updates or to access your subscriber preferences, please enter your contact information below. Minnesota, Nevada, and New York also used the CMS-optional measure for Plan All-Cause Readmission Rate (PCR-AD) in addition to the six CMS-required measures. Wherever we noticed data omissions, errors, or inconsistent reporting methods, we requested via email supplemental information from states and clinics, and states and clinics were highly responsive to our questions. New Jersey's cost reports covered an earlier time period (the year prior to the demonstration) than the cost reports from the other demonstration states. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. According to state officials, the CCBHCs and state agencies were successful in collecting and reporting data on the required quality measures to CMS during DY1. Certified Community Behavioral Health Clinics Demonstration Program: Report to Congress, 2019, Implementation Findings from the National Evaluation of the Certified Community Behavioral Health Clinic Demonstration, Preliminary Cost and Quality Findings from the National Evaluation of the Certified Community Behavioral Health Clinic Demonstration. The figure combines information on the PPS-1 and PPS-2 states, which were very similar in this regard. Many clinics also reported using CCBHC quality measures to support quality improvements, although the use of individual quality measures (for example, time to initial evaluation; depression remission; suicide risk assessment [SRA]) varied depending on site-specific areas of focus. This report summarizes the rate-setting process and the costs of providing care in the CCBHCs during DY1. During the site visits, we conducted in-depth discussions with clinic administrators and front-line clinical staff about how care has changed following implementation of the demonstration. CCBHCs provide person- and family-centered integrated services. Specifically, states selected between two PPS models developed by the U.S. Department of Health and Human Services (HHS) Centers for Medicare & Medicaid Services (CMS) (although states could exercise some flexibility in operationalizing the models). Across all PPS-1 clinics, the average DY1 visit-day cost was $234 and ranged from $132 to $639. ); and (3) explain how to complete the reporting template. States that adopted the PPS-1 model also had the option of including a quality bonus payment (QBP) mechanism--a payment above the standard PPS rate based on performance on quality measures. Thresholds for Triggering an Outlier Payment in New Jersey and Oklahoma, TABLE B.2. The vendors did some over promising and under delivering, particularly around the timelines and deadlines.". Pennsylvania officials decided to re-base clinic rates between DY1 and DY2 based on their analyses of interim and DY1 cost reports, which indicated differences between the DY1 rates and costs. We will also examine if states' changes to rates resulted in closer alignment with actual costs. Across all PPS-2 clinics, the blended visit-month costs averaged $759 and ranged from $443 to $2,043. For example, in DY1, 88 percent of CCBHCs reported providing emergency crisis services directly, suggesting that they provided these services to some consumers but also contracted with a DCO to supplement their crisis services (for example, to serve clients outside of regular office hours). CCBHCCostReportWalk-Through QualityBonusPaymentOption PPS/ManagedCareIntegration CCBHCResources Rate PROTECTINGACCESSTOMEDICAREACT(PAMA)OF2014, EFFECTIVEAPRIL1,2014(P.L.113-93,SECTION223) Establishcriteriathatstateswillusetocertifycommunitybehavioral healthclinicsthatwillparticipateintwoyeardemonstrationprograms Visit-days are unique days on which a consumer received at least one service, and visit-months are months in which a consumer received at least one service. B. Inconsistency in the reporting of staff cost information does not impact rate calculations, which are based on total costs. D. How did Visit-Day and Visit-Month Rates Compare with Actual Visit-Day and Visit-Month Costs Incurred during DY1? Overall, CCBHCs were ultimately able to provide the information in the cost reports. This reporting requirement introduced a more detailed and sophisticated level of accounting to clinics. We summarized interviewees' responses for each state and then identified cross-state themes in the findings. To understand the potential reasons for divergence of the rates from the actual DY1 costs, it is important to remember that the rates were calculated by dividing the total anticipated costs of operating the clinic by the anticipated number of visit-days or visit-months, depending on the PPS. Payments could be higher for improvement greater than 1 percent. Historically, Medicaid has reimbursed CMHCs through negotiated fee-for-service or managed care rates, and there is some evidence that these rates did not cover the full cost of CMHC services. CCBHC COST REPORT INSTRUCTIONS OMB #0398-1148 CMS-10398 (#43) 5 Line 6: The NPI for the primary center or headquarters will populate automatically from the NPI entered at the top of this worksheet. [7] PPS-2 rates tended to be higher in CCBHCs that served a smaller number of clients versus those that served a higher number of clients, as measured by the total visit-months. We calculated an average blended rate by weighting each rate by the number of visit-months in that category in DY1 according to the cost reports and then calculated the average for the clinic. Costs also varied widely across CCBHCs within states. (1) The CMHC must submit a properly completed enrollment application by the due date determined by HHSC. State officials reported in phone interviews their decisions for re-basing and/or adjusting rates between DY1 and DY2. States relied on historical cost data to set the PPS rates but they also had to make assumptions about the number of visits and costs for the full scope of services required by the CCBHC criteria (most CCBHCs added services to meet the demonstration requirements, and therefore did not have historical information on costs for every type of CCBHC service). Quality Measures Used for Determining Quality Bonus Payments, https://www.samhsa.gov/sites/default/files/grants/pdf/sm-16-001.pdf#page=94, TABLE I.1. In the above analyses, we assumed that the costs that clinics reported after DY1 were in fact accurate and allowable. vi. Similarly, information gathered from CCBHC site visit interviews supported the notion that challenges with quality reporting tended to be driven by site-specific data system issues; across clinics, staff did not systematically report that any given measure was more challenging to report than any other. Across all PPS-1 states, clinics with a higher volume of consumer visit-days had lower rates ($229 on average) than clinics with lower volume of consumer visit-days ($298 on average). Similarly, staff turnover at a CCBHC during the year could reduce CCBHC costs, since they would not be paying staff costs for positions that were unfilled. CCBHCs and demonstration states must also report a common set of quality measures and report their costs as a condition of participating in the demonstration. We will also examine whether changes to rates were successful in bringing rates into closer alignment with actual costs. The PPS-2 model has multiple rate levels--a standard rate and separate monthly rates for special populations defined by state-specified clinical conditions. These states launched their CCBHC demonstrations in mid-2017 with 67 CCBHC provider organizations in 372 locations across 190 counties. The CCBHCs report on nine of the measures, based on clinical data typically derived from EHRs or other electronic administrative sources. As of February 2019, only two states--Missouri and Nevada--had determined that all clinics in their states met the measure thresholds to receive QBPs for DY1; officials from five states reported that they were still receiving or analyzing data to finalize determinations of QBPs. DY1 data will be used to determine the DY2 thresholds for all required measures. However, in the final round of telephone interviews, state officials from Minnesota, New Jersey, and Oklahoma reported that CCBHCs continued to experience some challenges with collecting information on depression remission, primarily due to challenges with extracting follow-up data from EHRs and concerns regarding operational definitions of remission based on specific screening tools (for example, score of >= 5 on the PHQ-9). These differences required harmonization by the evaluation team for purposes of comparison. For each clinic, we weighted each population rate by the number of visit-months in that category in DY1 according to the cost reports and then calculated the average for the clinic. These changes were typically accompanied by extensive staff trainings and frequent data reviews to ensure provider compliance with screening and data entry procedures. The thresholds are unique for each measure and range from 0 percent improvement (maintaining the minimum performance threshold level) to 10 percent improvement. Interviewees noted that many clinics initially experienced challenges with reporting anticipated costs, due to limited familiarity with PPS and uncertainty over the extent to which staffing and the number of consumers served would change as a result of new services and efforts to increase access to care. ! " In PPS-1, payment rates were lower for clinics in rural areas than those in urban areas. This report answers the following evaluation questions: How did the states initially establish the CCBHC rates? This chapter describes CCBHCs' and states' experiences collecting and reporting quality measures for the demonstration, as well as the ways in which measures have been used to support quality improvement efforts over the course of the demonstration. The DY2 performance thresholds require CCBHCs to either meet state-specified improvement goals for each measure or improve on the measures from DY1 to DY2 by at least a 10 percent reduction in the gap between DY1 performance and the improvement goal. Cost-reporting by clinics. Each report shall include assessments of: (1) access to community-based mental health services; (2) the quality and scope of services provided by Certified Community Behavioral Health Clinics (CCBHCs); and (3) the impact of the demonstration programs on the federal and state costs of a full range of mental health services. The distribution of costs across these categories was similar across states. States can use the DY1 cost reports to inform rate adjustments. The blended rates ranged across CCBHCs from a low of $558 to a high of $902. This could happen, for example, if the CCBHC hired higher or lower salaried staff than anticipated or incorporated services that were more expensive to provide than anticipated. The third round of interviews collected information on the same categories covered in the second round of interviews, with an emphasis on any changes in implementation successes and challenges experienced in DY2. We also highlight potential reasons that the rates differed from the DY1 costs. Brown, C. Kase, J. Breslau, and M. Dunbar. Appendix Table B.1 summarizes the thresholds for triggering an outlier payment for each special population group. Mathematica and RAND conducted a total of 29 interviews (ten during each of the first two rounds, and nine in the third). Quality measure reporting was the most commonly cited reason for investing in improvements to EHRs during the CCBHC certification process. Osilla, M. DeYoreo, J. Breslau, J.S. 1. Certified Community Behavioral Health Clinics Demonstration - ASPE DCOs are entities not under the direct supervision of a CCBHC but are engaged in a formal relationship with a CCBHC and provide services under the same requirements. Quality measure reporting provided clinics and state officials with standardized metrics to monitor the quality of care and inform quality improvement efforts. In short, we do not know the extent to which data quality issues may distort DY1 actual costs; we simply used cost, visit-day, and visit-month data as reported. The state average rates ranged from a low of $197 in Nevada to $379 in Minnesota. RI CCBHC Cost Reporting - FAQs Last Updated: 02/01/2023 We observed this finding for 49 of the 66 CCBHCs. There were no outlier payments made to clinics in Oklahoma in DY1. We developed staffing categories to facilitate consistent comparisons across the clinics and states despite variability in the original staff classifications. Section 223 of the Protecting Access to Medicare Act (PAMA), enacted in April 2014, authorized the Certified Community Behavioral Health Clinic (CCBHC) demonstration to allow states to test new strategies for delivering and reimbursing services provided in community mental health centers (CMHCs). Rates relative to costs during DY1. Question 8: Is a state allowed to modify the staffing categories shown on the CMS CCBHC cost report template? States set the outlier payment amount and the cost thresholds that trigger the outlier payment. U.S. Department of Health & Human Services For additional information about this subject, you can visit the BHDAP home page at https://aspe.hhs.gov/bhdap or contact the ASPE Project Officer, Judith Dey, at HHS/ASPE/BHDAP, Room 424E, H.H. However, clinics in the seven other states participating in the demonstration did not have experience completing these types of cost-reporting forms or reporting their operating costs. The updated report will include an analysis of the performance of the CCBHCs on the required quality measures during DY1 and an analysis of cost reports from DY2. We obtained data on CCBHC costs during DY1 from the standardized cost reports that states were required to submit to CMS during the first half of 2019. As described in detail in the report, the PPS-2 states established rates for the general population and rates for special populations. Certified Community Behavioral Health Clinic - Cost Reports EOHHS, BHDDH, and DCYF drafted technical guidance to support provider completion of the CCBHC Cost Report. New York officials initially planned to only make an MEI adjustment for DY2, but they changed this plan after deciding to continue the CCBHC model beyond the two-year demonstration project. It is the Medicaid ID, NPI, reporting period, and rate period, automatically inserted from the provider information tab. The Department of Health Care Policy & Financing, in partnership with Colorado Department of Human Services - Office of Behavioral Health, has been awarded a Planning Grant for Certified Community Behavioral Health Clinics (CCBHCs) by the Substance Abuse and Mental Health Services Administration (SAMHSA). The CCBHC PPS is a Medicaid per-encounter rate set based on provider cost reporting that applies to services delivered either directly by a CCBHC or through a formal relationship with a Designated Collaborating Organization (DCO). The PPS-2 has multiple rate categories, one rate for the "standard" population and additional rates for special populations (that is, consumers who met criteria for certain conditions expected to have different costs on average). According to that survey, labor costs account for 68 percent of total outpatient care center costs in 2016. Several states assessed performance on the quality measures during the first six months of the demonstration and used that information to set improvement goals for the remainder of DY1. All the CCBHCs submitted cost reports that were approved by their state governments. For all other required CCBHC services, fewer than 10 percent of CCBHCs provided the service through a DCO. How did States Establish the CCBHC Rates? provided by a DCO, the cost of that DCO arrangement must be included in the cost report. Issued by: Centers for Medicare & Medicaid Services (CMS). Burnam, Review and Evaluation of the Substance Abuse, Mental Health, and Homelessness Grant Formulas. For example, officials in Missouri noted that, in response to requests from CCBHC leaders, they had shared such data with the CCBHCs to inform quality improvement and technical assistance plans. The PPS-1 model also includes a state option to provide quality bonus payments (QBPs) to CCBHCs that meet state-specified performance requirements on quality measures. As a condition of participation, all CMHCs participating in the program must allow for the following. Clinic-reported quality measures are primarily process measures that focus on how clinics are achieving service provision target (for example, time to initial evaluation, whether screening and services were provided) and are based on clinical data typically derived from EHRs or other electronic administrative sources. The cost reports included details on staff types, the salaries and benefits associated with each staff type, and staff work time (as measured in FTEs); however, this information was reported in varying ways and sometimes with significant gaps. Format developed by CMS. Quality Bonus Payment (QBP) programs. PDF Certified Community Behavioral Health Clinic Cost Report: Rhode Island
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