When it comes to fixing Montana’s behavioral health care system, policy experts often say there is no silver bullet. The next best option, though, may be a jargon-filled phrase that has many stakeholders sounding hopeful: Certified Community Behavioral Health Clinics, or CCBHCs, a Medicaid program and funding mechanism designed to make essential mental health and substance use treatments accessible to communities in need.
That clinical model is under consideration as part of an ongoing legislative study of the state’s adult mental health care system by the Children, Families, Health and Human Services interim committee. Supporters of the CCBHC model say it could be a boon to Montana’s currently strained and underfunded system for treating mental health and substance use disorders — if it gains traction with state lawmakers and Gov. Greg Gianforte’s administration.
Speaking to lawmakers on Friday, Department of Public Health and Human Services Director Adam Meier signalled a degree of open-mindedness about the model.
“We’re at the point now where we’re exploring it kind of alongside the providers and you guys,” Meier said to lawmakers on the committee. “Once we have more information, [and] we have feedback from whether the providers want to go this route, I think that allows us to know whether there’s interest on our side as well.”
Even that noncommittal response sparked excitement among some advocates of the program.
“It is tantalizing to see the administration circling around CCBHCs,” said Matt Kuntz, director of the nonprofit mental health advocacy group NAMI Montana, adding that the model could expand treatment and services in critical ways.
National proponents of CCBHCs are trumpeting the model’s potential. In a 2020 report titled “Hope for the Future,” the National Council on Behavioral Health said it aims to make CCBHCs available in every state.
“When that happens,” the report said, “we will have created the greatest opportunity to improve the health and well-being of the entire nation.”
WHERE DID CCBHCs COME FROM?
Starting in 2017, a handful of states have launched CCBHCs under a Medicaid demonstration program designed to make mental health and substance use disorder treatments more widely available. While 10 states have begun implementing statewide CCBHC programs, many more organizations have received federal grants to build infrastructure to support CCBHC services, including three providers in Montana: Rimrock Foundation in Billings, Center for Mental Health in Great Falls, and Western Montana Mental Health Center.
CCBHC care providers must offer a range of services to fill out the spectrum of mental health and substance use disorder treatment, as well as meet certain reporting requirements set by the federal government. In return, participating providers receive an enhanced federal funding match for treating Medicaid patients — a key incentive for behavioral health providers and practitioners.
A DIFFERENT WAY TO PAY FOR BEHAVIORAL HEALTH CARE
Advocates for CCBHCs say the critical difference between that model and Montana’s current behavioral health system lies in how Medicaid services are funded. If a statewide CCBHC program were implemented in Montana, the state would shift from its current fee-for-service model to what’s called a prospective payment system.
Under fee-for-service, “if a provider bills [Medicaid] for a 50-minute therapy session, they get paid for that 50-minute session,” said Mary Windecker, executive director of the Behavioral Health Alliance of Montana (BHAM), a group of providers currently studying the CCBHC model.
Alternatively, Windecker said, a prospective payment system would ensure providers a rate “that takes into account the actual costs of delivering that care,” such as documentation time, administrative staff, and case managers. “This is particularly important for community-based behavioral health care, where so many services are not reimbursed” under the current system for billing Medicaid, she said.
Behavioral health providers in Montana have long said the state’s Medicaid reimbursement rates are insufficient. While some providers can remain financially afloat by accepting private insurance, organizations that work mostly with Medicaid-enrolled or uninsured patients may be unable to retain staff or expand services. As a result, Montana struggles to provide robust and widespread treatments that meet the needs of the state’s population. By using a prospective payment system with a stronger federal match, advocates say, CCBHCs can reliably deliver essential services to communities in need.
The Medicaid rate afforded to CCBHCs “covers the real costs of delivering enhanced services to an increased number of patients and represents an important transformation in the sustainability of clinics,” the National Council for Behavioral Health report said.
Participating clinics can still provide services for patients with private insurance or no insurance at all — federal requirements stipulate that an organization must provide treatment regardless of a person’s ability to pay. The higher reimbursement rate that comes with licensure as a CCBHC applies only to patients with Medicaid.
DO CCBHCs ACTUALLY WORK?
After roughly five years of implementing the CCBHC model, state officials gave the program generally high praise to surveyors with the National Council for Mental Wellbeing.
Among the eight states surveyed, CCBHCs “lowered costs, improved outcomes, contributed to building critical mental health and substance use care system capacity and infrastructure required to meet rising levels of need,” the organization wrote in a 2021 report. In some states, individuals receiving treatment at CCBHCs saw reduced emergency room visits, fewer interactions with law enforcement, and lower readmission rates.
In a presentation to Montana lawmakers last week, a representative of the National Council for Mental Wellbeing said 100% of existing CCHBCs offer crisis response services such as a 24-hour mobile crisis team, a type of emergency protocol for people experiencing a mental health crisis that is inconsistently available in Montana. The presentation pointed specifically to positive results in Missouri and Texas, the latter of which is projected to save $10 billion by 2030 through implementation of the CCBHC model.
‘THE HOPE’ FOR MONTANA
In an often-struggling industry facing growing demand for services, Montana providers widely agree that stabilizing and bolstering behavioral health care is essential. NAMI Montana’s Kuntz said implementing a CCBHC model could be a game-changer for patients and providers.
“The hope is that we have a long-term solution for funding our mental health centers … so we actually have a model that works for things like crisis [care], where our therapists are fully funded at their cost,” Kuntz said. “If you get the payment model right, it is possible to deliver care for underserved communities.”
But implementing a CCBHC program would be a significant undertaking for Montana officials, who would either need to amend the current Medicaid state plan, join the federal demonstration project with 10 other states, or file a special waiver with the Centers for Medicare and Medicaid to get the green light for a state program.
Windecker said becoming a licensed CCBHC could also be a hurdle for individual facilities, which would have to comply with federal data collection requirements.
“There are 21 evidence-based outcome measures that are required to be collected” by CCBHCs, she said. “This would be a heavy lift for both providers and the state, but would ensure the state that CCBHCs are providing the care they are licensed to provide.”
Windecker said her organization’s study of transitioning to a CCBHC model, funded by a grant from the Murdock Charitable Trust, won’t be concluded for another six months. By then, BHAM providers will have a clearer sense of whether to advocate implementing CCBHCs statewide.
“The last thing any of us want is to implement a model that won’t work for Montana,” Windecker said, noting the state’s unique rural characteristics. “[W]e need to look at its applicability to Montana’s wide open spaces to make sure it would work here.”
Low-income families that need safety-net services, such as food and cash assistance, have become collateral damage in the bureaucratic scramble to determine whether tens of millions of people still qualify for Medicaid after a pandemic-era freeze on disenrollment ended this spring.
The decision to list wolverines under the Endangered Species Act comes nearly 30 years after conservation groups first proposed federal protections for the elusive, snow-dependent carnivores.
Cascade County officials have still not certified the results of municipal elections in three towns, prompting renewed calls for a change in who administers elections in and around Great Falls.