CBH: Serving Behavioral Needs of Medicaid Enrollees in Philadelphia - Research Paper

Introduction

Community Behavioral Health, abbreviated as CBH, is one of the largest managed-care organizations in the United States. It is a non-profit entity run by the city of Philadelphia and which specializes in satisfying the behavioral needs of residents enrolled in Medicaid. CBH is major component of Philadelphia's DBHIDS (Department of Behavioral Health and Intellectual disability Services) that offers a wide range of substance abuse and mental health services to people. It works in conjunction with the Philadelphia OHM (Office of Mental Health) and the OAS (Office of Addiction Services) to plan and coordinate how to deliver services to residents with no health insurance and those eligible for Medicaid. All these components together form a formidable and integrated system of care. Services covered by the CBH include inpatient, outpatient, residential, and partial hospital psychiatric and substance treatment.

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Formed in 1997, CBH has a responsibility of delivering medically necessary and effective services in a culturally competent, non-restrictive, and developmentally appropriate manner. By running such a managed care system, the organization promotes family and community participation, public accountability, maximum access, and local control. It also ensures that all the available resources are utilized efficiently. The primary goal of the CBH is to effectively support and address the overall health and wellbeing of Philadelphia residents across various domains. It partners with DBHIDS, the physical health managed care organizations in the city, and other government agencies. In the more than two decades it has been in existence, CBH has remained committed to ensuring that residents of Philadelphia have access to high quality and cost-effective health services. The agency also works with other social service organizations to advocate for and respond to the healthcare needs of all residents who lack health insurance.

A notable sociopolitical pressure faced by CBH involves funding and EBPs (evidence-based practices). Financing has always been a crucial factor when it comes to implementing EBPs. CBH often faces financial distress that results in concerns about expensive and complex implementation of EBPs. While stakeholders agree that the agency and the system should share the cost of implementing EBPs, there is no consensus on how the practices should be funded. Changes in how community mental health care is funded have altered the delivery of publicly-funded services over the last six decades or so.

Often, the rates of Medicaid reimbursement are less than those found in the private healthcare sector. Also, significant reductions in state funding for behavioral health programs since the 2008 financial crisis have raised concerns to do with behavioral health budgets. Concurrently, advocates, policy makers, and payers have encouraged community mental health programs such as CBH to implement EBPs. Such a situation is likely to worsen these financial pressures given the high cost of implementing and sustaining new practices. It is clear that funding plays a crucial role when it comes to putting in place EBPs and sustaining them.

DBHIDS is a large urban mental health system consisting of over 200 agencies and offering substance abuse and mental health services. Over the past decade or so, it has overseen the implementation of several EBPs in selected agencies, including CBH. The practices include cognitive therapy, dialectical behavioral therapy, prolonged exposure, and trauma-based cognitive-behavioral therapy. DBHIDS funds consultation and training, and pays for internal employees so that they can support each initiative. In some instances, the organization reimburses for time lost by staff members in supporting the initiatives and offers an adjusted reimbursement rate. All these efforts go a long way in helping CBH carry out its mandate. There are other sociopolitical factors that affect CBH, including organizational attitudes, culture, and climate. All in all, financing and the implementation of EBPs within community mental health care is the most prevalent issue.

The fact that CBH is based in Philadelphia is worthy of mention. The city has a well-organized public system that is strongly committed to EBPs in terms of funding and belief. While CBH and the other agencies do not pay start-up costs such as training and consultation, they incur a significant financial burden in terms of billing, productivity, and sustainability. Such a situation has a troubling effect on public systems that do not have enough funds to invest in EBP implementation. It also has a disturbing impact on community mental health programs that strive to implement EBPs without a source of funding.

Increasing the rates of reimbursement is quite an uphill task. Often, state Medicaid rates are usually below those of the private healthcare industry, a situation that undermines the system's ability to increase rates. Payers face an unpleasant dilemma of determining which services to prioritize payments for, such as outcomes, service delivery, and training. They also have a hard time resolving measurement, certification, and fidelity issues. All in all, EBPs are naturally a set of interventions that can easily be defined and that can theoretically attract a higher rate of reimbursement. CBH is yet to develop effective ways of conducting value-based reimbursement such as paying for outcomes, or put in place innovative financial structures that can offer financial incentives for promoting EBPs.

References

Beidas, R. S., Adams, D. R., Kratz, H. E., Jackson, K., Berkowitz, S., Zinny, A., ... & Evans Jr, A. (2016). Lessons learned while building a trauma-informed public behavioral health system in the City of Philadelphia. Evaluation and program planning, 59, 21-32.

Stewart, R. E., Adams, D. R., Mandell, D. S., Hadley, T. R., Evans, A. C., Rubin, R., ... & Beidas, R. S. (2016). The perfect storm: collision of the business of mental health and the implementation of evidence-based practices. Psychiatric Services, 67(2), 159-161.