HHS analyzes community-based behavioral health demonstration

May 18, 2021

The Government Accountability Office (GAO) released a new report that describes the Department of Health and Human Services’ (HHS') assessment regarding access, costs and quality of a Certified Community Behavioral Health Clinics (CCBHC) demonstration aimed at improving community-based behavioral health services. 

Many individuals with behavioral health conditions rely on community mental health centers for treatment, but the scope and quality of these services vary. HHS estimates that 61 million adults had at least one behavioral health condition in 2019—41 million of whom did not receive any related treatment in the prior year. 

The Protecting Access to Medicare Act of 2014 (PAMA) created the CCBHC demonstration and provided HHS with $25 million to support its implementation. Under the CARES Act, GAO is to issue another report on states' experiences by September 2021. PAMA directed HHS to assess the demonstration and to provide recommendations for its continuation, modification, or termination. To date, HHS has issued three annual reports assessing the initial demonstration period, which ran from 2017 to 2019. HHS plans to issue a fourth annual report and a final report by December 2021. 

Untreated mental health issues or substance use disorders can have ripple effects. In 2014, Congress approved a two-year program to improve mental health services in up to eight states, particularly for Medicaid beneficiaries. The program was extended to Sept. 2023. 

HHS will continue to have trouble determining how well the program works due to problems with program data. For example, most clinics hadn't reported quality measures before, so there is no baseline data available for measuring progress. As another example, HHS didn't tell states which services to provide under the program—a design decision that makes uniform assessments more difficult. 

PAMA also required HHS to assess the effect of the demonstration on service access, costs, and quality. HHS's preliminary assessments of the demonstration in eight states, with 66 participating CCBHCs, found the following:

·        Access. CCBHCs commonly added services related to mental and behavioral health, such as medication-assisted treatment, and took actions to provide services outside the clinic setting, such as through telehealth.

·         Costs. States' average payments to CCBHCs typically exceeded CCBHC costs for the first two years of the demonstration. CCBHC payments and costs were more closely aligned in the second year for most states, better reflecting the payment methods prescribed under the demonstration.

·         Quality. States and CCBHCs took steps, such as implementing electronic health records systems, to report performance on 21 quality measures.

GAO found data limitations complicated—and will continue to affect—HHS's efforts to assess the effectiveness of the demonstration. For example:

·         Lack of baseline data. PAMA requires HHS to assess the quality of services provided by CCBHCs compared with non-participating areas or states. The demonstration marked the first time these clinics reported performance on quality measures, so no historical baseline data exist. HHS officials noted that with time, additional data may provide insight on the quality of services.

·         Lack of comparison groups. PAMA requires HHS to compare CCBHCs' efforts to increase access and improve quality with non-participating clinics and states. HHS was unable to identify comparable clinics or states due to significant differences among the communities.

·         Lack of detail on Medicaid encounters. PAMA requires HHS to assess the effect of the demonstration on federal and state costs and on Medicaid beneficiaries' access to services. HHS plans to use Medicaid claims and encounter data to assess such changes. However, GAO has previously identified concerns with the accuracy and completeness of Medicaid data and has made numerous recommendations aimed at improving their quality.

HHS's decisions in implementing the demonstration also complicated its assessment efforts. HHS allowed states to identify different program goals and target populations, and to cover different services. HHS also did not require states to use standard billing codes and billing code modifiers it developed. The lack of standardization across states limited HHS's ability to assess changes in a uniform way. 

GAO has the report