Tag: primary care

The Innovation in Behavioral Health Model (IBH) is big news, and certainly worthy of a blog post. This newly unveiled state-run model from CMS’s Centers for Medicare and Medicaid Innovation (CMMI) employs that value-based mindset we’ve come to know and love from other CMS models. Among these latest offerings include Making Care Primary (MCP), ACO Reach, All-Payer Health Equity Approaches and Development (AHEAD), and Transforming Maternal Health (TmaH).

Each of these models strives to ease the clinical and fiscal burdens of care for all stakeholders by enhancing access for all beneficiaries, while reducing disparities experienced by minoritized and marginalized populations. Each model focuses on wholistic health approaches that leverage interdisciplinary team-based care to ensure timely screening, assessment and treatment of physical, behavioral, and psychosocial health needs. Each model is poised to ensure proactive attention to closed-loop care referrals that will hopefully yield decreased costs of healthcare utilization, reduce workforce burden and burnout, and ensure quality-driven care that heeds the Triple, Quadruple, and Quintuple or Quintile Aims (whichever you subscribe to). Clearly there’s lot of pent-up anticipation, but will the preliminary hype and the outcomes align?

The IBH Lowdown

  Primary care has long sheltered the full responsibility for mental health attention, though behavioral health practices will now receive extra funding to shoulder the burden. Here’s the IBH lowdown:

• Notice of Funding Opportunity will be released late Spring 2024. 
  • Up to 8 states will be picked for an 8-year run that will launch in Fall 2024.
    • Years 1-3: Pre-implementation periods for states to conduct outreach and recruit behavioral health practice participants into the model. Funding will go to upgrading health IT, advancing EHRs, aligning practices with the model, and adding staff.
  • Year 4-8: The chosen states will implement a Medicaid payment model to support practice participants in implementing the care delivery framework. Practice participants in selected states who participate in the additional Medicare payment model will receive a per-beneficiary-per-month payment to support implementation of the care delivery framework and performance-based payments.

  Community-based health practices will be front and center in IBH. These sites already have interprofessional models equipt to manage whole person care. The model will maximize its power through a single point of entry that uses 4 pillars; each one will bolster the model’s framework and critical infrastructure:

1. Care Integration: Behavioral health practice participants will screen, assess, refer, and treat patients, as needed, for the services they require across the wholistic health triad of behavioral, physical, and psychosocial health.
2. Care Management: An interprofessional care team led by the behavioral health practice participant will identify, and as appropriate address care of patients and provide ongoing care management.
3. Health Equity: Behavioral health practice participants will conduct screenings for HRSNs and refer patients to appropriate community-based services. Participating practices will be required to develop a health equity plan (HEP) that stipulates how the practice participant will address disparities that impact their service populations.
4. Health Information Technology: Capacity building will the priority with expansion of health IT through investments in interoperability and necessary tools (e.g., EHRs). These actions will also ensure greater emphasis on quality reporting and data sharing.

A Sustainable Fix

  To say this model is a must is an understatement:

• Medicaid is the large single payer in the US for mental health
• 25% of Medicare beneficiaries experience a mental illness, 
• 40% of Medicaid beneficiaries who are non-elderly adults experienced a mental illness or substance use disorder in 2020
  • The percentage of hospitalizations for patients with a mental health and substance use disorder condition (M/SUD) that involved a co-occurring physical health condition increases with age and has variation across subgroups:
    • These stays were more common among adults aged 45-64 years (92.3 %) and 65 years and older (97.9 %) than for adults aged 18-44 years (75.8 %). 
      • Co-occurring physical health conditions were more common among patients with Medicare (92.9 %) compared to patients in other payer categories (< 83 %) and among Whites (85.5 %) vs. Asian/Pacific Islanders (75.9 %)

  Patients and providers deal with a lengthy list of barriers to access and treatment, starting with how behavioral health services are not a specifically defined category under Medicaid benefits. Feel free to add further problems with service fragmention, poor reimbursement, limited treatment availability, and lack of true payment parity with physical health, but I digress. Many of behavioral health services are wiggled to fall under mandatory Medicaid benefit categories, such as when psychiatrist services are coded as physician evaluations or visits. Several states have defined mechanisms to cover behavioral health through optional benefit categories, such as case management services, prescription drugs, and rehabilitative services. Children diagnosed with behavioral health conditions can receive any service available under federal Medicaid law that is needed to correct or ameliorate the condition. However, the same requirements are not in place for adults. This lack of consistency is far from optimal and further perpetuates a dysfunctional system.

One Big Takeaway

  Under the IBH model, participating states will be responsible for ensuring delivery of integrated care to fully support the patient’s individual care needs. Comprehensive care coordination and care management will be key elements for inclusion. There are plenty of successful outcomes across the targeted populations that validate the power of those professional practices.

I know that my colleagues across case management and integrated care have developed successful models across Community Health Centers, Federally Qualified Health Centers, Rural Health Centers, Look Alikes, and other ambulatory care sites to meet the IBH requirements. I’ll be watching closely over the next 8 years to see where #IBH implementation goes and what the outcomes yield!