Addressing Community Mental Health Needs: A Comparison of the Federal and State Models
In the decades following deinstitutionalization, the U.S. has yet to find an effective model of a comprehensive behavioral health continuum of care, from prevention to intervention, treatment and recovery. Federal Certified Community Behavioral Health Clinics (CCBHC) have grown to be the dominant model for comprehensive community mental health services across the country since 2014. However, the mechanisms of federal policies and funding resulted in implementation of CCBHCs that is not consistent across all parts of the country, with large variations between states. Massachusetts’ Community Behavioral Health Centers (CBHC) is similar to the federal model and was launched in 2023.
In a new study in the journal Frontiers in Health Services, researchers from Boston University Chobanian & Avedisian School of Medicine compared the Massachusetts and federal models and found that these programs share a similar policy backbone and intention, such as a comprehensive outpatient clinic, 24/7 crisis services, bundled payments and quality incentives, but differ in important details like how they’re paid, who regulates them and how specific crisis services are structured.
Maxim Petrovsky“Clinically, our comparison shows how design choices can improve access, continuity and potentially reduce emergency visits and hospital stays through different models of care. For policymakers, this manuscript provides several options for building a comprehensive, responsive and effective behavioral health infrastructure while answering regulatory questions as to how they might do so,” explains corresponding author Maxim Petrovsky, a third-year medical student at the school.
The researchers performed a comparative policy review by synthesizing federal laws and guidance, Massachusetts regulations and specifications, payment rules and published evaluations. They then organized the services, financing, quality measures and early outcomes to make their comparison.
Several differences stood out including:
- The exact scope of the required integrated mental health and substance use services is slightly different. For example, the federal CCBHC model specifies a requirement for clinics to provide behavioral health services to veterans and individuals in the armed forces in particular, while this is not an explicit, regulation-based requirement in the Massachusetts CBHC program.
- Both models prioritize rapid access to care while Massachusetts goes further in specifying timeframes by which services need to be provided—in some cases, same- or next-day. This includes a 24-hour, community crisis stabilization program intended to be a diversionary service to provide individuals in a mental health crisis from going to an inpatient psychiatric program. This was intended to address the increased service burden on hospitals during the COVID-19 pandemic. The Massachusetts model also specifies in greater detail therapeutic modalities that must be offered to patients, such as dialectical behavior therapy and cognitive behavior therapy.
- Regarding provider payment, the federal demonstration program is grounded in a cost-based Prospective Payment System (PPS) similar to that used to reimburse Federally Qualified Health Centers. A PPS model provides a per-diem (i.e., per-day) reimbursement method that is more volume agnostic and assures predictable funding tied to costs, enabling investment in necessary but traditionally non-billable services as noted above. This is contrary to a traditional fee-for-service payment model that reimburses providers based on the volume of services that they provide. The Massachusetts CBHC per-diem “encounter bundle” is similar to a PPS payment method in that it is a bundled payment, though is not cost-based.
According to the researchers, as other states consider developing a community behavioral health program, these comparative findings suggest that their decisions should be oriented toward fitting with individual statutory authority, delivery system capacity and equity priorities rather than a presumption that one model is categorically superior. “The interaction between these models underscores the diverse pathways states can take toward expanding comprehensive behavioral health care,” adds Petrovsky.
The coauthors of this research represent a broad-based collaboration, including BU faculty member Christopher T. Lim, MD sharing his views through the lens of a health system-based provider and medical director in BMC’s Population Health Services team, and Swathi Damodaran, MD, MPH, from the Office of Clinical Affairs at UMass Chan Medical School and who serves as Associate Medical Director for Psychiatry at MassHealth.