The Perfect Storm: Collision of the Business of Mental Health and the Implementation of Evidence-Based Practices

Abstract

Financing has been hypothesized as an important driver of the implementation of evidence based practices (EBPs), yet there is little systematic investigation. This article presents a qualitative study of the effects of financial factors on the implementation of EBPs in a large urban publicly-funded mental health system. Our interviews with agency and system leaders identified financial distress in community mental health agencies, leading to concern about implementing complex and expensive EBPs. Stakeholders agreed that the cost of implementation of EBP should be shared between the agencies and the system, but disagreed on the solution.

Changes in the financing of community mental health have altered the organization and delivery of publicly-funded services over the last 60 years (1,2). Medicaid rates are often less than those in the private market place and substantial cuts in state aid to behavioral health programs since the financial crisis of 2008 have created increasing concern for behavioral health budgets (3). Concurrently, payers, policymakers, and advocates have encouraged community mental health programs (CMHPs) to implement evidence-based practices (EBPs)(4,5), which may exacerbate these financial pressures due to the high cost of adopting and sustaining new practices (6). Funding is posited as a key implementation factor in implementation science frameworks (7). A growing body of empirical literature supports the important role of funding in the implementation and sustainment of EBPs (8,9).

The City of Philadelphia Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) is a large publically-funded urban mental health system with over 200 provider agencies providing mental health and substance abuse services. Over the last 8 years, DBHIDS has supported implementation of several EBPs (i.e., cognitive therapy, trauma-focused cognitive behavioral therapy, prolonged exposure, dialectical behavior therapy) in select agencies (10). DBHIDS pays for training, consultation, internal employees supporting each initiative, and in some cases reimbursing for lost staff time, and an enhanced reimbursement rate. These efforts provide a unique opportunity to study implementation in a mental health system that has financially supported a large implementation effort. Unlike other important constructs thought to affect implementation, such as organizational climate, culture, and attitudes (11), there has been little empirical exploration of the role of funding in implementation of EBPs in community mental health. This study used qualitative inquiry to understand this pivotal construct from the perspectives of both agency leaders and system policymakers.

Method

Participants and Procedure

Data came from 49 stakeholder interviews. Procedures were approved by the University of Pennsylvania and City of Philadelphia Institutional Review Boards.

Thirty-three agency leaders from 42 agencies (response rate = 79%) who participated in DBHIDS initiatives completed interviews. Sixteen policymakers (hereafter: system leaders) from DBHIDS and Community Behavioral Health (CBH) were invited to participate; all agreed. System leaders included senior leadership of DBHIDS/CBH as well as internal coordinators dedicated to each EBP initiative. CBH is the non-profit behavioral health managed care organization for Medicaid-enrolled Philadelphians.

Qualitative Interview and Analysis

We developed a semi-structured open interview guide to collect information about participants’ experiences with EBP initiatives, with a focus on factors that support/impede the implementation process, particularly the role of funding. Transcripts were analyzed in an iterative process based upon a modified grounded theory approach (12). Interview guide and data analytic details are detailed elsewhere (13).

Results

Agency Leaders

Agency leadership agreed that implementing EBPs is costly and that the time commitment detracts from productivity. Agency leaders noted the time and expense of additional supervision, consultation, note-writing, trainings, technology, session preparation time, and for some protocols, longer sessions required by the EBP than billing permits. The majority thought that EBPs are financially advantageous via increased revenue through increased patient referrals, engagement, and retention as well as increased reputation and decreased employee turnover. Approximately half of agency leaders believed that the cost of EBPs should be a shared responsibility between agencies and the public system, and described financial restructuring and external grants to accommodate these extra costs. Agency administrators, especially those overseeing outpatient services, acknowledged financial distress due to rising costs and decreased funding and reimbursement. Nonetheless, a third of agency leadership reported that EBP implementation was fiscally impossible without external funding. The majority of agency leadership had suggestions for policymakers to support EBP implementation. Enhancing reimbursement rates and other financial incentives (i.e., pay-for-performance, preferred provider designation) comprised the majority of suggestion from agency leaders.

System Leadership

EBP implementation was described by system leaders as a financial commitment for both system and the agencies. Despite acknowledging fiscal challenges of EBP for the agencies, system leaders unanimously advocated less for enhanced rates and financial incentives, and more for financial and business planning at the agency level to accommodate the financial realities of EBP.

Discussion

This study was the first to systematically investigate how funding influences implementation of EBP from the perspective of multiple stakeholders. Both agency and system leaders agreed that EBP implementation is costly, and the majority agreed that this cost should be shared. The stakeholders did not agree on how EBPs should be financed.

Increasing reimbursement rates is never simple. State Medicaid rates are often below private market rates, which constrains the system’s ability to enhance rates (14). Payers have the difficult dilemma of figuring out what to pay for (e.g., training, service delivery, outcomes) and how to resolve fidelity, certification, and measurement issues. However, EBPs are by nature a set of easily definable interventions that can theoretically garner a higher rate. The development of methods for outcome-based reimbursement financial incentives and paying for outcomes to promote EBPs is in its infancy in mental health (15). More research is needed to identify and evaluate effective financial incentives (5). Nonetheless, the increasing policy emphasis on EBPs and excellence in health care delivery may be the single greatest future opportunity for enhanced rates.

This exploration into the funding of EBP implementation uncovers questions about financing in public mental health. The crumbling infrastructure in outpatient settings may endanger the implementation and sustainability of EBPs (13). The financial landscape has likely become even more constrained due to reduction of funding by state agencies. These programs may need to be more efficient than ever, particularly if they are to take on the additional cost of EBPs. This requires agency leaders to be proficient in effective business practices; however, many leaders do not have business backgrounds. New York State is attempting to improve fiscal effectiveness of organizations in concert with implementation efforts (http://www.ctacny.com/beep-business-efficiences-and-effectiveness-project.html). There has also been promising work in Australia where programs voluntarily share and discuss financial and service information in order to improve business practices (16). If the financing problem is in part due to business inefficiencies, more work is needed to identify organizationally efficient mental health agencies and how to promote better business practices. Cross-academic collaborations with business schools along with community-academic partnerships would be particularly beneficial.

The context of Philadelphia is worthy of note. Philadelphia is a public system that has evidenced a strong commitment to EBP in both belief and dollars. Agencies did not pay for training, consultation and other start-up costs yet still reported significant financial burden related to productivity, billing and sustainability. This has troubling implications for public systems that cannot afford significant investment for EBP as well as CMHPs that endeavor to adopt EBP without financial backing.

Three study limitations should be mentioned. First, this sample represented one system and it is possible that results of this study may not be generalizable to agencies outside of Philadelphia. Second, interviewee responses were subject to recall bias. Third, this study did not include financial analysis of agency operations. Whether agencies are actually inefficient or inadequately funded is an empirical question that begs further scrutiny.

The study findings have important implications. Much has been written about the importance of funding in the EBP implementation process, but little empirical work has delved into why financing is important and how the broader fiscal landscape influences the EBP implementation process from the perspectives of multiple stakeholders. It is our hope that this investigation launches a systematic research agenda that allows for a richer understanding of the fiscal challenges coupled with the financial realities of implementing EBPs in mental health.

Table 1.

Percentage endorsing themes and illustrative quotes.

Theme	N	%	Illustrative Quotes
Agency Leaders (n = 33)
EBPs are expensive	26	79%	Time is money.
EBPs are financially advantageous	19	58%	We have a belief that if you provide this level of support, training and care to clinicians than you are going to see less turnover and more stability which would be less costs to recruitment. It’s an incredibly valuable marketing tool to be able to say we practice EBP.
The cost of EBPs should be shared between the agency and the system	17	52%	It’s my problem to juggle finances and find a way to get the money somewhere. We’ve restructured to give the EBP the appropriate amount of time and resources.
Agency financial distress	13	39%	[Policymaker] said s/he is pleased to be able to offer this initiative training but s/he really expects the agencies to sustain. And I heard what the audience said: ‘How? We already do not have funding to support our basic program, let alone anything extra.
No EBP without external funding	11	33%	As great as it is to say that 14 out of 14 therapists are certified in [EBP], we’ll be out of business at this rate if we don’t get back to doing the things we need to do.
Financing suggestions	22	67%	…A 20% increase to our regular rate, then we start thinking about who else I can send to this training. Money gets people engaged. Services should be funded. Trainings should be funded. Supervision should be funded. If policymakers are serious about having these [EBPs] and those who say ‘the agency should go out and raise their own money and have bake sales…’ It’s not realistic.
System Leaders (n = 16)
EBPs are expensive for the agencies and for the system	15	94%	Very costly. Just as I think the providers would say they’re not paid to do this, we’re not funded to do this.
Financing suggestions	14	88%	If they are unwilling to change their business model and clinical and operational flow, then there is only one viable pathway [for EBP implementation] and it is increased rates.