I work as a project manager and biller for a BH agency in WA state. Here are some of my thoughts!

- Big general point: you are writing from the perspective of fee-for-service contracts, which are being phased out across the U.S. This is happening rather slowly, but it is happening. In 10 years, the transition to value-based contracts will likely (hopefully) be nearing completion.  That doesn't mean "services" will be obsolete, just that they wont be the whole picture.

- At our clinic (in WA state), we have clinicians that do many different types of therapy and use a relatively small number of codes to represent these. They might do a variety of evidence-based practices within an individual therapy session, but the individual therapy session code is always either 90832, 90834, or 90837 depending on the time of the session. The different codes come in to play when the therapist is doing sessions with more than one person or non-therapeutic work (such as case-management). We have one clinician who is very adventurous with her therapy and may use meditation, EMDR, and some sort of life coaching in one session - all of this is billed under the same codes.

- The points you made about EBPs and the difficulty of standardizing them based on the most important success factors makes sense to me, but that isn't connected to billing or reimbursement in my state, even under fee-for-service.  

- Low reimbursement for the mental health field is a big problem here, leading to worse care. 

This part is important and [becoming] inaccurate in my state: Quote from article: "So, back to your mythical mental health organization that wants to bill Medicaid for its new service. You can’t bill Medicaid for ‘our therapists are happy, motivated, well-paid, respond to clients in the moment without a script, and are in a position to build trusting relationships with their clients over time’. There’s a category error–this simply isn’t a ‘service’ and Medicaid only pays for ‘services’."

- With the new world of "Value-Based Payment", which is where Medicaid is moving, you are able to get paid for these sorts of factors (indirectly, of course). Some of the newest contracts I've seen have a base-rate that depends on fee-for-service and then adds bonuses based on other factors. This is still a "lower" model that incentivizes overutilization of services, which Medicaid is moving away from. In the future, there will probably be something like a (hopefully reasonable) minimum number of service hours needed to get paid to cover business expenses and then bonuses on top of that for business expansion.

- What are the bonuses based on? Examples: 1) penetration rate - if a client is diagnosed with a behavioral health problem, does that client engage in treatment. To increase this number, at least one of the factors is something like, to quote the article, "our therapists are happy, motivated, well-paid, respond to clients in the moment without a script, and are in a position to build trusting relationships with their clients over time". Mission, values, purpose - these are sensed by the client and are factors in engagement. What makes a client engage with services? The type of therapists you described would likely increase penetration rate. [note: adequate workforce is a necessary pre-requisite for penetration rates to improve and is a big problem, but that's for a different conversation...]

- Another example of a Medicaid bonus: 2) improved mental health assessment scores (PHQ-9, GAD-7, etc). To reliably increase or maintain these numbers to get a bonus, you need to actually be effective in treatment. This transcends the "services" orientation and focuses on actual mental health outcomes, regardless of the method. This frees up mental health agencies to try their own methods to see what works - again, in my state these codes don't differ based on modality.

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You’re missing the perspective of therapies like Coherence Therapy and Internal Family Systems, which set up a series of steps that have the effect of causing transformational change, but allow a great deal of improvisation and flexibility in how each step is done.

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Re the parable of Dr. X: getting amazing results initially, but failing to beat placebo later at scale.

(1) How many specific times has this sort of story happened? Once, twice? A dozen times? A hundred? Too many to count? It would be interesting if there was a meta study just examining this phenomenon alone.

(2) Does standardization always lead to effectiveness declines? This feels like its own kind of Replication Crisis, but turned on it heads. Instead of the issue being bad initial results, it’s bad replicators. How widely known is this problem within the field?

(3) Are there any notable exceptions, where a technique didn’t degenerate as it scaled? Or not as badly? Or perhaps even more surprisingly— it got even better results at scale? I’d want to know about any exceptions… what did they do differently?

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Thanks. So much great insight in here.

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