Years into a national behavioral health workforce shortage, many provider organizations are now seeking to leverage peer specialists.
Advocates argue that peers could be a crucial part of expanding behavioral health access and supporting patients holistically in their recovery. Yet reimbursement challenges and varying state licensure requirements have historically created barriers for providers utilizing the peer workforce.
This could soon change, however, as the federal government looks to solve some of these issues.
“Individuals with lived experience have a lot to bring to the table,” Samir Malik, CEO of firsthand, told Behavioral Health Business. “There are 20,000, 30,000 folks out there with lived experience who want to help others who are currently struggling. And so to see a narrative emerge around this is a positive signal that – as a country, at a governance level – we recognize these folks have something very important to bring.”
firsthand is a New York-based company that uses a peer support model to help engage with patients with serious mental illness (SMI). The company recently landed $28 million in a funding round led by GV, previously Google Ventures.
Last week, the Substance Abuse and Mental Health Services Administration (SAMHSA), the Office of Recovery, and the U.S. Department of Health and Human Services (HHS) released new national model standards for peer support certification focused on the behavioral health workforce.
While the new standards do not substitute for any state certification, their goal is to hasten “universal adoption, recognition and integration” of the peer mental health workforce across the country.
“States recognize the value that the peer workforce brings to behavioral healthcare and are exploring ways to support and advance these critical services,” a SAMHSA spokesperson told BHB in an email. “This includes continually refining certification approaches which these model standards can address as well as working with other states to further alignment and reciprocity.”
Although the new guidelines are not regulatory requirements, SAMHSA “will be exploring several strategies for encouraging adoption, alignment, and reciprocity through our collaborative relationships with our various state partners,” according to the spokesperson.
Some see this guidance as a way to help bring visibility to the peer support conversation.
“Certifications not only help define the roles and services peer specialists can provide, it reinforces their value in behavioral health care delivery,” Michelle Guerra, a senior consultant in population health and health equity at RTI Health Advance, told BHB in an email. “HHS and SAMHSA’s recent peer certification guidelines really elevates the entire peer support services conversation and may provide momentum for states to create advanced levels of certification or specialty child/adolescent certification, which could really fill workforce gaps in the pediatric behavioral health space.”
Historical challenges
One of the biggest challenges in utilizing peers has been at the business level, not necessarily at the clinical or operational level, according to Malik.
“The structural challenge we’ve seen has been at a systems level. How do we remunerate that … and what is the standard? What is the credential? How do we know that this is real or not, at a payment level,” Malik said. “While lots of states have developed their standards and certifications as early efforts to see some …acceptance of best practices… You’d hope that over time, you’re getting to a place where it is widely accepted and acknowledged that lived experience plus a certain level of training can make a real difference for folks who are still struggling.”
The U.S. Centers for Medicare & Medicaid Services (CMS) has also been at the forefront of peer reimbursement. Roughly 15 years ago, Medicaid provided states with guidance on covering peer support services.
Despite the federal government’s moves in this direction, commercial payers are still often lagging.
“Since 2007, Medicaid has allowed states to use funds to pay for peer support services and CMS considers peer support as evidenced-based interventions,” Guerra said. “Most states do reimburse for peer support services though not all cover them for both substance use disorder and mental health. Outside of programs by Aetna (CVS Health) and Cigna, many private health plans don’t reimburse specifically for peer specialist services.”
Providers engaging in value-based care contracting could be in a good position to include peer support services as part of their wrap-around care. Using peers could also help cut down on the overall cost of care.
Guerra pointed to a study from the Lancet, which demonstrated that peer-delivered self-management reduces the readmission rate for individuals discharged from a mental health crisis service.
“Adding peer specialists to engage clients during discharging planning and after the transition back into the community could help reduce readmissions,” Guerra said. “Health plans can incentivize this through financial rewards for showing incremental reductions as well as hitting pre-set outcome targets.”
While providers working on a value-based care model may have certain flexibilities that make it easier to use peers, that doesn’t mean that peers can’t be used in a fee-for-service model. Malik noted that both avenues could work.
“Fee-for-service that is willing to recognize the value of peer intervention and compensate for it will certainly bring more to the marketplace,” Malik said. “Value-based care has the potential to place [the peer model] in the most high-impact areas, and is not confined to the specific directives of how a state or a payer defines the only setting in which they pay for peer services. But really, with value-based contracting, you have a few more degrees of freedom, where it could be most impactful.”
A career ladder for peers
If providers can overcome the business challenges related to peer reimbursement, it could be a chance for them to tap into a new behavioral health workforce.
Peers could have a unique role within the behavioral health workforce that could help address a patient’s holistic care needs by assisting them to navigate services that impact their social determinants of health, such as housing and access to food. Peers may also be able to deliver more culturally informed care and supportive interventions than the traditional medical community, Guerra said.
“The peer specialist’s lived experience is that extra ingredient to building a different level of trust and understanding with clients, something clients may not be able to get with traditional providers,” she said.
Still, some warn that providers must invest in developing the peer workforce rather than exploiting them for lower wages than clinical staff.
While the U.S. Bureau of Labor Statistics does not explicitly collect data on peer support specialists, they are counted among community health workers, which make an average of just under $60,000. Career search platform Glassdoor estimates the average peer support specialist in the U.S. makes roughly $39,968.
Some behavioral health leaders have already raised this point as an issue that needs to be addressed.
“I have a problem [with providers] using them as cheap labor. Let’s think about education,” Dr. Nazlim Hagmann, senior vice president and associate chief medical officer at Commonwealth Care Alliance, said during a panel at the HMA Healthcare Quality Conference in March. “We have a shortage of providers. How can we give peers a possibility and a pathway to be maybe more than a peer? And don’t get me wrong, I’m not saying they aren’t enough. But again, are there ways to allow for licensing? Are they ways to make it easier for them to get higher education?”
The Commonwealth Care Alliance is a Boston-based nonprofit focused on integrated care. The system has a projected 2023 revenue of $2.5 billion and a workforce of more than 2,000.
Malik noted that equity is a top priority for firsthand, and all peers receive the same benefits as the CEO does. The company is also focused on providing peers with a career progression trajectory.
For example, at firsthand, peers start as a firsthand guide, but after a year, can move up to a senior firsthand guide. More experienced peer specialists are still working with clients in the community but also help train the new workforce.
“We’re still listening to [clients], we’re still doing documentation, we’re still doing all of those things,” Marie Hannah, a senior firsthand guide, told BHB. “It’s just that when it comes down to a senior firsthand guide, now we’re helping other colleagues that come in when they are hired. We’re helping them get on board with training, and all of that good stuff. And then, letting them see what we do. We take them out into the community, they watch us, we watch them, and then we proceed on.”
Despite the questions about the future of the peer workforce, many are still hopeful about what the future brings and welcome the national spotlight on the topic.
“I’m actually very optimistic about where we are at a policy level and also a payment level,” Malik said. “Yeah, there’s work to be done. But we’re in a good place right now. I think one of the important tide shifts that is yet to come is societal acceptance of the real impact people living with serious mental illness or have lived experience with serious mental illness can bring to the table, we still have a stigma battle.”
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