Peer support services are rapidly gaining mainstream acceptance thanks to recent federal initiatives, new reimbursement opportunities and the fallout from the opioid crisis.

Peers have a unique ability to drive sustained patient engagement, industry insiders said at Behavioral Health Business’ VALUE conference. This makes the peer support model cost-effective for providers looking to shift away from fee-for-service models and toward value-based care.

“Pretty much every person who is getting treatment for a mental health or substance use condition will benefit from peer support,” Shrenik Jain, founder and CEO of Marigold Health, said at BHB’s VALUE conference.

Boston-based Marigold employs peer specialists and recovery coaches and embeds them with partner providers, including outpatient MAT programs, residential treatment and primary care groups. It also operates a technology platform where members can communicate with each other in anonymous forums moderated by peer specialists.

Peer support specialists are people with lived experience of behavioral health conditions who are now in recovery and can offer support to people currently grappling with similar conditions. They are not clinically trained and do not offer diagnoses or treatments.

“That scope of practice is really important,” Dr. Kim Newell Green, co-founder and chief medical officer of Flourish Labs, said. “Peer supporters say, I have been there in your shoes, and I know that you can recover, I know that you have everything you need inside of you. So let’s figure out what your strengths are, set some goals, and I’m going to be alongside you as you walk this path towards recovery.”

Flourish Labs uses technology to help scale professional peer support. It trains young adults to become certified peer support specialists and then pairs them with teens in need of help.

Peers role in value-based care

Peers play a critical role in value-based behavioral health care as part of a full continuum of care, according to Dana Foglesong national senior director of recovery and resiliency services at Magellan Healthcare.

Magellan Healthcare is the managed care subsidiary of Magellan Health, a health plan focused on special populations. Magellan Healthcare covers 19.5 million lives and has more than 1,000 employer contracts.

Peers are a valuable resource for providers to drive value, not just because of the evidence supporting their effectiveness.

“In my mind, there’s a massive opportunity in this space to begin to use peers,” Green said. “In many ways, they are a faster workforce to train, maybe a little bit less expensive than some of the more licensed providers and can provide incredibly high-quality work.”

Despite the potential benefits of value-based arrangements, peer support is most commonly reimbursed through a fee-for-service model.

“If you think about the sophistication that has to go into a values-based arrangement, it’s mostly because the field in general collectively has not gotten to that level of sophistication,” Foglesong said. “But we at Magellan definitely do case rates and bundled payments.”

Marigold most commonly operates on a case rate model. Peers’ roles mainly involve getting patients engaged in care, Jain said, but traditional fee-for-service models do not account for the research and effort that peers put in before connecting with patients.

“Whereas on the day rate, that continuous work to keep someone sticky in a personalized way [is reimbursable],” Jain said. “We’ve found that conceptually for a lot of the plans we talk to, paying for more peer support is actually not a controversial thing. It’s a no-brainer. It’s a very cost-effective service and a very, very small percentage of the people who could benefit currently use it.”

Growing adoption of peer-based models

Peer models are gathering momentum nationwide, especially over the last five years, Jain said, citing his company’s quick expansion. Two years ago Marigold operated in a single state. The company now operates in half a dozen.

Also signaling increased traction for peer support models, certification processes now exist in every state and are Medicaid reimbursable in 35. The Substance Abuse and Mental Health Services Administration (SAMHSA) considers peer support to be a best practice. 

Multiple factors have spurred increased discussion and adoption of peers at the national level, Foglesong said.

“One of those is the opioid crisis,” Foglesong said. “As a result, millions of dollars have flowed through states, localities and different federal agencies that have focused on the substance use peer support workforce. Since in many spaces, those certification trainings are combined, that’s just naturally grown the capacity around building a workforce.”

The White House has also driven an increased spotlight on peers.

In 2022, The Biden-Harris administration released a national mental health strategy that included a commitment to build a national certification program for peer specialists to “accelerate universal adoption, recognition and integration of the peer mental health workforce.”

In January, The Centers for Medicare & Medicaid Services (CMS) furthered the legitimization of peers by releasing a code specific for principal illness navigation-peer support that defines the role of peers in Medicare.

Despite the progress with the CMS code, Foglesong noted that it would likely take at least a decade before Medicare fully utilizes peers.

There is more of an opportunity for peers in Medicaid, Jain said.

“In Medicaid, the money’s there, the rates have gone up, plans want to see the service delivered more,” he said. “And there’s a shortage of actually scalable care delivery models.”

A barrier to fully leveraging peers in the behavioral health industry, Jain said, is providers’ lack of experience in effectively operationalizing a peer workforce.

“Especially if you see a large Medicaid population … look at the waiver for your state and actually look at what the benefit says, because the benefit is oftentimes saying that it’s a service that a broad range of folks can actually receive,” Jain said. “But we as providers don’t always have the model to operationalize that efficiently.”

Despite growing acceptance, progress is still being made in the large-scale adoption and regulation of peers.

It would be “much easier” for companies offering peer support if there was a single national certification standard, rather than each state having its own process, Green said.

By Morgan Gonzales