Figure 1 presents the revised PEF that reflects substantive updates to key domains which are described in detail below. Dashed lines are used to represent the interplay and reciprocity across levels in the ecology as the boundaries are permeable.

Fig. 1

Policy Ecology Framework 2.0

Changes in the organizational context

Since the original PEF, several changes have occurred in the organizational context surrounding the delivery of mental health services including (1) enhanced reimbursement; (2) value-based purchasing, and (3) novel organizational arrangements. These changes are largely linked to the passage of the Patient Protection and Affordable Care Act (ACA).

Enhanced reimbursement

EBPs in mental health are typically expensive to gain expertise in, and to deploy and sustain [27]. The past decade has seen considerable expansions of the necessity to support the added costs of implementation [28]. Many interventions are receiving enhanced reimbursement in various states [29]. Enhanced rates are especially important for interventions that are complex and expensive, and increased rates are part of the reason for the success of multisystemic therapy implementation in New Mexico [30]. Enhanced reimbursement can also be provider-focused (e.g., expanding the range of individuals who can be reimbursed for providing mental health interventions, such as peer specialists) [31]. These enhanced reimbursement models work in a generally uniform way—they are designed for specific treatments (e.g. trauma-focused cognitive behavior therapy), usually work with a dedicated billing code providers can use, and restrict the use of these codes to providers who have met certain state requirements. These enforcements are typically backed up by audit flags.

Population outcomes-focused purchasing

One way to deploy enhanced reimbursement is via billing codes for specific interventions. Another emerging way to increase EBP delivery is to enhance reimbursements for condition-specific or population-specific care and require the use of EBPs within them. For example, California provides enhanced reimbursement rates for care for persons with serious mental illness and/or addictions, and for those who are houseless [32]. The purpose of funding is not to support the delivery of specific EBPs, but to reduce disparities—a population-level outcome—among disadvantaged populations [32]. Another population-specific initiative is OhioRISE (Resilience through Integrated Systems and Excellence). Designed for youth with complex behavioral health needs, the program incorporates both value-based and incentive-based (i.e., both outcome-based and volume-based in this context) financial supports that are higher than standard Medicaid reimbursements [33]. This type of fiscal model is a type of “bundled” reimbursement with an emphasis on achieving broader population-focused outcomes. These reimbursement strategies differ from narrower value-based purchasing programs (detailed below). Currently, there is substantial design complexity and programmatic heterogeneity in these types of programs; yet, the core idea of increasing reimbursement for specific service packages is an increasingly common way to support EBP implementation.

Novel organizational arrangements

Another way that policies can promote EBP deployment is to reengineer the organization that delivers them. In 2014, the Protecting Access to Medicare Act created a demonstration program to establish and evaluate certified community behavioral health clinics (CCBHCs). As of 2022, there were 450 CCBHCs operating in the USA [34]. CCBHCs receive enhanced Medicaid reimbursement rates for services. In exchange, they provide nine defined types of services (e.g., 24-h mobile crisis mental health care teams), and are required to deliver an array of services, including EBPs, that are not only focused on specific treatments but also cover service integration and treatment planning [35, 36]. CCBHCs are one type of organizational arrangements that have emerged in recent years. Below, we discuss Accountable Care Organizations ([ACOs; groups of healthcare providers who coordinate care, take responsibility for total cost and quality of care, and, in return, receive a portion of the savings they achieve) [37].

These novel arrangements reside in parallel to the kinds of arrangements identified in the original PEF—purchasing cooperatives, service delivery cooperatives, public–private partnerships, health plan-sponsored provider networks, provider-supported or -directed care organizations, and a similar array of structural and institutional mechanisms to deliver health care. While these organizational arrangements are usually driven by financial arrangements, the extent to which they represent a better implementation model remains to be seen.

Changes in the agency context

Since the original PEF, several changes have occurred in the agency context that relates to the following areas: (1) expansion of agency-level tools; (2) contracting and bidding; (3) disease management; (4) prior authorization; (5) outcomes-based reimbursement; and (6) ACOs.

Expansions of agency-level tools

Originally focused on service delivery agencies (e.g., state departments of mental health) and financing agencies (e.g., state Medicaid departments), the PEF aligned with calls from implementation scientists to cultivate a “tailored selection” of strategies specific to the goals, barriers, and contextual demands of an implementation effort [12, 38,39,40]. Now, owing to federal and state policy actions, regulatory agencies (child welfare or mental health departments) have greatly increased their implementation-focused activities. They have been aided in their efforts by advisory/evaluative bodies (e.g., the Washington State Institute for Public Policy), novel financing mechanisms (e.g., new sources of Medicaid funding for home and community-based services [41]), quasi-public funding bodies (e.g., Children’s Service Funds), and expanded roles of accreditation bodies (e.g., the Council on Accreditation that accredits human services providers). A succeeding section on changes in the political landscape summarizes key legislative efforts driving the adoption and implementation of EBPs.

Though states vary significantly, policymakers apportion resources to support EBP infrastructure and enact regulations that dictate which services are available and reimbursable under state Medicaid plans. Subsequently, these actions work together to influence EBP implementation in practice [20]. In a recent study, several factors (e.g., per capita income, controlling political party, Medicaid expansion) predicted the level of state fiscal investments in adopting EBPs in public mental health systems [42]. By contrast, modifiable factors (e.g., interagency collaboration and investment in research centers) were more predictive of state policies supportive of EBPs. State per capita debt and direct state operation of services (versus contracting for services) predicted both child and adult EBP adoption [43].

Regulatory changes have provided new, or reformulated, tools for policymakers, including (1) defining levels of evidence; (2) funding mandates/funding targets; (3) codifying laws that aid implementation; (4) establishing state inventories that classify programs by evidence of effectiveness; and (5) increased oversight and monitoring of EBPs [43, 44]. Policymakers in Oregon, Washington, Utah, Minnesota, and Connecticut, for example, have made legislative changes to support the implementation of EBPs—allocating at least 50 percent of purchasing dollars towards EBPs [43]. Additionally, 39 states have defined one level of evidence at minimum, 49 states have created an inventory of funded EBPs and have employed targeted funding to support those effective programs, and 33 states have created laws to sustain support for the implementation of these programs [43, 44]

Contracting and bidding

The PEF assumed that specialized contracting and bidding occupied an exclusively intra-organizational locus. Currently, drawing from key constructs of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, these policy actions are better understood as “bridging factors.” [19, 45,46,47,48]. System-wide efforts to implement EBPs have grown largely due to the deployment of fiscal policies (provided for by the ACA, discussed below), and contracting procedures and performance-based contracting have emerged as key tools in shaping the implementation context of agencies and local service agencies [49, 50].

Contracts often operate as an ‘on–off’ switch for the implementation and sustainment of EBPs within community mental health systems [51, 52]. They have begun to dictate performance targets, compensation for service delivery, and determine the level of funding—directly impacting the agency [18]. Within county-based health systems, contracts tether county agencies and private, non-profit agencies to fill service gaps [18, 53]. Contracts are key elements of a multi-level fiscal support mechanism increasingly seen across the USA that braid contracting, incentives, fees for service, and grants [38, 50]. Contracts explicate the expectations of organizations to deliver EBPs and, in turn, communicate system-level support of agencies and their service environments.

Between agencies and service systems, there is a bi-directional flow of information in which contracting serves as the conduit for this information [19, 50, 54]. For example, Walker and colleagues [55] highlight the role of contracting agencies in their case study of a state-level, EBP service delivery tracking system in Washington state. Reporting EBP use per session and, thus, the number of sessions in an agency and healthcare system as a contract requirement increased awareness and motivation amongst contracted agencies and increased transparency and social pressure to implement EBPs. Service system-level decision-makers influence the type of care delivered by agencies and utilize contracts to specify to whom and by whom this care is delivered.

The evolution of disease management

The original PEF identified state-level efforts to improve the quality of healthcare by applying a disease management framework. Many of those elements (e.g., identifying high-risk patients, matching interventions to patient needs), have changed following the passage of the ACA. Section 2703 of the ACA instituted an option for states to receive a 90% enhanced Federal Medical Assistance Percentage to establish health homes to connect Medicaid beneficiaries with chronic conditions to coordinated healthcare services [56]. Health homes offer care coordination services with core elements being patient education, monitoring and appointment reminders, and linkages to behavior modification programs [57]. Once connected to a health home, people have access to a team of providers including those who deliver mental health EBPs and substance use services, which is particularly important in rural and remote communities [58]. CMS (Centers for Medicare and Medicaid Services) determined eligibility for health homes and provided protection from exclusion of the benefits for people with both Medicare and Medicaid, but allowed state-level regulation of how health home services were distributed geographically. An explicit goal of the health home program–holistically treating two or more chronic conditions and a serious and persistent mental health condition—is a current iteration of disease management strategies. In these ways, the ACA has modified the venues and structures of disease management programs, while retaining disease management as a model for implementing best practices.

Prior authorization

Prior authorization (PA)—originally intended as a measure of cost containment to control pharmaceutical expenditures—has persisted, albeit much reduced and modified, in the last decade. The advent of mental health parity brought to bear the utility of PA for payors with respect to managing resource utilization (i.e., inpatient psychiatric hospitalization and intensive outpatient services where EBPs are largely utilized) [59]. Overall, PA remains functional as a policy lever to moderate access to mental health EBPs, particularly for managed care enrollees, as PA determines the scope and duration of benefits [60, 61]. There has been persistent criticism of prior authorization from the provider community, as many providers cited concerns over administrative burden, lack of transparency in determinations, and hampered access to timely care; all of which have contributed to federal efforts to streamline the PA process [62].

Outcomes-based reimbursement

Outcomes-based reimbursement has seen enormous development with the proliferation of pay-for-performance, value-based care, and affordable care organizations. CMS has led efforts to bring value-based care forward with Pay for Performance models and has increased access to EBPs through such mechanisms as Sect. 1115 waivers. These waivers allow states to test and implement approaches that support Medicaid program objectives that differ from what is allowed by federal statute [63]. Today, payment arrangements are rapidly moving away from volume-based payments (e.g., fee-for-service) towards value-based payments [63.] These payment models fall under three main umbrellas: (1) fee-for-service with enhanced payment for increased quality, (2) alternative payment models that utilize the architecture of the fee-for-service model with either shared savings, or shared savings and risk, and (3) population-based models which is the most evolved of these alternative payment approaches. The best example of the last, Accountable Care Organizations, or ACOs, is discussed in greater detail below.

Accountable care organizations

Earlier in this paper, we described what constitutes an ACO. In general, however, all newer payment models share the goals of managing soaring healthcare costs by eliminating duplicative services and reducing preventable hospitalizations and other complications of care. As alternative payment models evolve, there is increasing emphasis on moving towards population-based models that incentivize and remunerate healthcare providers for delivering high-quality, coordinated, person-centered care within a predetermined budget [64]. As of 2023, 14 states have reported ACOs [65]. Further, ACO contracts may support access to EBPs for people with persistent mental illness in some arrangements as provider organizations are incentivized by the potential cost savings [66, 67].

As of 2019, 46 states and 2 territories were implementing state-coordinated value-based reimbursement programs, leaving only Georgia, Louisiana, Mississippi, and Indiana with no coordinated value-based reimbursement strategy at the state level [63]. The past decades have solidified a shift from paying for processes to paying for outcomes, even as how to pay for outcomes is still being worked out.

Changes in the political context

Since the original PEF, several changes have occurred in the political context that relate to the following areas: (1) EBP-focused legislation; (2) behavioral health parity laws; (3) COVID-19 mitigation efforts; (4) structural stigma; and (5) consumer involvement. We recognize that political and group-level factors within a state or county (e.g., the political party that controls the legislature) can be key to EBP support. For brevity, and in keeping with the theme of the paper, we discuss political actions that influence implementation, not the reasons for such actions.

EBP-focused legislation

Legislative strategies are blunt policy instruments. The PEF’s focus on legislation was based on the observation that policies that support access to, and quality of, health services ultimately wind up supporting implementation and sustainment of those services. An example of a policy promoting access to EBPs is the Family First Prevention Services Act of 2018 (FFPSA), which created the ‘Title IV-E Prevention Services Clearinghouse’ which contains a list of prevention services and programs that states can implement utilizing title IV-E funds [68]. Though the comprehensiveness of the clearinghouse is debated, this can increase the adoption of EBPs, and through such effects, support their widespread implementation [69]

One traditional way to increase access to EBPs is to legislate parity. The Mental Health Parity and Addiction Equity Act (MHPAEA) [70] and the ACA shared three overall goals—expand access to health insurance, improve coverage of mental health and substance use services, and extend the scope of coverage past medical-surgical benefits to include mental health and substance use benefits (MH/SUD) [71]. While MHPAEA codified significant new protections for consumers, sustained implementation of mental health and substance use services has not occurred as expected because of some problems with the design and implementation of the MHPAEA [72]. These problems include its complexity, including the involvement of enforcing agencies, and weak enforcement of parity [73]. MHPAEA’s rulemaking and enforcement provisions also shifted the onus onto the individual to file a complaint about non-compliance with the law [71, 74], such that non-implementation became an individual, rather than systemic, problem.

The enactment of the ACA on March 23, 2010, overcame some of MHPAEA’s shortcomings [37]. The ACA deemed mental health and substance use disorder services one of ten essential health benefits (EHB) and required non-grandfathered individual and small group plans to include these in coverage. The ACA lowered the estimated number of uninsured by approximately 20 million from 2010 to 2020 [75, 76], thereby laying the groundwork for scalability of services. The ACA also directly supported the implementation of preventative services, especially in states that chose to expand Medicaid eligibility [77]. The impact of the ACA today is seen in Medicaid expansions, and increased access to primary care. Through such demand-side expansions, access-focused pieces of legislation indirectly support large-scale implementation and create entitlements that can support the sustainment of specific EBPs and services.

Expanded reach in the context of COVID-19

The COVID-19 pandemic highlighted the tenuous link between ACA, MHPAEA, and the reality of seeking care. The Biden-Harris Administration—responding to reports of the impact of the pandemic on the nation’s mental health—highlighted alleviating the mental health crisis in the USA as a core aim of the Administration’s Unity Agenda. In response, several policies have passed to expand the reach of EBPs in the context of COVID, including insurance coverage of telehealth services [59].

Structural stigma

Structural stigma and discriminatory policies are important to consider as a key lever of the implementation of EBPs, especially in health and mental health settings [78, 79]. Corrigan and colleagues [80] define structural stigma in terms of “policies of private and governmental institutions that intentionally restrict the opportunities of people” and “policies of institutions that yield unintended consequences that hinder the options of people” (p. 481). Structural stigma relates to institutional racism, which captures the role of institutional, systemic, and cultural forces perpetuating racism against ethno-racially minoritized groups [81, 82]. Hatzenbuehler and Link [83] describe this as “societal level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatized” (p. 2).

The past decades have recognized that stigma-focused policy strategies can enhance access and support the implementation of EBPs, especially for individuals and groups experiencing marginalization. The MHPAEA and the ACA both emphasize reducing structural stigma towards individuals with mental illness by improving access and coverage of services that were previously less accessible to them [71]. While less is known about the effects of structural stigma on the implementation of EBPs, Reid and colleagues [