Last week the Department of Health Care Services released the CMS approved DMS-ODS Intergovernmental Agreement, which will serve as the contract between the Department and the counties implementing the DMC-ODS Waiver Standard Terms and Conditions. The creation of a full continuum of care for Medi-Cal beneficiaries for substance use disorder treatment is revolutionary. As stated in the contract, “the objective of this Intergovernmental Agreement is to make SUD treatment services available to [all] Medi-Cal beneficiaries through utilization of federal and state funds … for reimbursable covered services rendered by certified DMC providers.” Following this good news, I had the opportunity to speak with the Director of the San Mateo County Behavioral Health and Recovery Services, Stephen Kaplan LCSW, about his County Plan which was the first plan submitted to CMS back in January 2016 – it was the first plan approved in April 2016 – and will be the first implemented this fall, if all goes smoothly. When asked how SMCO achieved all of these firsts, Steve commented that the ideas and innovations contained within this plan are the culmination of the work of many dedicated professionals and stakeholders over many years, as incremental changes were made to establish Health Care Reform in San Mateo County.
Steve is ready and anxious to Go Live and hopes to see provider contracts amended in the upcoming months. SK: “The Waiver has given us the opportunity to create a continuum of care and pay those that work in the field a living wage.”
ESS: How does the DMC-ODS Plan change the current services in San Mateo?
SK: The SUD delivery system has never been adequately funded. In fact, there has only been two significant increases for SUD treatment services in the community in the past 25 years and these increases were committed to those involved in the criminal justice system. Prior to the DMC-ODS Waiver, the benefits were extremely limited in scope and limited to priority populations. We fought for many years to emulate the mental health system use of the Rehabilitation Option but to no avail.
We have been able to build a strong continuum of Re-Entry Services and coordinated one stop multi-disciplinary case management for the AB 109 eligible population, as well as mobile health and outreach services. I am most proud of the creation of health homes for this population ensuring access to primary care and behavioral health services. The weak link has been SUD treatment simply due to the lack of funding; however, our stakeholders and partners in our managed care plan, probation department, courts, judges and district attorneys, have stepped in to coordinate and ensure services for those who met criteria for service. The new organized delivery system will cover all Medi-Cal beneficiaries.
ESS: What unique conditions exist in San Mateo that supported the Implementation Plan?
DMC-ODS Implementation Plan Infomation: San Mateo supports a service delivery model unlike any other California County – a comprehensive health system managed by a single public insurance plan and an administration that integrates governmental and private institutions, multiple funding streams, including local property tax, and public health programs, known as the San Mateo Health System. The Behavioral Health and Recovery Services Division manages the entire mental health and substance use disorder continuum of care.
SK: I have been fortunate to work in a county that is invested in supporting behavioral health treatment and other health/social services and have therefore been able to incrementally build a foundation for a continuum using local funds along with realignment and Federal resources. Participating in the Medicaid Low Income Health Program (LIHP) under the Bridge to Reform Waiver launched the use of health homes for defined populations in San Mateo. We were able to provide a dozen or so community based providers with access to an electronic health record system (Avatar). To date, the system has been used for billing only, but it is an important foundation as we move to include client management information and treatment plans in population based analyses of outcomes. Our Health System is implementing a master patient index whereby all Medi-Cal beneficiaries will have one universal ID. Health Information Exchange is one of our key executive initiatives.
We are fortunate to have an umbrella in the San Mateo Health System, which respects the unique practice specialties, while acting as the glue between all of the component services to meet the person served needs.
ESS: As I read your Implementation Plan, it is clear that care management is the well-defined engine of whole person care. I also noticed the clearly defined role of the CBO in case management. Can you comment on your structure?
SK: We see these two roles as different and equally important. As we develop we expect to learn more about the specific responsibilities of the county vs. the provider practitioners. Our County Care Management Team is small and will focus on authorizations, utilization management and quality assurance. Case Management services will support beneficiaries as they move through the continuum of care from initial engagement, treatment and through recovery supports. All practitioners in the ODS will utilize a uniform and comprehensive case management model based on the ASAM assessment. Most importantly, to support the SUD provider network BHRS will make available physician consultation services to Medical Directors and Licensed Practitioners of Healing Arts.
ESS: What are the biggest changes for providers?
Probably the biggest hurdle for the current providers will be the use of ASAM and determination of medical necessity and client care documentation. Because of Avatar the transition to new billing structures will not be as difficult as the county will build the IT backroom.
We will need to enhance and support the SUD workforce. Fortunately, we may be able to get this right with better salaries and a career path in the organized delivery system.
ESS: What are your key objectives for the first year?
SK: To make sure our access to care system is working and the clients get to the services they need as efficiently as possible. As our implementation unfolds we will learn what works and what needs refinement. Communications with our stakeholders has been critical and will continue to be for our success and we need to keep our communications active with all of them. For example there will be significant changes in how individuals involved in the criminal justice system will now access care. We need to work closely with our criminal justice partners to make this work.
ESS: What are you most excited about?
SK: That we will now have a system of care for individuals with Substance Use Disorders that matches the trajectory of their recovery. That we can provide them the necessary services and supports adjusted to what they need at any particular time. That we can facilitate the recognition that SU treatment is a bona fide intervention and pay professionals commensurate with those of other treatment providers.
ESS: What are your reservations or concerns?
SK: Change is hard and there is a lot of moving parts to successfully demonstrate over the remaining Waiver timeframe. Can our providers respond to increasing federal regulations, are we able to deliver individualized, evidenced based/promising practices? Can we produce outcomes that help bend the cost curve while improving recovery and population health? Will we attract a highly skilled and diverse workforce? Will we meet access demands and attract and maintain a sufficient pool of providers? There are many other issues that we will need to be addressing as we move forward but these are what come to mind.
On a state level, I am concerned that we will not have a large number of counties that opt into the DMC-ODS. This will certainly impact, the flow of clients into and out of counties for services. But my larger concern, it that we will not have sufficient data to support the outcomes of the demonstration project.
ESS: What would you say to your colleagues who do not have the same infrastructure nor perhaps the resources developed over years in San Mateo?
SK: Over many years and through today is an undeniable inequity in how Substance Use Disorders are addressed in comparison with medical and mental health challenges. In California there has never been a real opportunity to address these inequities while the deleterious damage to individuals, families and communities is undeniable. The DMC-ODS is the first (and maybe the only) opportunity to alter this course.
At a minimum I would urge each County to study the pros and cons, risks and rewards and be as creative as possible in finding a way to opt in. Utilize the available technical assistance resources, seek out colleagues from other counties etc. Work hard with the Medicaid Managed Care Plans- these are their members and we have a great opportunity to reduce high end care. Forge strong partnerships with criminal justice-we have much more the offer than ever before. And find ways to active those who have received services or are in need to speak up and advocate for this change!