The teenage years typically mark the first exposure to substances, and thus the first risks of developing a substance use disorder (SUD). Interventions designed to reduce the risk of developing a SUD later in life or to treat an active SUD can change the course of a young person’s life. Providers have struggled for years to provide adequate prevention and treatment services under previous Drug Medi-Cal constraints. In May 2018, the California Institute of Behavioral Health Solutions invited Dr. Rachel Gonzales-Castaneda, PhD, MPH to present the treatment modalities available for reimbursement under the Drug Medi-Cal-Organized Delivery System 1115 Waiver (DMC-ODS); discuss the intersection of DMC-ODS Waiver with the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefits; and illustrate a model for the use of these benefits as implemented in the Los Angeles County Organized Delivery System. This webinar was presented as a component of the DMC-ODS Waiver Forum, funded by the Blue Shield of California Foundation. Dr. Gonzales-Castaneda is an Associate Professor at the Department of Psychology, Azusa Pacific University, and an Associate Research Psychologist, at the UCLA Integrated Substance Abuse Programs.
The American Society of Addiction Medicine designates level 3.3 as the level of residential substance use disorder treatment delivered to those suffering from cognitive impairments. In May 2018, the California Institute of Behavioral Health Solutions invited Mardell Gavriel, Psy.D, the Vice-President of Mental Health Services at HealthRIght 360 to “decode” the ASAM 3.3 Level of Care. Dr. Mardell is a California licensed psychologist who has developed and directed clinical programs at HealthRight 360 since 1997 and has been instrumental in the implementation of evidence-based practices, workforce development, and programming for specific populations. This webinar was presented as a component of the DMC-ODS Waiver Forum, funded by the Blue Shield of California Foundation. The project’s aim is to provide a collaborative think tank for county administrators in the planning and implementation of the Drug Medi-Cal Organized Delivery System. The fact that this level of care needs “decoding” speaks to the challenge of providing services that are robust enough to incorporate significant needs in this population’s other life areas while keeping the pace of the program at a level that ensures comprehension. HealthRIght360 operationalized this level of care in response to the increased presentation of individuals suffering not only from substance use disorders but significant cognitive impairments. Dr. Gavriel walks us through the complexities of this level of care, discussing the program requirements, appropriate screening tools, clinical accommodations, and staff training needs that are required for successful implementation of a level 3.3 clinical program.
Following two years of collaboration and negotiations with the Partnership Health Plan of California (PHC), seven of the northernmost counties in the state and Solano County hammered out an innovative regional approach which allowed them to opt into participation in the Drug Medi-Cal Organized Delivery System 1115 Waiver. The collaboration will allow access to screening, assessment, early intervention and a continuum of SUD treatment across the eight counties meeting the levels of care stipulated in the Waiver Special Terms and Conditions. Participation in the DMC-ODS will bring significant federal financial resources to these eight communities. The new partnership will increase access to an organized continuum of SUD services directly linked to primary care. This increase in access would be unachievable for the eight counties without this regional partnership. For PHC, the partnership is consistent with its vision and mission and the goals.
“Diversity”, “underrepresented”, “underserved” – these are terms that we often use to describe populations that require cultural and linguistic considerations in service provision. Counties and their contracted providers choosing to participate in the California Department of Health Care Services (DHCS) Drug Medi-Cal Organized Delivery System (DMC-ODS) demonstration project through the State Medicaid Plan waiver are responsible for compliance with the provisions of the Code of Federal Regulations Section 438 (42 CFR 438) pertaining to Medicaid managed care health plans. These requirements include specific instructions for oral and written communication with enrollees in non-English languages and enrollee access to culturally competent services. (DHCS) also, requires counties to comply with National Standards for Culturally and Linguistically Appropriate Services (CLAS) established by the federal Office of Minority Health. These seem like reasonable DHCS provisions for publicly-funded substance use disorder (SUD) service providers.
DHCS monitors the quality of all care provided to Medi-Cal beneficiaries in a number of ways. For mental health and substance use disorder benefits, the Center for Medicare and Medicaid Services requires that states which contract with Medicaid Managed Care Organizations (MCO) or Prepaid Inpatient Health Plans (PIHP) conduct an External Quality Review (EQR) of each entity. These regulations have been in effect since January 2003. The DHCS Mental Health and Substance Use Disorders Services Division contracts with Behavioral Health Concepts, Inc. (BHC) to provide EQRO services for Mental Health Plans and for DMC-ODS opt in counties or PIHPs. At the June 2017 CBHDA Substance Abuse Prevention and Treatment Committee meeting, Rama Khalsa, Ph.D., Director DMC-ODS EQRO, provided an overview of the work that has been done by BHC to develop quality outcome measures, in addition, those system measures required by the Waiver Special Terms and Conditions. This work has been done in collaboration with counties through a Clinical Steering Committee over the past year. Core areas for measures include the DMC-ODS Waiver Special Terms and Conditions, metrics linked to timely access to care, positive client treatment outcomes, initiation, engagement, retention, and recovery supports.
When a county agrees to opt into participation in the DMC-ODS, it does so as a managed care organization known as Prepaid Inpatient Hospital Plan (PIHP). The county as such agrees to comply with all federal managed care plan conditions and requirements, including very defined standards and requirements related to the protection of the beneficiaries. Under the administration of the Substance Abuse Prevention and Treatment Block Grant services, SUD delivery system prioritizes standards related to waiting list fairness and a great deal of diversity in service access. These standards and practices change and will develop under the DMC-ODS in an environment of service entitlement, beneficiary rights, and care coordination.
With the support of the Blue Shield of California Foundation, the CIBHS DMC-ODS WAIVER FORUM creates a collaborative think tank to support county behavioral health and substance use disorder leaders in the planning and implementation of the Drug Medi-Cal Organized Delivery System. Working with the California Behavioral Health Directors Association (CBHDA) Substance Abuse, Prevention, and Treatment (SAPT) Committee, the second FORUM was held in December of 2016, to explore Building Successful Partnerships with Managed Care Plans. A prevailing challenge for individuals served by the public-sector safety net is their lack of access to physical and behavioral health services. With the expansion of Medi-Cal eligibility, health care is available to them for the first time; however, treatment for substance use disorders remains a carve-out and requires planned coordination. We will now need to build the on ramps and bridges between providers for these individuals to access coordinated care.
One of the key components of the California DMC-ODS 1115 Waiver approved by CMS in August 2015, is the use of selective contracting arrangements to create a network of providers meeting the Terms and Conditions of the Waiver. Selective Contracting is one of the primary means used by health care insurers to control costs in a managed care environment vs. contracting practices used in a grant environment. Selective Contracting limits beneficiary freedom of choice to those providers within the selected network. On December 5, 2016, the staff of the CIBHS DMC-ODS Forum and the CIBHS DMC Training Project, hosted a Webinar on Selective Contracting. Bill Manov, Ph.D. and three county administrators, each at different stages of the application and implementation process, were invited to provide the fundamentals and lessons learned over the past year.
With the support of the Blue Shield of California Foundation, the CIBHS DMC-ODS WAIVER FORUM creates a collaborative think tank to support county behavioral health and substance use disorder leaders in the planning and implementation of the Drug Medi-Cal Organized Delivery System. Working with the CBHDA SAPT Committee, the first FORUM was held in September 2016 and focused on the transition from the current county alcohol and drug services administration to a specialty managed care organization.
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.
I had the opportunity to attend the County Behavioral Health Directors Association (CBHDA), Substance Abuse Prevention and Treatment (SAPT) Committee and to meet with county administrators to discuss the Drug Medi-Cal Organized Delivery System Waiver (DMC-ODS) Implementation. There are 10 counties that have submitted Drug Medi-Cal Organized Delivery System Implementation Plans including, San Francisco, San Mateo, Riverside, Santa Cruz, Santa Clara, Marin, Los Angeles, Contra Costa, Napa and Monterey. DHCS reports that San Francisco, San Mateo, Santa Cruz, and Santa Clara County Plans have been approved. After reading each of the posted plans, I am impressed by the diversity of each county system, its stakeholders, providers, service populations and the enormity of the changes that are on the horizon.
In 2010, the leadership of the mental health and substance abuse treatment fields, both public and private, successfully advocated to include mental health and substance use disorder services as one of Ten Essential Benefits in the Patient Protection and Affordable Care Act (PPACA). In 2014, the California Department of Health Care Services applied for an 1115 Medicaid Waiver to initiate a Drug Medi-Cal Organized Delivery System in California. This demonstration project is one earlier step in the larger health care system changes that includes California Medi-Cal 2020.
With the support of the Blue Shield of California Foundation, the CIBHS DMC FORUM creates a collaborative think tank to support county behavioral health leaders and key local stakeholders in the planning and implementation of the Drug Medi-Cal Organized Delivery System. Working with CBHDA, the FORUM will identify issue areas that warrant a policy and practice deep dive. We know that there is a rich base of successful practices, programs,and innovation, going on in counties throughout the state. We want to capture these ideas.