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.
There are 34 counties that have submitted DMC-ODS Implementation Plans. Nineteen are approved and services are in operation in four counties – Riverside, San Mateo, Marin and Santa Clara. On July 1, 2017, Los Angeles and Contra Costa will go live. The Special Terms and Conditions of the California Medi-Cal 2020 Demonstration require that the state monitors the County PIHP once per year through the External Quality Review Organization. Critical components of the DMC-ODS which is embedded in the 2020 waiver require that the counties can demonstrate network adequacy and meet access requirements, including that services, are delivered in a culturally competent manner. Providers must meet standards for timely access to care and services. The Clinical Steering Committee has been building a consensus regarding the outcome measures as well as the system outcomes. BHC has launched a PIP Library where real performance improvement projects from counties tackling the common issues of access, timeliness, quality, and outcomes can be found. Take a look at the attached newsletter and visit the BHC website.