Onward and Forward

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.  

There are an additional seven counties reporting a pending submission – all expected to be in by October. These 17 plans will represent coverage for the continuum of SUD Benefits for 80% of the state’s Medi-Cal beneficiaries. Many components of the new organized delivery system have required the development of infrastructure from the ground up and the approval by the Center for Medicare and Medicaid Services (CMS). So it has been slow going. Activities will accelerate as CMS has recently approved the State-County Contract outlining the role and responsibilities of DHCS and of each County as the Specialty Managed Care Organization. The Certified Public Expenditure Protocols and the UCLA Evaluation Plan have been approved.

The challenges faced by the small counties are unique and will require innovation such as regionalization of services. Even with this flexibility, the lack of infrastructure and of an adequate workforce in many of these counties creates enormous barriers to beneficiary access. Partnership Health Plan is working with nine of the northern counties to create a joint agreement for service delivery and management infrastructure. This collaboration will be a positive step toward working under a Managed Care Organization (MCO) and toward initiating an integrated health home model. However, at this time many small and rural counties have not determined a business model that will improve value and reduce costs.

Each county has the option to participate in the DMC-ODS Waiver as a Specialty Managed Care Organization, developing and executing an organized delivery system for Medi-Cal beneficiaries in compliance with the Standard Terms and Conditions of the 1115 Waiver. The key activities of a MCO include network development and selective contracting; setting payment rates; obtaining performance measurement; implementing utilization management, and the coordinating care. Managed Health Care emerged in the 1980s and developed significantly over the years – most recently defined by CMS in the sweeping Medicaid Final Rule. Up to now, the delivery of alcohol and drug prevention and treatment services in most counties in California developed as a confederation of programs funded primarily by the Substance Abuse Prevention and Treatment Block Grant and /or criminal justice treatment initiatives. The reimbursement rates from these funding sources have been low. Administrative infrastructure has been minimal except where individual counties invested in oversight and uniform standards through contracting.

To understand the new management standards and accountability, we can learn a great deal from the National Committee for Quality Assurance (NCQA) and Federal External Quality Review regulations at 42 CFR Part 438, subpart E. Over the past 20 years, the NCQA has emerged as the leader in developing quality standards and in initiating improvements throughout the health care system. NCQA is known for the Healthcare Effectiveness Data and Information Set (HEDIS) – the most widely used set of health care performance measurements in the United States. The standards do not yet reflect behavioral health or substance abuse disorder treatment in any depth; however, we can expect to see the development of measurements in the future. Notably, the NCQA has initiated accreditation for Managed Behavioral Health Care Organizations (MBHO) requiring proficiency in five categories of standards: quality management and improvement; care coordination; utilization management; credentialing; and beneficiary rights and responsibilities.

Federal regulations at 42 CFR Part 438, subpart E (External Quality Review) set forth the parameters that states must follow when conducting an external quality review (EQR) of its contracted managed care organizations. An EQR is the analysis and evaluation by an external quality review organization (EQRO) of aggregated information on quality, timeliness, and access to the services that an MCO or its contractors, furnish to Medicaid recipients. DHCS has contracted with Behavioral Health Concepts, an accredited EQRO, to conduct the mandated annual EQR reviews of each new County Specialty SUD MCO; and to provide the technical assistance and support during this phase of development. Each county will submit a Performance Improvement Plan based on the Federal regulations.

There are significant changes and challenges ahead – at the system level; the organization level; and the program level. We can expect to be confronted by those who prefer the status quo. We cannot however overlook the need to educate and engage both providers and consumers, as well as referral partners and other stakeholders. As a cautionary note, there may be unintended consequences and expectations for the new delivery system that we have not anticipated and that will not be known until the system is implemented.

For today – onward and forward!


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