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.
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.
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.
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.
Participants in the CIBHS Drug Medi-Cal Organized Delivery System
(DMC-ODS) waiver trainings are vocal about implementation
successes, barriers and challenges.
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.
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 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.
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.
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.
“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.
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.
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.
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.
