Major System Change Forces that are Reshaping Substance Use Disorder Services in California

1. Major System Change Forces that are Reshaping Substance Use Disorder Services in California Richard A. Rawson, PhD UCLA Integrated Substance Abuse Programs

3. I was seldom able to see an opportunity until it had ceased to be one.Mark Twain

4. Major System Change Forces in California • Affordable Care Act • Mental Health Parity and Addiction Equity Act • California’s Bridge to Reform1115 Waiver • Mental Health Services Act: Prop 63. • AB 109: Criminal Justice Realignment • Elimination of California’s Department of Alcohol and Drug Programs (July 1, 2013)

5. Affordable Care Act The Patient Protection and Affordable Care Act (PPACA) and The Health Care and Education Reconciliation Act of 2010

6. ACA 2014 Changes • New insurance for about 32 million more adults. • Medicaid (2014): To 133 % of poverty. • State Health Insurance Exchanges (2014): Individual and Small Group Plans. • In California, it is estimated that 1.4 million people will be newly eligible for Medi-Cal coverage. 6

7. Wellstone-Domenici Mental Health Parity and Addiction Equity Act of 2008(MHPAEA) and the Interim Final Rule (IFR)

8. Mental Health Parity and Addiction Equity: Overview of the Law • Effective January 1, 2010 • Expected to affect more than 150 million people • Adds SUD to MHP • Impacts retirement care (ERISA) plans for the first time • Impacts Medicaid Managed Care Plans • Stronger State Laws Protected 8

9. Overview of the Parity Law Mental health and addiction treatment benefits must have the same financial terms, conditions, requirements, and treatment limitations as they do for medical and surgical conditions 9

10. Wellstone-Domenici Parity Act of 2008 • Does Address: • MH and SUD Tx • Private health plans that cover 50 or more persons • Day and visit limits care management factors • MBHCOs combine data with MCOs for single deductible. • Does Not Address: • Small group (<50) or individual plans • Medicare • The uninsured • A common definition of medical necessity • Scope of services • Quality or outcome. 10

11. How will Health Care Reform and Parity effect the treatment of substance use disorders?

12. Abuser Addiction Addict Substance Use Disorders (SUD) Chemical Dependence Dependence The language we use matters Abuse Drug Addict Alcoholic Substance Misuse

13. What happens when benefits for SUD are expanded? Hints from… Massachusetts Vermont Maine 13

14. Background • 2006-2008 - 39 States enacted laws to expand access to health insurance • Maine, Massachusetts and Vermont – the states that sought to achieve universal health coverage • Need empirical studies of HCR effects on access to, as well as quality and outcomes of, substance abuse treatment (SAT) services 14

15. Under StateHealth Care Reform Maine, Massachusetts and Vermont: Saw the percent of uninsured drop ME - 13% in 2002 to 10.3% in 2007 MA - 11.7% in 2004 to 2.6% in 2009 VT - 9.8% in 2006 to 7.6% in 2009 SUD admissions rose between 50% (Maine and Massachusetts) to 100% (Vermont). Uninsured rate dropped, admissions rose, but many individuals with SUD clients still without health insurance 15

16. Integration of SUD/MH Services into Primary Care

17. What is “Primary Care Integration”? • Primary care integration is the collaboration between SUD service providers and primary care providers (e.g., FQHC’s, CHC’s) • Collaboration can take many forms along a continuum MINIMAL BASIC At a Distance BASIC On-Site CLOSE Partly Integrated CLOSE Fully Integrated Coordinated Co-located Integrated

18. What SUD/MH/PC Integration Does (Hopefully) • Strengthens organizational linkages between medical and behavioral health care • Improves access by expanding availability of services and removing barriers (administrative, transportation) • Improves coordination of services • Identifies service needs and links clients to appropriate treatment • Blends interventions to treat whole person rather than isolated problems or disorders. • Reduces overall healthcare costs by addressing MH and SUD problems which can cause/exacerbate costly medical conditions. (See Weisner and others)

19. Healthcare Settings for locating individuals with SUD • Primary care settings • Emergency rooms/Trauma centers • Prenatal clinics/OB/Gyn offices • Medical specialty settings for diabetes, liver and kidney disease, transplant programs • Pediatrician offices • College health centers • Mental health settings

20. FQHCs in California • 113 clinic corporations with 1,049 sites • 3.7 million patients served • 53% of state’s population below 100% of Federal Poverty Level (FPL) and 26% below 200% • 15% of state’s uninsured residents served • 46% of total revenues from Medi-Cal

21. SUD Integration in FQHCs (SIF) • Study on SUD/PC integration in a sample of California FQHCs (survey data, administrative data, qualitative interviews and focus groups). • 18 FQHCs in 5 counties invited to complete a web based survey, 14 (78%) have completed survey. • Interviews and focus groups are also currently being scheduled with these FQHCs

22. SIF Results • 57% reported screening all patients for SUD, 21% reported screening a targeted group of patients, and 21% did not screen for SUD. • 43% of organizations do not yet have an electronic medical record system that integrates physical health and mental health and SUD. • 79% reported having individual SUD counseling available onsite, and 29% reported having group counseling onsite.

23. SIF Survey • The most common behavioral practices include motivational interviewing, cognitive behavioral therapy, and social skills building (all 50%). • Only 21% reported prescribing Buprenorphine (Subutex, Suboxone) “sometimes”, and none do it routinely. Lower percentages were reported for extended release naltrexone (Vivitrol). • 78% agreed that additional SUD-related training would be helpful for their clinic’s staff.

24. SIF Survey • (57%) included SUD services in their FQHC prospective payment system rate, however 21% provide SUD services without any reimbursement 36% bill to other county sources, including grants (36%). • No organizations reported providing SUD services on the same day as a primary care referral. 29% said it happened within seven days. The other 71% reported more than seven days

25. SIF Recommendations • There were three recommendations that were brought up by multiple FQHCs: • Expand the billable workforce • Allow same day billing of two services • Stabilize funding

26. County Medical Services Program Behavioral Health Pilot Program

27. County Medical Services Program Behavioral Health Pilot Program The County Medical Services Program (CMSP) provides health coverage for low-income, indigent adults in thirty-five, primarily rural California counties. • The CMSP Governing Board initiated the Behaviroal Health Pilot Program (BHPP) to test the effectiveness of providing short-term mental health and SUD services integrated with primary care in improving health, utilization, and cost outcomes. • Conducted at 14 sites over 3 years (March 2008 to February 2011). • Pilot included 15 of 34 CMSP counties.

28. CMSP Behavioral Health Pilot Program • Primary care providers referred patients to a licensed behavioral health provider for an assessment when appropriate • The pilot allowed reimbursement on the same day as a primary care visit to encourage continuity of care and coordination. • Utilization and cost-effectiveness were evaluated by comparing CMSP claims data for a sample of 1,649 pilot participants with an equivalent number of matched control group members

29. CMSP Behavioral Health Pilot Project • Services offered per calendar year included: • Mental health: 1 behavioral assessment and 10 counseling sessions (individual or group) • SUD: 1 alcohol and drug assessment, 2 individual counseling sessions, and 20 SUD group counseling sessions (no medications)

30. CMSP Behavioral Health Pilot Program Results • The most commonly diagnosed conditions were: • Depression (40%) • Anxiety (38%) • SUD (23%) • Far more pilot participants received MH counseling (79.6%) than SUD counseling (5.8%) • Few participants received both MH and SUD counseling (1.5%) • More participants who received SUD treatment were in groups (5.3%) rather than individual counseling (2.5%)

31. Cost-Effectiveness and Utilization Findings • The pilot resulted in a massive redistribution of total costs. • PMPM costs for study participants increased by 20.3% (from $453.29 to $545.51) • PMPM costs increased by 17.5% for the control group ($523.01 to $614.47). • Utilization shifted from inpatient hospitalization towards primary care and outpatient behavioral health services (e.g., clinic, outpatient, and pharmacy), as summarized below for selected measures

32. Cost-Effectiveness and Utilization Findings

33. CALIFORNIA BRIDGE TO REFORMA SECTION 1115 WAIVER

34. California’s Bridge to Reform1115 Waiver • Federal government approved a section 1115 Medicaid Demonstration Waiver entitled “California’s Bridge to Reform” • Approved for the five-year period ending October 31, 2015 • Roughly $10 billion in federal Medicaid matching funds available for expanding coverage to low-income uninsured adults

35. California’s Bridge to Reform • Allows the state to test models of integrated care ahead of the nationwide expansion required by 2014 • The state will extend coverage to 500,000 low-income adults through a Low Income Health Program (LIHP) • The 1115 Waiver did not require an SUD benefit but it allowed it as an option (mental health services were included as a required benefit). 

36. LIHP Counties • Eight counties explicitly proposed add-on SUD services in their Low Income Health Program (LIHP) applications to the California Department of Healthcare Services • Counties include: Kern, Orange, Riverside, San Francisco, San Mateo, Santa Clara, Santa Cruz, and Tulare

38. San Francisco LIHP Program • Setting/Population: All SUD clients eligible for LIHP (including PC patients) • Screening: Conducted by PC provider using CAGE if provider suspects SUD • Brief Intervention: Conducted by Behaviorist at same clinic visit (if available) • Referral: Behaviorist provides up to 6 individual sessions and refers offsite for higher levels of care

39. Santa Cruz: LIHP Program • Setting/Population: PC patients in two county-operated clinics • Screening: Conducted by medical assistant and PC provider using AUDIT and DAST • Brief Intervention: Conducted by SUD counselor and PC provider (if SUD counselor not available) • AOD Counselor can provide up to 12 on-site group and 2 individual counseling visits, refer to off-site treatment for more intensive care

40. San Mateo County • Population/Setting: All primary care patients in 2 county operated clinics • Model: SBIRT with LIHP patients • Screening: Medical assistant using DAST and Audit • Brief intervention by SUD counselor • SUD counselor may deliver up to 10 treatment sessions on site and for more serious cases, referral to specialty care. • All data entered into EHR

41. Orange County • Population/Setting: Frequent emergency department users • Model: SBIRT with high cost populations • Brief interventions done by behavioral health personnel • All treatment for SUD referred to specialty care

42. Kern County • Population/Setting: All medical inpatients and all emergency room patients. • Model: SBIRT with high cost populations • 2 item screener implemented by nurse • Brief intervention done by SUD counselor • Referral to SUD treatment off site. • All data captured in patient EHR

43. Riverside County • Population/Setting: SBIRT with psychiatric hospital patients • Model: SBIRT with high cost populations • Screening using a clinical interview by MH staff. • Brief intervention done by SUD counselor • Referral for co-occurring disorder treatment off site.

44. Santa Clara County • Population/Setting: All SUD patients in SUD treatment specialty care. • Model: Enroll all eligible SUD patients in LIHP and increase access to medical care. • Plan is to analyze data on changes in hospital and ER costs for SUD patients before and after enrollment in LIHP

45. Mental Health Services Act (MHSA) Projects

46. Mental Health Services Act (MHSA) MHSA imposes a 1% income tax on personal income in excess of $1 million. Statewide, the Act was projected to generate approximately $254 million in fiscal year 2004-05, $683 million in 2005-06 and increasing amounts thereafter. In a number of counties, MHSA funding has been used for pilots of SUD/MH/PC Integration.

47. Kern County SUD/MH/PC Pilot

48. Integrating Mental Health & Substance Use Disorder Services into Primary Care: Kern County • Kern County Mental Health (KCMH) is working with FQHC partners to implement an SBIRT model within 6 FQHCs (Project Care). • Using MHSA funds Project Care provides select MH and SUD screening and brief intervention and brief treatment services within the FQHCs. • Referrals to specialty care are made when appropriate.

49. Kern County Integration Model Universal screening Brief consultation in the exam room Brief interventions Brief treatment Integrated case conferencing Using data to monitor progress

50. Kern County: Project Care • The goals of Project Care are to provide universal screening of all adult patients in 6 FQHCs. • Three screening instruments are used (PHQ9, GAD7, and Audit-C+). • Brief interventions are delivered onsite and include SUD assessment and MH solution centered treatment (using the Assist Model and Motivational Interviewing techniques) that take place over 6-10 visits. • Integrated case conferencing with the physician, psychiatrist, and behavioral health staff are mandatory • Provider trainings have included Confidentiality/Ethics, SBIRT and MI, Pain Management, and key principles of behavioral care within a primary healthcare setting.