How Medi-Cal Expanded Substance Use Treatment and Access to Care: A Close Look at Drug Medi-Cal Organized Delivery System Pilots AUGUST 2020 AUTHORS Allison Valentine, MPH, Patricia Violett, MPP and Molly Brassil, MSW, Aurrera Health Group Contents About the Authors 3Introduction Allison Valentine, MPH, Patricia Violett, MPP, 4DMC-ODS Program Overview and Molly Brassil, MSW, are consultants with Aurrera Health Group, a mission-driven Eligibility for DMC-ODS health policy and communications firm based 5Measuring the Impact of DMC-ODS in Sacramento. 5Transforming Substance Use Disorder Care For more information about Aurrera Health Through DMC-ODS Group, visit www.aurrerahealth.com. Improved Access to SUD Services Patient-Centered Care About the Foundation Improved Quality and Increased Standardization of The California Health Care Foundation is SUD Services dedicated to advancing meaningful, measur- able improvements in the way the health care Expanded Access to Medication-Assisted Treatment delivery system provides care to the people of The Added Value of Case Management Services California, particularly those with low incomes Extending Treatment Through Recovery Services and those whose needs are not well served by the status quo. We work to ensure that 9Financial Implications for Counties people have access to the care they need, when they need it, at a price they can afford. 10Keys to Success in DMC-ODS Strong Leadership CHCF informs policymakers and industry Working Hand-in-Hand with Providers leaders, invests in ideas and innovations, and connects with changemakers to create A Culture Shift a more responsive, patient-centered health 11Remaining Challenges and Opportunities care system. for Growth For more information, visit www.chcf.org. 13 Conclusion 14 Endnotes California Health Care Foundation www.chcf.org 2 “This program has helped save my life. It has helped me find safe coping skills to better deal with my PTSD symptoms. The staff are caring, compassionate, and work hard to Figure 1. C ounties Implementing DMC-ODS make a positive difference in as many lives as possible. I’m very thankful and grateful Implementing DMC-ODS (37) for this opportunity to live a better life.” State Plan DMC (21) — TPS client respondent Introduction I n 2015 California set out an ambitious, first-in- the-nation experiment to provide organized and comprehensive substance use disorder care for Medicaid enrollees — while reducing overall health care costs. California received the country’s first Medicaid Section 1115 waiver to expand access to substance use disorder services and launched the Drug Medi-Cal Organized Delivery System (DMC- ODS). While county participation in the program is voluntary, uptake has been strong. As of August 2020, Source: “Counties Participating in DMC-ODS,” California Department of 37 of California’s 58 counties are actively implement- Health Care Services, accessed August 2020. ing DMC-ODS, representing 96% of the Medi-Cal population statewide (see Figure 1).1 The California Health Care Foundation’s 2018 paper Additional DMC-ODS Resources Medi-Cal Moves Addiction Treatment into the Visit CHCF’s ”Drug Medi-Cal Organized Delivery Mainstream highlighted the initial experiences of four System” project page for more information and counties — Los Angeles, Marin, Riverside, and Santa resources on the program. Key resources: Clara — that were early adopters of DMC-ODS. For $ Medi-Cal Moves Addiction Treatment into the this paper, the authors interviewed county substance Mainstream (August 2018): An initial look at use disorder (SUD) program administrators and behav- the experience of some of the first counties ioral health directors in the original four counties plus to implement DMC-ODS.2 five additional counties representing various popula- $ The Drug Medi-Cal Organized Delivery tion sizes and geographic areas throughout the state: System (August 2019): A brief overview of DMC-ODS.3 Nevada, San Francisco, San Luis Obispo, San Mateo, $ How Medi-Cal Is Improving Treatment and Santa Cruz. for Substance Use Disorder in California (December 2018): A summary of the key The authors also referenced the University of California, changes of the DMC-ODS program.4 Los Angeles, annual evaluation of the program and $ “Briefing— How Medi-Cal Is Modernizing the External Quality Review report. For more informa- Addiction Treatment:” A recording of the tion on these reports, see the “Measuring the Impact December 2018 briefing on DMC-ODS.5 of DMC-ODS” section. How Medi-Cal Expanded Substance Use Treatment and Access to Care: A Close Look at Drug Medi-Cal Organized Delivery System Pilots 3 DMC-ODS Program program, which, like DMC-ODS, is administered at the county level by each behavioral health department Overview (see Table 1). The goal of the DMC-ODS pilot program is to increase the number of people receiving effective SUD treatment Notably, for residential services, DMC-ODS includes by expanding services and reorganizing Medi-Cal’s an exemption from the federal Institution for Mental SUD delivery system. DMC-ODS is the nation’s first Disease (IMD) exclusion, which prohibits Medicaid SUD demonstration project under a Medicaid Section programs from using federal funding for the treatment 1115 waiver from the Centers for Medicare & Medicaid of SUD and mental health conditions for Medicaid Services (CMS).6 A Medicaid Section 1115 waiver gives enrollees age 21 to 64 in any facility with more than 16 states additional flexibility to design and improve their beds that is primarily engaged in providing diagnosis, Medicaid programs in order to demonstrate and evalu- treatment, or care of persons with mental diseases, ate state-specific policy approaches intended to better including medical attention, nursing care, and related serve Medicaid populations.7 To date, 27 other states services.9 The IMD exclusion, a part of the Medicaid have followed California’s lead and received approval program since it was established in 1965, has limited for similar SUD waivers.8 Medi-Cal enrollees’ access to residential treatment for SUD, since residential providers have found it finan- Counties participating in DMC-ODS are required to cially prohibitive to operate facilities with so few beds. provide Medi-Cal enrollees with access to a full con- Historically, counties that provided residential treat- tinuum of SUD services modeled after the American ment in facilities with more than 16 beds could not Society of Addiction Medicine (ASAM) criteria. These draw down federal Medicaid matching funds to pay criteria, first developed in 1991, are the nation’s most for treatment, and had to find other sources of fund- widely used guidelines for creating comprehensive ing, such as grants and local resources. Under the and individualized treatment plans for people with expenditure authority for DMC-ODS, however, partici- SUDs. Services provided under DMC-ODS are sig- pating counties can claim federal Medicaid matching nificantly more comprehensive than the limited set of funds for covered residential SUD treatment regard- services provided under the standard Drug Medi-Cal less of the number of beds in the facility. Table 1. Services provided through Drug Medi-Cal and DMC-ODS DRUG MEDI-CAL DRUG MEDI-CAL ORGANIZED DELIVERY SYSTEM $ Outpatient drug-free treatment $ All services provided under standard Drug Medi-Cal $ Intensive outpatient treatment $ Multiple levels of residential SUD treatment $ Residential SUD services for perinatal women only (not limited to perinatal women or to facilities with (limited to facilities with no more than 16 beds) no more than 16 beds) $ Narcotic treatment programs expanded to include $ Naltrexone treatment buprenorphine, disulfiram, and naloxone $ Narcotic treatment programs (methadone only) $ Withdrawal management (at least one ASAM level) $ Recovery services $ Case management $ Physician consultation $ Partial hospitalization (optional) $ Additional medication-assisted treatment (optional) California Health Care Foundation www.chcf.org 4 Eligibility for DMC-ODS of quality metrics in each county that has been To be eligible for DMC-ODS services, people must: implementing DMC-ODS for at least 12 months. The EQRO produces a county-level report and an $ Be eligible for Medi-Cal annual summary of all county findings. The External $ Live in a county participating in DMC-ODS Quality Review is a federal requirement of all Medicaid managed care programs.14 $ Have received at least one diagnosis from the Diagnostic and Statistical Manual of Mental Disorders for substance-related and addictive disorders (except for tobacco-related disorders) Transforming Substance $ Meet the ASAM criteria definition of medical Use Disorder Care necessity for services10 Through DMC-ODS Note: Under the Early and Periodic Screening, Across California, counties implementing DMC-ODS Diagnostic, and Treatment benefit of the federal are transforming their SUD treatment delivery systems. Medicaid program, for people under age 21, SUD They are working to improve access to SUD services, treatment services are considered to be medically center care on the individual needs of patients, necessary if the individual is assessed to be at risk for improve quality of SUD services, and expand access developing an SUD.11 to medication-assisted treatment (MAT).15 DMC-ODS also provides reimbursement for case management and recovery services benefits that were not available through Medi-Cal in the past. Interviews with the nine Measuring the Impact counties in this paper show that this transformation is well underway. of DMC-ODS Several entities are monitoring the implementation of DMC-ODS to measure the successes and challenges Improved Access to SUD Services in improving care quality as a result of the program. The number of patients accessing services has risen in most DMC-ODS counties.16 While an increase in the $ University of California, Los Angeles, evaluation. number of people seeking treatment was expected, in The UCLA Integrated Substance Abuse Programs some cases the demand has greatly exceeded expec- conducts an annual evaluation of counties imple- tations. For example, Marin County’s increase was menting DMC-ODS, measuring its impact on double what the county behavioral health department access to care, care quality, care coordination, and expected. Despite this large increase, Marin County’s costs. As part of the annual evaluation, UCLA also system was able to accommodate the higher utiliza- conducts the Treatment Perceptions Survey (TPS), tion without significant disruption. which asks clients for their perceptions related to their access to care, quality of care received, care According to the UCLA 2019 evaluation, the num- coordination, outcomes, and general satisfaction ber of patients who received SUD services funded by with their care.12 The most recent evaluation report DMC-ODS increased by 20% in the first five months for fiscal year (FY) 2019 was published in September after counties launched their DMC-ODS programs. 2019.13 However, some of this increase is due to patients who were receiving treatment through other fund- $ External Quality Review. As California’s External ing sources and switched to DMC-ODS, so the actual Quality Review Organization (EQRO), Behavioral change in new patients is likely lower. UCLA was unable Health Concepts completes an annual review to quantify this in 2019 due to data reporting issues. How Medi-Cal Expanded Substance Use Treatment and Access to Care: A Close Look at Drug Medi-Cal Organized Delivery System Pilots 5 More than 80% of county DMC-ODS administrators in the appropriate level of care. San Mateo County reported that the program has resulted in increased is working closely with one of its providers to cre- access to SUD services in their county. The FY 2019 ate an ideal treatment environment and incorporate UCLA evaluation also estimates that more than 60% additional services to optimally treat patients with co- of enrollees in DMC-ODS counties who thought they occurring severe mental illness. needed treatment accessed services through DMC- ODS. However, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), “We are building out levels of care that 95% of people with an SUD do not think they need treatment.17 we never had and expanding choice for existing services.” More than 60% of enrollees who thought — Marin County they needed treatment accessed treatment through DMC-ODS. Improved Quality and Increased Standardization of SUD Services In addition to increasing the number and scope of ser- vices, DMC-ODS is also focused on improving service quality. DMC-ODS requires participating counties to operate as managed care plans, which requires them to develop quality-improvement plans. DMC-ODS Patient-Centered Care counties are also required to increase coordination Under DMC-ODS, providers use the comprehensive between physical and mental health delivery systems guidelines of the ASAM criteria to determine the to aid in an individual’s sustainable recovery. These appropriate level of care for each patient. The assess- requirements work together to ensure continuity of ment is based on a multidimensional evaluation of care and improved quality of services. each patient’s individual risks, strengths, skills, and resources.18 The result is an individualized, patient- San Mateo County applies a continuous quality- centered treatment plan continuously adjusted improvement approach in its DMC-ODS program. throughout the course of treatment to best meet the The county and its providers view DMC-ODS as an patient’s needs. opportunity to improve the services they provide and to shift toward consumer-centered care. Providers are In addition to the patient-centered approach of the actively working to build trust with patients who have ASAM criteria, DMC-ODS also covers a wider set of experienced stigma and negative treatment experi- benefits than the standard Drug Medi-Cal program ences in the past. (see Table 1 on page 4). These two factors allow coun- ties to offer more services tailored to the needs of DMC-ODS has also allowed counties to standardize their patients and communities. Santa Cruz County available services for patients. Previously, services described how their services have become signifi- available at one provider or in one county differed cantly more consumer-centered, flexible, and focused based on the varying requirements of a patchwork on the needs of the individual in treatment rather than of funding sources and arrangements with different expecting the patient to fit into the limited menu of community providers. Now, Medi-Cal enrollees have services available under the standard Drug Medi-Cal access to the same set of services throughout their program. San Luis Obispo County noted increased county and, except for some minor variation related success in being able to diagnose and place people to optionally covered services, across all counties California Health Care Foundation www.chcf.org 6 participating in DMC-ODS. In Los Angeles County, the “Being in the clinic has been a good care system has transformed from isolated programs serving certain locations or populations to a network experience. I’ve been able to get [sober], with bridges between levels of care and between the finish my master’s program, get a job, and SUD, physical, and mental health systems. care for my child. It saved my life.” While benefits for Medi-Cal enrollees have been stan- — TPS client respondent dardized within DMC-ODS counties, challenges remain when serving enrollees from neighboring counties, particularly in areas with larger homeless populations. Expanded Access to Medication- The “county of residency requirement” stipulates that Assisted Treatment people can only receive DMC-ODS services in the Medication-assisted treatment (MAT) is the use of county of their residence, per their Medi-Cal eligibility US Food and Drug Administration–approved medi- file. If a person moves to a different county, it can take cations, combined with counseling and behavioral up to 90 days for their Medi-Cal enrollment to transfer therapies, to treat SUDs. It is an evidence-based to their new county of residence. During this 90-day treatment for patients with opioid use disorders and period, they may face delays getting care, or provid- alcohol use disorders. MAT is offered in a variety of ers and counties may carry the cost of delivering care settings including narcotic treatment programs (NTPs), before they can reconcile reimbursement responsi- the only setting licensed to offer methadone to treat bilities, which can be complex and administratively opioid use disorder. Through DMC-ODS, NTPs that burdensome. contract with counties are required to provide more MAT medications, including methadone, buprenor- phine, and disulfiram. They are also required to offer In patient surveys, adult patients naloxone, a medication designed to rapidly reverse opioid overdose. According to the FY 2019 UCLA rated their satisfaction following SUD evaluation of DMC-ODS, access to MAT has increased treatment an average of 4.3 out of 5.19 in counties that were early implementers of DMC- ODS and remained relatively steady in counties that implemented more recently.21 In parallel with DMC-ODS implementation, other Perhaps most importantly, patients are satisfied with targeted efforts to address the opioid epidemic in the care they receive through DMC-ODS. According California were implemented in recent years. Of par- to the results of the Treatment Perception Survey, adult ticular note is the California MAT Expansion Project, patients rated their satisfaction following SUD treat- which is funded by federal grants totaling $265 mil- ment an average of 4.3 out of 5. Patients provided the lion and aims to expand access to MAT, reduce unmet highest ratings on quality-of-care topics — 95% of sur- treatment need, and reduce opioid overdose deaths.22 vey participants judged that their treatment providers In addition to the California MAT Expansion Project, treated them with respect and communicated in a way counties have formed unique partnerships in a variety they could understand. The lowest ratings were in the of settings including residential treatment programs care coordination domain; however, 82% of patients and outpatient programs, hospitals, primary care clin- still agreed that their SUD provider was working with ics, health plans, criminal justice system agencies, their mental and/or physical health providers to pro- and opioid safety coalitions.23 MAT provided through mote their overall wellness.20 these partnerships often is not reimbursed through DMC-ODS. Instead, these services may be covered by other payers or, within Medi-Cal, as non-Drug How Medi-Cal Expanded Substance Use Treatment and Access to Care: A Close Look at Drug Medi-Cal Organized Delivery System Pilots 7 Medi-Cal services. As a result, it has been challenging Although case management is a powerful tool, many to fully quantify the increase in access to MAT across counties and providers reported challenges with maxi- the state, given the complexity of the delivery system mizing its potential. One barrier is the requirement that and payer structure. For example, Santa Cruz County case management services under DMC-ODS be con- partnered with primary care clinics to expand access ducted by registered/certified counselors or licensed to MAT services, but the services are not captured in practitioners of the healing arts, which include physi- the county’s DMC-ODS claims data.24 cians, registered nurses, and other licensed clinicians. According to San Luis Obispo County, this require- ment prevents the county from being able to seek The Added Value of Case reimbursement for case management services deliv- Management Services ered by trained peer support specialists, as most do One new benefit under DMC-ODS is the coverage not meet these requirements. of case management services. While some counties may have offered limited case management services Another barrier counties frequently cited was a lack before DMC-ODS, these were not a Drug Medi-Cal of clarity around the documentation required to be benefit, and costs had to be covered with grants or reimbursed for DMC-ODS case management ser- other funding. Case management services assist vices. Case management services provided without patients in accessing complementary medical, mental sufficient documentation — including duration of ser- health, educational, social, prevocational, vocational, vice and how it relates to the treatment plan — cannot rehabilitative, and other community services — ser- be claimed for reimbursement. Santa Clara County vices that can significantly impact a person’s success reported that, since providers have operated for years with SUD treatment. According to the FY 2019 UCLA without case management as a covered benefit, it has evaluation, more than 90% of county administrators taken a lot of training to help them understand the reported that DMC-ODS had a positive impact on the importance of sufficiently documenting these services. delivery of case management services in their county.25 San Mateo County is using case management to better Extending Treatment Through meet the needs of its patients with the most com- Recovery Services plex needs. Case managers are assigned to patients Another DMC-ODS benefit not covered by the stan- with complex needs who are involved with multiple dard Drug Medi-Cal program is recovery services. systems. These case managers help connect these Recovery services are intended to support a person’s patients to an array of needed services and supports, wellness and recovery after they complete a course including housing, and mental health and physical of treatment. These services can be a valuable tool in health services, and help them transition between preventing relapse and promoting continued recovery. levels of care — an important function to ensure treat- ment continuity and to promote better outcomes. In Marin County, recovery coaches provide continued support to those who have completed treatment. Marin credits its recovery coaches for many of the county’s successful patient outcomes in DMC-ODS. 28% of SUD treatment patients also According to Marin County, recovery coaches bring received mental health services in a unique passion to the services they provide and the same year.26 are afforded a level of flexibility that enables them to truly “meet clients where they are at.” In Santa Clara County, all outpatient discharge plans include a recov- ery services component. In developing the recovery California Health Care Foundation www.chcf.org 8 services benefit, Santa Clara County built in significant Financial Implications flexibility, encouraging providers to tailor recovery ser- vices to individuals and their unique recovery needs. for Counties One key benefit of DMC-ODS is the availability of DMC-ODS allows counties to use peer providers — federal Medicaid funding for services not covered by people in recovery from SUD — to provide recovery the standard Drug Medi-Cal program. In addition to services. As part of Riverside County’s Peer Support expanded MAT medications, case management, and Specialist program, people with lived experience are recovery services, DMC-ODS counties receive federal present at almost every county-operated SUD treat- matching funds for residential treatment (previously ment facility. The peer support specialists work with only available to perinatal women), new levels of SUD counselors to help support those in recovery. withdrawal management, physician consultation, and Peer providers can only provide recovery services; partial hospitalization. they cannot be reimbursed for any other services under DMC-ODS. Historically, a significant portion of county SUD ser- vices — those not covered by the standard Drug Medi-Cal program — were paid for with grant funding, “Recovery services allow the county particularly the SAMHSA Substance Abuse Prevention and Treatment Block Grants (SABGs). Now that Medi- to continue treatment — a true Cal covers expanded benefits in DMC-ODS counties, continuum of care.” county SABG funds are freed up and can be used to further expand and support the community SUD treat- — Santa Clara County ment and prevention system. While recovery services can be a valuable tool in pre- In particular, many counties are now directing these venting relapse and promoting continued recovery, freed-up SABG dollars to fund recovery housing. according to DMC-ODS claims data, in 2018 less than Since Medicaid funding cannot be used for “room and 3% of those served received recovery services. County board,” it cannot fund housing support for people in administrators noted that the low percentage in claims SUD treatment — but there is no such restriction on data reflects challenges interpreting the new recovery SABG funds. In San Francisco County, an estimated services benefit, particularly around the use of peer 90% of all patients treated in a residential treatment services, as well as a lack of clarity around billing and setting were experiencing homelessness.28 If a patient documentation requirements.27 leaves residential treatment and returns to the streets, they will face significant challenges in achieving suc- Marin County acknowledged that outside of county- cessful recovery. San Francisco uses SABG funds to pay contracted recovery coaches, claims for recovery for residential step-down beds, ensuring that patients services through provider sites are low. This does not can continue their outpatient treatment in a safe envi- indicate that providers in Marin County are not offering ronment following a residential treatment stay. Santa recovery services, but that they are not documenting Clara County is using increased federal funding and or billing for the services. San Luis Obispo County also freed-up grant funds to develop additional outpatient indicated that while providers are providing recov- services and to build up its provider network to meet ery services, they struggle with Medi-Cal billing. As a community needs. As Los Angeles County noted, result, recovery services provided are not reflected in counties are more willing to challenge the status quo the county’s DMC-ODS claims, which means less fed- and try something new given the opportunity to do eral matching funds in the program. so through new and increased funding enabled by DMC-ODS. How Medi-Cal Expanded Substance Use Treatment and Access to Care: A Close Look at Drug Medi-Cal Organized Delivery System Pilots 9 In San Mateo County, the partnership between the “DMC-ODS hasn’t solved complex problems, county and providers evolved into improved relation- but the flexibility has allowed the county to ships between the providers. San Mateo County held be more creative in how we are able to meet monthly calls with its providers during DMC-ODS implementation. Through this increased collaboration, these complex needs.” providers created their own coalition to form their own — Marin County partnerships. In addition, several smaller San Mateo County providers employ the same medical director, who serves as a common thread and contributes to Keys to Success in the overall unity of the provider community. DMC-ODS Regularly checking in with providers has helped counties identify needs and then deliver technical Strong Leadership assistance to help providers successfully implement Most counties voiced that strong leadership was the new requirements of DMC-ODS. San Francisco essential to successful implementation of DMC-ODS. began its DMC-ODS implementation with an exist- Whether educating the community about new services ing, robust continuum of providers. Although many of offered under DMC-ODS; engaging stakeholders, pro- these providers had operated successfully for years, viders, or boards of supervisors; training staff on new they are now doing so in a new environment, requiring billing and cost report systems as well as ASAM levels them to change their processes to align with DMC- of care; or efforts to address stigma, strong leadership ODS requirements. For instance, providers formerly was seen as key to ensuring a smooth implementa- used their own processes to determine the proper tion of DMC-ODS. In Riverside County, “leadership level of care for a person seeking treatment. Under was willing to take the risk and invest in the commu- DMC-ODS, all providers must use the ASAM criteria nity.” With the support of county leadership, Riverside to determine level of care placement. By regularly County increased its staff dedicated to SUD services convening and encouraging discussion, counties can to successfully expand services to county residents.29 assess their providers’ needs and provide them with necessary technical assistance. Working Hand-in-Hand with In addition, DMC-ODS encouraged counties to Providers strengthen relationships with other players, such as Strong partnerships between the county and its local hospitals, community clinics and health centers, contracted providers are essential to DMC-ODS. and health plans. Since the implementation of DMC- In Riverside County, contracted providers helped ODS, Marin County’s Substance Use Division has develop the program during planning and implemen- been able to forge more effective relationships with tation. Riverside County summed up its approach local hospitals and the county’s Medi-Cal health plan. to provider partnerships with a quote from General As an example, the county recently entered into an George Patton: “Never tell people how to do things. expanded data-sharing arrangement with the local Tell them what to do, and they will surprise you with Medi-Cal health plan, allowing for expansion of qual- their ingenuity.” This inclusive process fostered a team ity management and collaboration opportunities. In mindset among the providers and the county in which Riverside County, mental health providers, hospitals, both parties felt invested in the program and its over- and community clinics have all reached out to the all success. county to build partnerships. These relationships help to integrate services delivered in separate environ- ments, and ultimately create a better, more seamless experience for those they serve. California Health Care Foundation www.chcf.org 10 A Culture Shift Attitudes about people who use drugs and SUD Remaining Challenges treatment are changing within the health care sys- and Opportunities for tem as more providers recognize SUD as a disease. Perceptions of community SUD treatment are shifting, Growth and SUD treatment is now more likely to be regarded Residential treatment limitations. Currently, adult as a component of the larger health care system. residential SUD treatment services may be authorized Nevada County recounts that SUD treatment feels for two noncontinuous stays within a 365-day period less siloed under DMC-ODS, with greater coordina- for up to 90 days for each stay, and a 30-day exten- tion and integration with other health providers. sion can be permitted for one of the stays. Similarly, adolescent residential treatment services may be authorized for two noncontinuous stays within a 365- day period of up to 30 days each, and an extension “DMC-ODS brings addiction treatment into can be permitted for up to 30 days for one of the stays.31 Several counties expressed challenges with the family of medicine.” the residential length-of-stay requirements. For exam- — San Francisco County ple, Santa Cruz County expressed that sometimes someone may leave residential treatment after just a few days, return, and then leave again. Under the cur- Although stigma surrounding SUD treatment still rent structure of the program, this would count as two exists, counties reported that stigma is diminishing, stays, even if each of the stays were only a few days, particularly for MAT. Nevada County initially experi- leaving the county responsible for additional residen- enced a dramatic “not in my backyard” response to its tial treatment attempts. efforts to establish medication unit services at a new site. The county responded to concerns by educating The Department of Health Care Services (DHCS) has residents on the value of MAT, locating the building’s recognized the challenges counties face surrounding entrance in the back rather than directly on the street, residential treatment lengths of stay and in a pro- and having staff stationed outside the entrance.30 posal to incorporate most DMC-ODS provisions into In San Mateo County, community partners such as a new waiver has stated that “residential length-of- emergency departments and mental health provid- stay should be determined based on the individual’s ers are increasingly supporting MAT, discovering that condition, medical necessity, and treatment needs.” medications — paired with appropriate services and DHCS has proposed to remove the two-episode limit supports — can make a tremendous difference in on residential treatment stays as DHCS has found this patient outcomes. “inconsistent with the clinical understanding of relapse and recovery from SUDs.”32 Inpatient withdrawal management. All counties participating in DMC-ODS are required to offer at least one level of withdrawal management, a service that provides medical or psychological supervision in either an outpatient or inpatient setting while a patient reduces or stops substance use. Most coun- ties have struggled to secure contracts with providers in their communities for inpatient levels of withdrawal management, a level of care provided in a hospital How Medi-Cal Expanded Substance Use Treatment and Access to Care: A Close Look at Drug Medi-Cal Organized Delivery System Pilots 11 setting, including chemical dependency recovery hos- Confidentiality of SUD patient records (42  CFR pitals and freestanding acute psychiatric hospitals. Part  2). Several counties said that 42  CFR Part  2 is Providers who have contracted with counties to pro- a barrier to coordinating care in DMC-ODS. 42  CFR vide inpatient withdrawal management services have Part 2 is a federal law that requires providers to obtain encountered challenges with licensure, certification, patient consent before sharing their treatment or staffing, and billing. Several counties are in the pro- medical information, except in rare circumstances.36 cess of contracting with providers to offer inpatient Providers noted 42  CFR Part  2 hinders their ability withdrawal management services. Riverside County to coordinate care for the most complex patients as has a contract in place with an inpatient withdrawal obtaining patient consent to release health informa- management services provider, although no services tion has been challenging, particularly in counties have been delivered to date. without countywide electronic health records.37 Some counties have employed three-way calling to over- Adapting to Medi-Cal documentation and billing come this barrier, connecting the Access Call Center requirements. As discussed above, for many provid- referrer, the provider, and the patient who can consent ers, DMC-ODS is their first experience as a Medi-Cal to information sharing in real time.38 provider and they have had to learn the new docu- mentation and billing requirements of the Medi-Cal Resources in small counties. To date, few small program. Many counties described the lack of clarity counties (those under 200,000 in population)39 have around the DMC-ODS documentation requirements, implemented DMC-ODS, and those that have face particularly for case management and recovery ser- unique challenges. Smaller counties are less likely vices, as a challenge. Riverside and Santa Clara than larger counties to have the resources needed Counties both noted that adapting to new documen- to significantly expand their SUD systems of care — tation requirements has been challenging for many such as county staff and wide networks of community of their residential providers. Additional guidance treatment providers — but they are still subject to the on billable activities and sufficient documentation for same DMC-ODS requirements. While most counties these services, as well as trainings for providers on the have added new positions to manage these require- importance of sufficiently documenting these activi- ments, rural Nevada County was only able to add half ties, are needed.33 of a full-time employee position. To compensate, the county cross-trained existing staff and shifted them to DMC-ODS. Training the Future SUD Workforce to Succeed in DMC-ODS Los Angeles County is working with the certification bodies for SUD counselors to enhance counselor training for the DMC-ODS environment. The result- ing SUD Workforce Enhancement for Longitudinal Learning (SWELL) Initiative curriculum focuses on the knowledge, competency, and skills required of an effective DMC-ODS workforce. Trainings are available for new counselors as part of their regis- tration and certification process through the SUD counselor certifying bodies, and as continuing edu- cation for existing counselors seeking to renew their certifications.34 To date, 145 counselors have been trained by SUD counselor certifying bodies follow- ing the principles outlined in the SWELL Initiative.35 California Health Care Foundation www.chcf.org 12 Conclusion Research for this report was conducted before the counties, requested a delay in implementing CalAIM COVID-19 public health emergency was declared. to focus on addressing the pandemic. While the goals Counties and providers have faced new challenges in and objectives of CalAIM continue to be a high pri- providing services during the COVID-19 pandemic. ority for stakeholders and state officials alike, in May To address these challenges, DHCS has implemented 2020, DHCS officially announced the delay of CalAIM. new flexibilities around telehealth, buprenorphine, As a result, DHCS will submit a 12-month Section take-home medications, and information sharing, 1115 waiver extension request to CMS to ensure that among other things.40 programs authorized through Medi-Cal 2020 con- tinue and are eventually transitioned under CalAIM. The Medicaid Section 1115 waiver that established The proposed Medi-Cal 2020 12-month extension DMC-ODS expires December 31, 2020. In October request is expected to be submitted this fall and, if 2019, California released the California Advancing and approved, will provide continuing authority for DMC- Innovating Medi-Cal (CalAIM) proposal, a multiyear ODS through the end of 2021. initiative to implement overarching policy changes across all Medi-Cal delivery systems.41 The CalAIM ini- As part of the extension request, California is also tiative proposes to incorporate most of the provisions proposing to clarify and update certain provisions of in DMC-ODS into a Section 1915(b) waiver, except DMC-ODS based on counties’ experiences imple- for the IMD expenditure authority, which will be pur- menting the program to date. Proposed technical sued through another Section 1115 waiver. A Section changes include removing the limitation on the num- 1915(b) waiver allows states to deliver Medicaid ben- ber of residential treatment episodes that can be efits through managed care systems and is typically reimbursed in a one-year period, clarifying that considered a more “permanent” waiver than an 1115 reimbursement is available for SUD assessment and waiver, which aims to demonstrate and test new pro- appropriate treatment even before a definitive diag- grams. Moving DMC-ODS to a 1915(b) waiver sends nosis is determined, clarifying the recovery services a strong signal to the counties and providers that this benefit, expanding access to MAT, and increasing program is here to stay. Furthermore, CalAIM pro- access to SUD treatment for Native Americans.42, 43 poses to seek federal authority for SUD (DMC-ODS), specialty mental health, and physical health programs As California moves forward with the CalAIM initia- all under the same 1915(b) waiver, which also sends a tive and works to address the COVID-19 public health strong message about integration and the role of the emergency, DMC-ODS will continue to play a piv- SUD services within the broader health care system. otal role in expanding access to SUD treatment and While county participation in DMC-ODS would remain recovery services across the state of California. While voluntary, the state encourages all counties to partici- challenges remain, Nevada County emphasized that pate and will provide technical assistance to counties by learning from each other, particularly drawing on that have not yet implemented the program. lessons from counties that were early implementers, each county does not need to reinvent the wheel. However, just as the state was preparing to initi- ate the formal waiver application process with CMS to move CalAIM forward, the nation was struck by the COVID-19 public health emergency, which has greatly impacted all aspects of California’s health care delivery system. As a result, key partners and stake- holders, including managed care plans, providers, and How Medi-Cal Expanded Substance Use Treatment and Access to Care: A Close Look at Drug Medi-Cal Organized Delivery System Pilots 13 Endnotes “County Plans & Contracts,” California Dept. of Health 1. 17.Drug Medi-Cal Organized Delivery System: 2019 Evaluation Care Services (DHCS), last modified January 23, 2020; and Report. Medi-Cal Certified Eligibles Data Table by County and Aid 18.For additional information about the ASAM criteria, see Code Group June 2020 (Dates Represented: March 2020), ASAM’s “What is The ASASM Criteria?” web page. DHCS, June 2020. Humboldt, Lassen, Mendocino, Modoc, Shasta, Siskiyou, and Solano Counties are part of a regional 19.Drug Medi-Cal Organized Delivery System: 2019 Evaluation model implementing DMC-ODS in partnership with their Report. local Medi-Cal managed care plan, Partnership HealthPlan 20.Drug Medi-Cal Organized Delivery System: 2019 Evaluation of California. Report. Medi-Cal Moves Addiction Treatment into the Mainstream: 2. 21.Drug Medi-Cal Organized Delivery System: 2019 Evaluation Early Lessons from the Drug Medi-Cal Organized Delivery Report. System Pilots, California Health Care Foundation (CHCF), August 2018. 22.For additional information, see the California MAT Expansion Project website. 3.Chelsea Kelleher, Allison Valentine, and Molly Brassil, The Drug Medi-Cal Organized Delivery System (PDF), CHCF, 23.Drug Medi-Cal Organized Delivery System External Quality August 2019. Review Report: FY 2018–19 (PDF), Behavioral Health Concepts, October 20, 2019. How Medi-Cal Is Improving Treatment for Substance Use 4. Disorder in California (PDF), CHCF, December 2018. 24.2018–19 Drug Medi-Cal Organized Delivery System External Quality Review: Santa Cruz DMC-ODS Report (PDF) “Briefing – How Medi-Cal is Modernizing Addiction 5. (March 20–21, 2019), Behavioral Health Concepts, n.d. Treatment,” CHCF, December 6, 2018. 25.Drug Medi-Cal Organized Delivery System: 2019 Evaluation 6.The DMC-ODS pilot program was approved by the Centers Report. for Medicare & Medicaid Services (CMS) as an amendment to California’s 1115 “Bridge to Reform” waiver in August 2015. 26.Drug Medi-Cal Organized Delivery System: 2019 Evaluation The program was then reauthorized in January 2016 as part Report. of California’s waiver renewal, now called “Medi-Cal 2020.” 27.Drug Medi-Cal Organized Delivery System: 2019 Evaluation 7.For additional information about Medicaid Section 1115 Report. waivers, see “About Section 1115 Demonstrations.” 28.Interview with San Francisco County, November 18, 2019. “State Waivers List,” CMS, accessed August 12, 2020. The 8. other states are AK, DC, DE, ID, IL, IN, KS, KY, LA, MA, MD, 29.Drug Medi-Cal Organized Delivery System External Quality MI, MN, NC, NE, NH, NJ, NM, OH, PA, RI, UT, VA, VT, WA, Review Report: FY 2018–19. WI, and WV. 30.2018–19 Drug Medi-Cal Organized Delivery System 9.42 U.S.C. § 1396d. External Quality Review: Nevada DMC-ODS Report (PDF) (June 18, 2019), Behavioral Health Concepts, n.d. 10.The CalAIM initiative is exploring opportunities to update and clarify the eligibility and medical necessity criteria for those 31.“California Advancing and Innovating Medi-Cal Proposal,” seeking SUD treatment services. For additional information, DHCS, accessed August 2020. see the CalAIM web page. 32.“California Advancing and Innovating Medi-Cal Proposal.” 11.California Medi-Cal 2020 Demonstration (PDF), Medicaid.gov, 33.Drug Medi-Cal Organized Delivery System: 2019 Evaluation August 3, 2020: 96–128, 384–415. Report. 12.For additional information, see UCLA’s TPS web page. 34.“SUD Workforce Enhancement for Longitudinal Learning 13.For additional information, see UCLA’s DMC-ODS Evaluation (SWELL) Initiative,” California Consortium of Addiction web page. Programs and Professionals, accessed August 2020. 14.For additional information, see Behavioral Health Concept’s 35.Email communication with Los Angeles County, May 5, 2020. DMC-ODS EQRO web page. 36.The Coronavirus Aid, Relief, and Economic Security Act 15.Some providers use the term “medications for addiction (CARES Act) signed into law March 27, 2020 made changes treatment.” to 42 CFR Part 2 easing patient consent requirements to align more closely with the Health Insurance Portability and 16.Drug Medi-Cal Organized Delivery System: 2019 Evaluation Accountability Act (HIPAA). Report (PDF), UCLA Integrated Substance Abuse Programs, September 16, 2019. 37.Drug Medi-Cal Organized Delivery System: 2019 Evaluation Report. California Health Care Foundation www.chcf.org 14 38.Drug Medi-Cal Organized Delivery System External Quality Review Report: FY 2018–19. 39.Based upon county categorizations as determined by DHCS. See Performance Outcomes System Reports (PDF), report run on August 3, 2016. 40.“COVID-19 Information for Providers & Partners,” DHCS, accessed August 2020. 41.For additional information, see the CalAIM web page. 42.For additional information, see the “Medi-Cal 2020 12-Month Extension Request” web page. 43.Medi-Cal uses the term American Indians and Alaska Natives. How Medi-Cal Expanded Substance Use Treatment and Access to Care: A Close Look at Drug Medi-Cal Organized Delivery System Pilots 15