NOVEMBER 2020 Mental Health Disparities by Race and Ethnicity for Adults in Medi-Cal Overview Community advocates have long highlighted the need for a mental health system that better serves California’s cultural and linguistic diversity.1 They have pointed out the need to assess how people are Contents faring in the system and where there are differences in access and outcomes. 2 The Medi-Cal Mental “Mental health disparities” are inequitable differences in risk of illness, access to services, utilization of Health Care System services, and health outcomes experienced by individuals or groups based on age, race, ethnicity, gender and AB 470 identity, sexual orientation, immigration status, primary language, disability status, income level, or other factor, or a combination of these factors. 4 About the Data Although California has legal requirements for cultural and linguistic access for people who are enrolled 6 Findings in Medi-Cal, a lack of quantitative system performance data and measures has made it difficult to enforce 15 Conclusion these requirements or to meet performance targets. 16 About the Authors In 2017, Governor Jerry Brown signed AB 470 into law. It requires robust tracking and evaluation measures for mental health services in Medi- Cal. The goal is to ensure that Medi-Cal enrollees receive timely access to quality mental health services which would then reduce mental health disparities. Newly available Medi-Cal data, released as required by AB 470, demonstrate mental health access disparities for adults in Medi-Cal. 1. California Reducing Disparities Project: Strategic Plan to Reduce Mental Health Disparities, California Pan-Ethnic Health Network, 2018. CALIFORNIA HEALTH CARE FOUNDATION 1 Medi-Cal’s Mental Health Care System California has 56 county-run mental health plans, which are responsible for providing Medi-Cal specialty In Medi-Cal, mental health services to adults enrolled in Medi-Cal who have serious mental illness. Specialty mental responsibility for the health services include but are not limited to mental health treatment, crisis intervention, targeted case mental health benefit management, intensive care coordination, outpatient residential treatment, and inpatient services. is split between county Prior to 2014, adult Medi-Cal enrollees with mental health conditions who did not meet the medical specialty mental health necessity criteria for county specialty mental health services had only limited access to outpatient mental plans and Medi-Cal health services. These services were delivered by primary care providers or by referral to Medi-Cal fee-for- managed care plans. service mental health providers. This report focuses on In 2014, California implemented portions of the Affordable Care Act that expanded the range of mental Medi-Cal mental health health services available to adult Medi-Cal enrollees. This implementation created a mental health benefit services for adults. for people enrolled in a Medi-Cal managed care plan who have “mild-to-moderate” impairment of mental, California’s counties also emotional, or behavioral functioning. provide mental health As a result, the Medi-Cal mental health benefit is now delivered through two separate systems. Counties services for people with retain responsibility for providing Medi-Cal specialty mental health services, while managed care plans and without Medi-Cal have responsibility for arranging and providing mental health services for enrollees with mild-to-moderate through a variety of conditions. County mental health plans manage the inpatient psychiatric benefit for all Medi-Cal enrollees, funding sources, across whether or not they are members of a managed care plan. There is some overlap between the two the entire spectrum of systems: some people receive services through both types of plans, and others move back and forth care, from prevention between them.” and early intervention through specialty care. CALIFORNIA HEALTH CARE FOUNDATION 2 History of AB 470: The Mental Health Equity Act In 2017, Governor Jerry Brown signed AB 470 (Arambula).1 As previously noted, it requires robust tracking and evaluation measures for mental health services in Medi- Cal. AB 470text sidebar (Arambula) In 2018, the California Pan Ethnic Health Network (CPEHN) convened an Advisory Workgroup to develop establishes robust recommendations for implementation of AB 470. The workgroup included behavioral health and physical tracking and evaluation health care experts. Workgroup recommendations were provided to the California Department of Health measures for mental Care Services (DHCS) to consider as part of the AB 470 stakeholder engagement process. CPEHN also health services in Medi- published Measuring Mental Health Disparities, a report detailing the workgroup’s recommendations, in Cal, and a goal of June 2018.2 ensuring that Medi-Cal In 2019, DHCS published the first report of data required by AB 470, providing enrollment and access enrollees receive timely details for Medi-Cal enrollees served by county specialty mental health plans by race/ethnicity and access to quality mental language. health services and thus reducing mental health In 2020, DHCS published an updated data set that also included data from Medi-Cal managed care plans, disparities. which cover 82% of Medi-Cal enrollees across the state. Data are currently available for adults and children. This report draws from that updated adult data set, available online at the California Health and Human Services Agency Open Data, “Performance Dashboard AB 470 Report Application.” 1. AB 470, 2017 Leg., Reg. Sess. (Cal. 2017). 2. Measuring Mental Health Disparities, California Pan-Ethnic Health Network, 2018. CALIFORNIA HEALTH CARE FOUNDATION 3 About the Data Data in this report are from FY 2014–15 through FY 2017–18, depending on the specific source. It does not account for policy and program developments since then, and of course the impact of COVID-19 This report sidebar text focuses on cannot be seen. Medi-Cal mental health Throughout this report, the denominator for managed care plan access and continued engagement services using data rates and for county specialty mental health plan access and continued engagement rates are different. previously published by The denominator for managed care plan rates is the number of adult Medi-Cal managed care plan DHCS through FY 2017- enrollees. The denominator for county specialty mental health service rates is the total number of adult 18 primarily for adults Medi-Cal enrollees, including both those in managed care plans and those who use the fee-for-service served by Medi-Cal. system. The analysis in this report is limited to adults, except as noted. Children and youth (to age 21) also receive mental health services through both the county specialty mental health system and through managed care plans. Their care is governed by the federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, which provides expanded entitlement to services according to individual need. CALIFORNIA HEALTH CARE FOUNDATION 4 Defining Terms ➤ Specialty mental health services:1 These are services for Medi-Cal enrollees with serious mental illness. For adults, medical necessity criteria for these services include having a listed diagnosis and meeting The Medi-Cal sidebar text mental specified impairment and intervention criteria. Specialty mental health services include, but are not health care system limited to, rehabilitative mental health services, crisis intervention, targeted case management, intensive uses several technical care coordination, outpatient residential treatment, and inpatient psychiatric hospitalization. County terms. We offer detailed mental health plans are responsible for providing specialty mental health services. explanations of those ➤ “Mild-to-moderate” mental health services:2 These services are for adults enrolled in a Medi-Cal terms here. managed care plan who have a “mild-to-moderate” impairment of mental, emotional, or behavioral functioning. “Mild-to-moderate” mental health services include, but are not limited to, individual and group psychotherapy, psychological testing, outpatient services, medication management, and psychiatric consultation. Managed care plans are responsible for providing “mild-to-moderate” mental health services. ➤ Access rate: The access rate (also called penetration rate) is the percentage of people eligible for a Medi-Cal mental health service who receive one or more such services in a given time period. This is one of several measures that can be used to evaluate access to services in both the specialty and managed care Medi-Cal systems. ➤ Continued engagement: The California Department of Health Care Services defines continued engagement as five or more Medi-Cal mental health visits in a year. In this document, continued engagement rate is the percentage of eligible enrollees who received five or more mental health services in that year. This is a measure of ongoing access to care. ➤ Time to stepdown: This reflects the time elapsed (in days) from when a person is discharged from an inpatient service to when they receive their first outpatient specialty mental health service. It is a measure of system performance and of how well services are integrated across systems. 1. Kimberly Lewis and Abigail Coursolle, Issue Brief: Mental Health Services in Medi-Cal, National Health Law Program, January 12, 2017. 2. Lewis and Coursolle, Issue Brief. CALIFORNIA HEALTH CARE FOUNDATION 5 Medi-Cal Mental Health Access Rates, Adults, Managed Care Plans and County Specialty Mental Health Plans, by Year Between 3% and 4% of Eligible Enrollees Received Medi-Cal Mental34% Health Since 2014–15, the Services in 2017–18 percentage of all Medi-Cal enrollees using specialty mental health services has Managed Care County Mental Health decreased slightly, but remains close to 4%. 5 The percentage of adults with “mild-to-moderate” mental health conditions who receive services for those conditions 4.3% via Medi-Cal managed care 4 plans has increased over the same period. Among adult 3.8% Medi-Cal managed care consumers, 3.3% received mental health services in FY 3.3% 2017–18, an increase from 2% in FY 2014–15 when the 3 benefit was introduced. 2.0% 2 2014–15 2015–16 2016–17 2017–18 Source: Performance Dashboard AB 470 Report Application, California Health and Human Services Open Data Portal, accessed September 14, 2020. CALIFORNIA HEALTH CARE FOUNDATION 6 Medi-Cal Mental Health Access, Adults, by Year, vs. Estimated Prevalence The number of people receiving Medi-Cal mental health services has grown Access to Medi-Cal Mental Health Services Falls Short of Estimated Prevalence since 2014–15. But many people in need still are not Enrollees Receiving Mental Health Services receiving care. Estimated Number of Enrollees with Any Mental Illness This chart compares the total number of adult Medi-Cal 1,316,107 1,294,860 enrollees receiving services 1,223,297 from either the managed care 1,088,690 or county specialty mental health plans each year to the estimated number of adult Medi-Cal enrollees with mental illness. Prevalence estimates used 564,684 here are taken from the 549,195 510,518 National Survey on Drug Use 450,494 and Health, which estimates that 17.9% of California adults have any mental illness. This percentage has been applied to the total number of adult enrollees to estimate numbers with mental illness for each 2014–15 2015–16 2016–17 2017–18 year shown. Note: The number of adult enrollees receiving mental health services shown here is the sum of those receiving services through a managed care plan and those receiving services through a county specialty mental health plan, for each year. As a result, it double counts those who receive services in both systems. DHCS has previously estimated the number of Medi-Cal enrollees receiving mental health services in both systems in a given year at about 5% of the total number of people receiving Medi-Cal mental health services. Sources: Adults Older Than 20 Receiving Psychosocial Services Statewide by Fiscal Year as of 5/1/2019 (PDF), DHCS, 2019. “National Survey on Drug Use and Health: 4-Year RDAS (2015 to 2018),” Substance Abuse and Mental Health Services Administration (SAMHSA), n.d. CALIFORNIA HEALTH CARE FOUNDATION 7 Medi-Cal Mental Health Access and Continued Engagement Rates, Adults, Managed Care Plans and County Specialty Mental Health Plans, by Year Approximately 4% of adult Few Enrollees Receive Five or More Mental Health Services in a Year Medi-Cal enrollees received any specialty mental health service for serious 4.3% mental illness in each of Access Continued Engagement the four years shown, and 4.0% 3.8% 3.8% approximately 2.5% received five or more mental health 3.3% services in those years 3.0% (“continued engagement rate”). 2.7% 2.6% 2.5% 2.4% 2.4% Mental health services through managed care plans 2.0% were a new benefit under the ACA beginning in 2014. By FY 2017-18 just over 3% of 1.2% adult Medi-Cal managed care 1.1% 0.9% enrollees received mental 0.6% health services, and 1.2% received five or more services in that year. 2014–15 2015–16 2016–17 2017–18 2014–15 2015–16 2016–17 2017–18 Managed Care County Mental Health Sources: Performance Dashboard AB 470 Report Application, California Health and Human Services Open Data Portal, accessed September 14, 2020. CALIFORNIA HEALTH CARE FOUNDATION 8 Medi-Cal Mental Health Access Rates, Adults, by Race/Ethnicity, FY 2017–18 Mental Health Care Access Rates Vary by Race Medi-Cal mental health access rates vary significantly by Managed Care County Mental Health race and ethnicity, with some Black groups accessing services 3.3% at much higher rates than 7.4% others. Alaskan Native or American Indian Black Medi-Cal enrollees 5.7% use specialty mental health 6.2% services at the highest rate White of all racial and ethnic groups 5.0% (7.4%) but use managed care plan mental health services at 5.8% a much lower rate than White Unknown enrollees. 3.5% 5.4% Latinx and Asian and Pacific Islander Medi-Cal enrollees Other access mental health services 4.4% at the lowest rates of all racial 4.3% and ethnic groups in both Latinx managed care plans and 2.5% county specialty mental health 2.3% plans. Asian and Pacific Islander 1.5% 2.0% Note: Data source uses Hispanic. Source: Performance Dashboard AB 470 Report Application, California Health and Human Services Open Data Portal, accessed September 14, 2020. CALIFORNIA HEALTH CARE FOUNDATION 9 Medi-Cal Mental Health Continued Engagement Rates, Adults, by Race/Ethnicity, FY 2017–18 Continued Engagement (5+ services) Varies by Race/Ethnicity Continued engagement in care, defined as receiving five or more mental health Managed Care County Mental Health services in a year, varies by Black race and ethnicity. 1.1% Asian and Pacific Islander and 4.5% Latinx enrollees are less likely Alaskan Native or American Indian than enrollees from other 2.2% racial and ethnic groups to 3.7% receive five or more mental White health services from managed care plans or county specialty 2.3% mental health plans. 3.6% Unknown 3.3% 1.5% 3.6% Other 1.7% 2.7% Asian and Pacific Islander 0.4% 1.4% Latinx 0.8% 1.4% Note: Data source uses Hispanic. Source: Performance Dashboard AB 470 Report Application, California Health and Human Services Open Data Portal, accessed September 14, 2020. CALIFORNIA HEALTH CARE FOUNDATION 10 Medi-Cal Mental Health Access Rates, Adults, by Language, FY 2017–18 Medi-Cal enrollees whose preferred written language Mental Health Care Access Rates Vary by Language is not English are less likely than those who indicate their preferred written language is English to receive Medi-Cal mental health services. (Data 4.8% on preferred spoken language are not available.) Managed Care This chart shows the five most 3.8% 3.7% County Mental Health commonly preferred written languages among adult Medi-Cal enrollees and the mental health access rates for 2.7% each of these groups. Across both the managed care and county specialty mental health 1.8% systems, enrollees who prefer Spanish, Vietnamese, and 1.5% 1.4% 1.4% Cantonese have access rates 1.1% less than half that of enrollees whose preferred written 0.6% language is English. Only people who list Russian English Russian Vietnamese Cantonese Spanish as their preferred written language are as likely as Preferred Written Language people who prefer English to receive mental health services and that is only through Medi- Cal managed care plans. Note: These data do not tell us in what language(s) mental health services were delivered, only the language preference of the person who received services. Source: Performance Dashboard AB 470 Report Application, California Health and Human Services Open Data Portal, accessed September 14, 2020. CALIFORNIA HEALTH CARE FOUNDATION 11 Medi-Cal Mental Health Access Rates, Adults, by Age, FY 2017–18 Mental Health Care Access Rates Vary by Age Older adults (ages 57 and above) make up over a fifth of all Medi-Cal enrollees receiving mental health Managed Care County Mental Health services from both county specialty mental health plans and managed care plans (not 5.2% shown). 4.7% 4.0% 3.8% 3.6% 3.4% 3.4% 3.1% 1.9% 1.2% 21–32 33–44 45–56 57–68 69+ Source: Performance Dashboard AB 470 Report Application, California Health and Human Services Open Data Portal, accessed September 14, 2020. CALIFORNIA HEALTH CARE FOUNDATION 12 Stepdown Services After Inpatient Discharge, Adults, FY 2017–18 Adult Medi-Cal Enrollees Receive Follow-Up Services After Psychiatric Across all racial/ethnic groups, Hospitalization Only Half the Time patients receive no follow- up (“stepdown”) specialty mental health services after psychiatric hospitalization nearly half the time (47%). Patients who do receive stepdown services usually No Under 7 get them within a week of Stepdown Days discharge from inpatient care Services (37%). 36.7% 46.9% Between 8 and 30 Days Over 30 Days 7.4% 9.0% Note: AB 470 data show limited variation by race or ethnicity (not shown). Source: Performance Dashboard AB 470 Report Application, California Health and Human Services Open Data Portal, accessed September 14, 2020. Calculations by authors. CALIFORNIA HEALTH CARE FOUNDATION 13 Managed Care Plan Mental Health Services per 1,000 Members, All Ages, June 2019 White Enrollees Receive More Mental Health Services from Medi-Cal Managed This measure looks at the Care Plans Than Other Racial and Ethnic Groups number of mental health services provided by Medi- Cal managed care plans, as opposed to the number 48.9 of people receiving those services. Controlling for population size, White Medi-Cal enrollees receive many more Medi-Cal managed care plan mental health services than enrollees 27.9 from any other demographic group. Non-White Medi-Cal enrollees use services at less 19.4 than half the rate of White enrollees. 14.4 13.5 8.4 White Other/ Black Latinx Native Hawaiian or Asian Unknown Other Pacific Islander Notes: Data source uses Black or African American and Hispanic. This measure includes managed care enrollees of all ages, including children, youth, and adults. Source: Managed Care Performance Monitoring Dashboard Report, California Department of Health Care Services, accessed September 14, 2020. CALIFORNIA HEALTH CARE FOUNDATION 14 Conclusions ➤ Current AB 470 data sets focus on process measures such as visit types and service counts, which provide This data analysis important measures of how the system is performing. They can also highlight inequities in enrollee access highlighted several and movement through the mental health system. However, they do not answer questions about potential opportunities for inequities in care quality and outcomes, nor do they capture whether providers treat enrollees in a continued work towards respectful and equitable manner during treatment or enrollees’ experience of care. statewide quality ➤ To paint a clearer and more complete picture of the enrollee experience of the mental health system, improvement. future AB 470 data releases should also include measures around timely access to care, care quality, and outcomes. Such measures would allow for more meaningful analyses across the managed care and county specialty mental health systems. ➤ AB 470 also requires more detailed demographic data than are currently published by DHCS, including by sexual orientation and gender identity. Adding these categories may help pinpoint additional disparities for LGBTQ+ communities of color. ➤ California should use AB 470 performance outcome reports to create recommendations for statewide quality improvement and to reduce mental health disparities. AB 470 requires continuing stakeholder engagement, and DHCS should work with stakeholders to make sure that performance and disparities reduction measures reflect consumer needs. CALIFORNIA HEALTH CARE FOUNDATION 15 About the Authors The California Pan-Ethnic Health Network (CPEHN) is a multicultural health policy organization dedicated to improving health of communities of color in California. CPEHN’s mission is to advance health equity by advocating for public policies and sufficient resources to address the health needs of the state’s new majority. We gather the strength of communities of color to build a united and powerful voice in health advocacy. For more information, visit cpehn.org. About CHCF The California Health Care Foundation is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system. For more information, visit www.chcf.org. CALIFORNIA HEALTH CARE FOUNDATION 16