Behavioral Health Improvements In The 2020-25 Waiver Proposal
MediCal has one managed care plan for physical health, a separate plan for chronic and severe mental illness and a third plan for substance abuse treatments. The counties separately administer mental health and substance abuse plans, using state realignment, state Prop 65 and county dollars as the match for federal financial participation. To add to the complexity, mild and moderate mental health are the responsibility of the traditional managed care plan, while severe and chronic mental illness is the responsibility of the county mental health plan. In short, it's a confusing mess for an ill patient with a substance use disorder and co-occurring serious mental illness. Part of the background for this division was that mental health was treated as a second class illness and at one point the state mental hospitals were a primary source of treatment/non-treatment. The federal Medicaid statute excluded the large “institutions for mental disease” (IMDs) from the federal Medicaid match for covered services. And when mentally ill patients were deinstitutionalized back in the 70’s, the state money associated with them did not follow the patients into the community mental health settings. Substance abuse treatments were always severely underfunded, and in most counties very little treatment was available.
Federal parity laws and then the designation of behavioral health as one of the ten essential health benefits under the ACA began a process of upgrading behavioral health coverage in California. The 2015 waiver expanded the scope of covered treatments to include a continuum of behavioral health care, while it authorized whole person care pilot programs, it did not repair the fragmented delivery systems and the bars to sharing vital treatment information across the disciplines.
The waiver proposes behavioral health payment reform, which would move from cost-based, volume driven payments to one that incentivizes and rewards good patient outcomes – value based payments. Reimbursements would incent coordination and integration of physical and behavioral health. Counties will need to build a high quality continuum of behavioral health care that is integrated and coordinated with the patient’s physical health coverage.
The waiver will modify and clarify the medical necessity criteria to comply with state and federal requirements. This is an essential improvement, but it gives no specificity as to how this will be done.
Counties will need to join their mental health and substance use disorder into a single fully integrated behavioral health program and delivery system. This too is long overdue and could bring important improvements to treatments of patients with co-occurring disorders.
Rural regional contracting for behavioral health is recommended as an option for counties too small and/or too rural to support a full continuum of behavioral health care and treatments. The administration proposes new opportunities for small counties to opt into the substance use disorder treatment plans in order to achieve statewide coverage. It does not answer how it will be a statewide benefit if these counties still decline to opt in.
Fully integrated care combining physical, mental and substance abuse in a single plan is proposed as one or more pilots. That should be the goal for all of California.
Prepared by: Lucien Wulsin
Dated: 1/24/20