SYSTEM TRANSFORMATION TO ADVANCE RECOVERY AND TREATMENT STARTODS Los Angeles Countys Substance Use Disorder Organized Delivery System Expansion of Substance SUD Services under ACA March ID: 713460
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Los Angeles County Department of Public Health Substance Abuse Prevention and Control
SYSTEM TRANSFORMATION TO ADVANCE RECOVERY AND TREATMENT
START-ODS
Los Angeles County’s Substance Use Disorder Organized Delivery System
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Expansion of Substance SUD Services under ACA
March
23
, 2010: President Obama Signs the Affordable Care Act (ACA) to Achieve the “Triple Aim”
Improving the Individual Experience of Care
Improving the Health of Populations
Reducing the Per Capita Costs of Care for Populations
January 1, 2014: Medi-Cal Eligibility ExpansionNew beneficiaries now include single adults without children,
with income up to 138% Federal Poverty Level (
FLP
)
November 21, 2014:
DHCS Submits DMC-ODS Waiver Amendment to CMS
Expands available levels of care, adopts ASAM criteria, supports
quality assurance/utilization management
August 13, 2015: Stakeholder Process LaunchedSAPC Launches DMC-ODS Stakeholder Process to Officially Launch Efforts to Expand and Improve SUD Services in LAC
February 11, 2016: Implementation Plan Submitted
LAC Submits plan to DHCS and CMS for review
and approval, pending response
May 1, 2016: Medi-Cal Eligibility Expansion
Children under 19 are eligible for full-scope Medi-Cal regardless of immigration status, if other eligibility requirements are met
July 1, 2016: My Health LA SUD Expansion
Substance use disorder (SUD) treatment services available to individuals eligible for My Health LASlide3
This is the greatest opportunity in recent history to design and implement a substance use disorder (SUD) system of care that has the financial and clinical resources to more fully address the complex needs of all our patients.
SYSTEM TRANSFORMATION TO ADVANCE RECOVERY AND TREATMENT OF SUBSTANCE USE DISORDERS
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SINGLE BENEFIT PACKAGE BASED ON DMC:All beneficiaries/patients have the same access to services regardless of health coverage or funding/referral source. Other funding sources (e.g., CalWORKs, GR, AB109) will be use for uncovered services or to extend services if capped and medically necessary.
My Health LA SUD benefit package for low income uninsured individuals will be the same and commence July 1, 2016.
KEY CHANGES: SYSTEM OF CARE DEVELOPMENTSlide6
NEW DMC BENEFITS…
Beneficiary Access LineMedically Necessary Services:
Individually CounselingFamily CounselingGroup CounselingCase-Management and Care CoordinationRecovery Support Services
Short-Term Residential Youth: up to two 30-day episodes
Adults: up to two 90-day episodesWithdrawal ManagementAmbulatory
Residential …A SINGLE BENEFITS PACKAGE FOR ALL PATIENTS, INCLUDING MY HEALTH LADMC covered services are significantly expanded, and most are not capped if medically necessary (except residential) and available for
all Medi-Cal beneficiaries.Slide7
DMC 1st Payer for Most clients and Services:Medi-Cal eligible individuals must receive DMC reimbursable treatment services by DMC providers.
This includes outpatient, intensive outpatient, residential, and withdrawal management (formerly detox), case management, and recovery support.
This will be required once the new State-County contract is signed and the SAPC SUD benefit package is launched.
KEY CHANGES: BUSINESS DEVELOPMENTSlide8
NOW
: Multiple primary payers and funding sources
LATER (by July 1, 2017)
: DMC will fund most services for most patientsSlide9
YOUTH:
IN THREE YEARS, PROJECTED CHANGE IN ADMISSIONS
10,793
16,696
(+55%)
ADULTS
: IN THREE YEARS, PROJECTED CHANGE ADMISSIONS
60,403 88,698 (+47%)
INCREASED DMC
ELIGIBLES
MORE PATIENTS SERVEDSlide10
DMC RATES: New fee-for-service DMC rates will be negotiated with DHCS with an opportunity to transition to an alternate reimbursement structure (e.g., performance-based, capitation) in later years of the waiver.
SAGE: SAPC’s MANAGED CARE INFORMATION SYSTEM: Efforts to support use of MCIS, and other technology based systems.
KEY CHANGES:
INFRASTRUCTURE
DEVELOPMENTSlide11
Los Angeles County DMC Rates for Fiscal Year 2017-2018
ASAM LOC/Service
Unit of
Service (UOS)
Interim Rate
per UOS
Projected Persons Served
1.0 Outpatient
15-minute
(except group* session)
$29.63
25,667
2.1 Intensive Outpatient
15-minute
(except group* session)
$32.01
10,591
3.1 Residential
Day Rate
$145.71
(includes $36.43 for R&B, non-DMC funds)
1,648
3.3 Residential
Day Rate
$187.85
(includes $46.96 for R&B, non-DMC funds)
3,244
3.5 Residential
Day Rate
$166.70
(includes $41.47 for R&B, non-DMC funds)
10,026
1-WM Withdrawal Management
Day Rate
$210.46
1,047
3.2-WM Withdrawal Management
Day Rate
$381.37
(includes $95.34 for R&B, non-DMC funds)
4,186
Case
Management
15-minute
$33.83
24,511
Recovery Support Services
15-minute
$20.89
10,748
Group
Sessions calculated by # minutes for the group / # of beneficiaries / # of counselors = Total Minutes per Beneficiary.Slide12
NOW: Not all SAPC providers and provider sites are DMC certified.
LATER (by July 1, 2017)
: All SAPC Treatment Contractors will be DMC Certified and AOD Certified/Licensed for all Contracted Levels of CareSlide13
ASAM CRITERIA AND MEDICAL NECESSITYThe American Society of Addiction Medicine (ASAM) Criteria and medical necessity will determine initial and ongoing patient eligibility for level of care placement.
EVIDENCE-BASED PRACTICES
At minimum, all clinical/counselors staff must be capable of effectively implementing and consistently using Motivational Interviewing and Cognitive Behavioral Therapy
QUALITY IMPROVEMENT and UTILIZATION MANAGEMENT
SAPC QI and UM will be a central component to ensuring effective care, including appropriate placements and transitions in levels of care.
KEY CHANGES: CLINICAL DEVELOPMENTSlide14
SERVICE CHANGES TO MEET PATIENT NEEDS:Services need to be patient-centered versus program-centered (e.g., individualized treatment plan determines type and frequency of services).
Patients will have more opportunities to decide
which provider best meets their needs, and choose accordingly. Agencies can expand field-based services, business hours, days of operation, and otherwise tailor the program to better match patient preferences.
KEY CHANGES: BUSINESS DEVELOPMENTSlide15
MEDICATION-ASSISTED TREATMENT (MAT):Adult patients will be informed of MAT as one of the treatment services available for alcohol and/or opioid dependence.COORDINATE HEALTH AND MENTAL HEALTH SERVICES
:
Care coordination and case-management will include ensuring necessary collaboration and connections (e.g., attended appointments) with physical and mental health services.
KEY CHANGES: SYSTEM OF CARE DEVELOPMENTSlide16
STAKEHOLDER
WORKGROUPS
TRAINING & TECHNICAL ASSISTANCE
Contribute to
the new service design and clinical expectations
Staff development, train-the-trainer, and agency-specific assistanceSlide17
…..enhancing substance use disorder services to achieve improved individual and community health outcomes
….you play an essential role in the success of this transition!
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