SUMMARY REPORT
MEETING 25
Date: Wednesday, July 24, 2013
Time: 11:00AM – 12:00PM
Location:Tele-conference
Hosts: UCLA Integrated Substance Abuse Programs (ISAP) & CA Dept. of Health Care Services (DHCS)
Topic: Financing Integrated Services
Presenter:Patrick Gauthier
Director
AHP Healthcare Solutions
Review of Previous Meeting
UCLA ISAP
- The previousILC meeting, conducted on June 26, 2013,covered the topic of behavioral health screening instruments. UCLA would like to thank everyone who participated, with special thanks to those who contributed samples of their screening instruments for the discussion.
Logistics
- Summary and materials discussed from the previous ILC meetings are available at Subsequent meeting materials will continue to be posted on this site.
- The next ILC meeting will be held on August 28, 2013 from 11:00AM to 12:00PM.All further meetings are scheduled to be held at 11:00AM (PT) on the 4th Wednesday of every month, unless otherwise noted.
ILC Meeting 25 Topic: Financing Integrated Services
Topic Introduction – Brandy Oeser, MPH UCLA ISAP
- In response to common questions and concerns about the topic, Patrick Gauthier will discuss strategies for financing integrated services. With a focus on partnering with ACOs, managed care contracts, billing, and parity, he emphasizes the need for further incorporation of behavioral health providers into health care systems.
Summary of Questions & Answers
Patrick Gauthier
AHP Healthcare Solutions
Accountable Care Organizations (ACOs)
ACOs are any constellation of providers organized to participate and contract in the Medicare Shared Savings Program.
- They stimulate the consolidation/integration of providers into organized systems of care in order improve the patient experience of care, improvepopulation health, and control costs.
- They report data onpatient care, health outcomes and cost to CMS quarterly and receive a distribution of savings. Some arrangements are lower risk for ACOs and will result in payments for savings but no penalties. Other models are higher risk, where ACOs may receive payments for savings but may also be charged if they don’t perform well.
ACOs were originally designed to address the Medicare population, but similar modelshave spread to Medicaid in certain states like Illinois and Oregon, where they have been rebranded as coordinated care organizations (CCOs). In those states, they have both ACOs (Medicare) and CCOs (Medicaid).
Question:
At CATES, it was explained that SUD providers would need to find an ACO to collaborate with and that FQHCs would be the preferred organization? Could you elaborate more on this?
Answer:
About half of ACOs in the U.S. are majority owned and operated by hospital systems,while the other half are majority owned and operated by consolidated groups of physicians (MSO and IPA networks). FQHCs can be involved but such models are not as common.
What is paradigm-shifting about ACOs is that they put the health plan, hospital system, and the primary care network under the same roof. In California, as in other states, ACOs are already doing business with the commercial market and not limiting themselves to Medicare dollars.Because at least half of the uninsured population will end up being covered by commercial health insurance plans, ACOs will be an important strategic partner to pursue.
Providers should do what they can now and find out how to do business with them as subcontractors, before ACOs solidify their provider networks and lock everyone else out. There are an estimated 32 ACOs in California today and their contact information can be found online.
Question:
Would it be fair to say that people should be looking at ACOs and any other participants in the Shared Savings Program even if they’re not ACOs? (If I understand correctly, I believe there are different levels—meaning you can be in the Shared Savings Program but not an ACO? Or is it really the ACOs we want to target?)
Answer:
You should not limit yourself to the ACO parent companies because there are participants in that ACO and participants in the community of health care providers who make very good business partners whether they are participating formally in an ACO or not.
Other entities will participate in the program – mainly hospitals. But regardless of the ACO’s majority ownership, providers need to focus on building relationships with them, and packaging, pricing, and selling services appropriately.
Question:
It’s unclear if any Medi-Cal ACOs exist today ( They seem to be Medicare only. If they don’t exist today, when might they start popping up?
Answer:
At this point, ACOs have formed to serve the Medicare Shared Savings Program and some have formed to market themselves to the commercial and employer sectors. Medi-Cal is not yet tied into any ACOs but if Oregon and Illinois are viable examples for CA, it’s possible in the future.
Medicaid currently has health homes, which is a similar model to look into.
Community-Based Recovery Support Services and Referrals
Question:
Our county currently provides limited SUD services (primarily for the mandated, court, DUI and CWS clients) and does not contract out. There are no community-based resources, particularly for Medi-Cal.Our group is working (with UCLA and local FQHCs) to create a community-based system of care for local physician referrals of non-mandated clients. We would like to develop a program of "recovery coaches" available for some of the referrals.
Are there models to help us encourage the development of detox resources, inpatient, outpatient and private providers (trauma informed) for the Medi-Cal and community populations?
Answer:
Some suggested models you can try in this situation:
- Peer Recovery Support Services
- These services are very nonthreatening to payers and providers
- There is a lot of interest and adoption of these services
- Crisis Stabilization Units
- This is a relatively short-term alternative to hospitalization
- Does not introduce residential because providers know they will be met with cynicism or rejection
- Make beds available for a detox at rates much lower than those for a hospitalization
- Once that person is medically cleared to come to our unit that is staffed with nurses and a psychiatrist/MD, can stay for maybe 10-15 days for crisis stabilization
- The reception to this business model has been very good (e.g. Illinois, Iowa) because it is non-threatening
- Basically, when the family wants that person in a safe setting and the hospital is not the right place, this is a good option.
- Doing business with other payers
- Cast net a little wider in terms of commercial health insurance and the employer community
- Half of the uninsured population is going to go into qualified health plans on the health insurance exchange marketplace. How do we do business with those plans so that we can insure that dually-insured population?
Question:
Will there be guidelines set up at the state level to assist in referrals to SUD treatment (especially peer support in the community)? Or will the counties have to work this out with FQHCs and other providers?
Answer:
There is a model and best practice, though each county will be unique. Deb Warner is the holder of a lot of that for SAMHSA. Implementation and guidelines for referral will be managed at the local/county level.
Medi-Cal Expansion and MH/SUD Services
Question:
How will the passage of SB1x1 (Medi-Cal expansion) affect Medi-Cal patients in terms of what is covered for behavioral health care and SUD services?
a)How will the managed care plans and the counties determine what services are funded, how they set the rates, and what the county responsibility will be in all this?
b)Describe how severe mental illness works as a carve-out and how the funding for that system works, versus Medi-Cal managed care.
Answer:
These are complicated questions and the answers are unclear.
AB1x1 (Speaker John A. Perez and Assemblyman Pan) and SB1x1 (Sen. Ed Hernandez and Senate President Pro Tem Steinberg) take major steps toward implementing changes such as expanding Medi-Cal to low-income adults without children at home and setting a floor on benefits of the existing Medi-Cal benefit package plus essential health benefits, providing comprehensive benefits to very low income individuals.
We can expect issues with Essential Health Benefits (what is covered and how it is managed). Under ACA, insurance companies must cover MH and SUD services, but we already know that parity and equity law is not being complied with adequately.
The state of California is free to define what the Essential Health Benefits are within MH/SUD.Under the Medicaid Managed Care, whether SMI is carved out or not, it must comply with the Parity & Equity law.
- Therefore, any Medicaid or Medicare managed care plan that does not follow the final rule is out of compliance with the law. This is an argument that needs to be had and it just isn’t happening at the Medicaid managed care plan level yet.
- In the final MHPAEA Rule in 2013, Medicaid and Medicare health plans will need to be held to the fire and will have to comply with the Parity & Equity law.
On the commercial side, there are three class-action lawsuits against managed care companies—one in Vermont, one in Connecticut, and one in New York. Those are going to be important to follow because they answer the first part of this question.What’s important now is to collect yourselves and define your most desirable answers to those questions.
Commercial Health Plans and Parity
Question:
Are commercial health plans actively recruiting SUD/MH providers to expand their networks so they can comply with parity law?
Answer:
I wish the answer were yes.
State legislatures and the insurance commissioner who governs all of the plans in California have taken a very conservative view of what ought to be covered under parity. The more conservative their position is, the less pressure there is on the payer to extend their network.
A lot plans throughout the country are saying that their network is full and that they don’t need any more BH care providers. That is a very common refrain. There is actually a section in the rule (see Appendix 1 of this Summary Reportfor additional resources) that states they cannot keep BH treatment providers to a different network admission set of criteria or standards than they would a primary care physician. Whatever method they are using to take in a primary care physician, it also needs to be provided to BH providers.
This is why in New York, Vermont, and Connecticut, it’s taking class action lawsuits to get these health plans united. You would think they would be eager to extend, but often times they’re not and are actually being discriminatory.
Medi-Cal, Managed Care, and Billing
Question:
Can I assume that if a Managed Care Organization (MCO) contracts with the state for medical/surgical, that they are therefore also contracting with the state for MH/SUD?
If so, does that entitle a Medi-Cal beneficiary, via their MCO, to access a list of psychotherapy and MH/SUD providers? AllI have heard from the MCOs is that mental health is a carve out. Maybe MCOs can contract with the state for medical/surgical, but not for MH/SUD.
Answer:
The MCOs, when they’re contracting with the state, cover a limited range of MH services. It’s what allows people to go to their primary care physician to get their antidepressant adjusted.
An MCO will not necessarily be managing MH/SUD and it’s more likely that Drug Medi-Cal will remain a carve-out to county managers. The fact that it is a carve-out is often used as an excuse for non-compliance with the law, which is actually not correct. Unless an MCO is engaged at a county level with some involvement with Drug Medi-Cal, it may not be worthwhile. On the other hand, if a provider provides both Medi-Cal services and MH services, it may make sense to sit down and talk with them.
Question:
One big problem in California is that only psychologists, psychiatrists, and LCSWs can bill Medi-Cal for behavioral health currently, not MFTs or counselors. If we don’t have Medi-Cal ACOs yet, is there flexibility for Medi-Cal Managed Care companies to pay for services from these providers?
Answer:
The short answer is no.
But it depends on CA managed care regulations and how strictly they tie managed care organization (MCO) hands.MCOs are doing essentially what they have to do and contracting between the managed care company and Medi-Cal tendsto be very prescriptive in the state by virtue of its regulations at the managed care and Medi-Cal level.
If the regulations leave some “wiggle room” it would behoove folks to meet with and directly advocate to each MCO separately OR to advocate for the inclusion of what you want to see through the legislature and Insurance and Managed Care Commissioners as was done last year in Illinois.
Question:
Normally, two services can’t be billed to Medi-Cal in one day in California. But can an FQHC bill for two services in one day if the second gets billed to Drug Medi-Cal, which is a carve-out?
Answer:
I don’t know the answer. It is probably not allowed at this point but some quick calls to a few FQHCs will turn up the practical answer.
The reason is because of subrogation. In subrogation, the same coverage and insurance rules apply to both plans – so they shouldn’t be able to be billed for two things in one day even though one is carved out.
Question:
If MFTs and SUD counselors at an FQHC are supervised by a billable provider (Psychologist, Psychiatrist, LCSW), is there some way that the billable provider can sign off while the MFT/counselor delivers services so that Medi-Cal can be billed?
Answer:
I don’t know the answer. It is probably not allowed, because if it were allowed, I believe that we would know it would be allowed.
What the regulatory issues at CMS around FQHCs are and what the regulatory issues at DHCS around Medi-Cal are two main issues. I included several resources that may be helpful in answering these questions (see Appendix 1 of this Summary Report). One resource addresses from a legal standpoint the addition of specialty services to Californian FQHCs, because although FQHCs provide many services, they don’t provide them all.
It is complex because there are two sets of laws and regulations that govern this question. Not only is it about coordinating the services and trying to untangle billing processes, but there are also issues surrounding malpractice, federal court claims, the distinction between Medicare and Medi-Cal reimbursement, referrals, compensation, licensing and permits.
The other resource deals with Medicaid and regulations specific to FQHCs and was put together by their association at a national level called the National Association of Community Health Centers (NACHC). Their interpretation of Medicaid and the exchange are all in this paper, but I’m skeptical that it’s an easy answer. It is probably a little more complex because it’s at the intersection at two very different sets of laws and regulations.
Question:
Is there a list of the formulary medications that are available to an FQHC?
Answer:
It varies by state and program. The best thing to do is ask FQHCs.
APPENDIX 1 – ADDITIONAL RESOURCES
APPENDIX 2 – ATTENDEES
PRESENTER
Patrick Gauthier (AHP Healthcare Solutions)
COUNTY PARTICIPANTS
San Luis Obispo County: Sue Warren, Kena Burke
Glenn County: Tom Waggoner
Tuolumne County: Clint Huffman
Orange County: Brett O’Brien
Solano County: Andy Williamson
Los Angeles County: Donna Lee-Liu, MarghotCarabali
DHCS Participants
Jonathan Graham
Robert Moss
UCLA Participants
Darren Urada
Cheryl Teruya
Brandy Oeser
Elise Tran
Beth Rutkowski
ADDITIONAL Participants
Petra Stanton (CPCA)
Erynne Jones (CPCA)
Wendy B. (Mental Health Systems)
APPENDIX3– Agenda and Relevant Materials
- Overview of Previous Meeting
- Introduction – Patrick Gauthier (AHP Healthcare Solutions)
- Topic Discussion (Q&A) – Financing Integrated Care
REFERENCE Materials for this meeting
- PPT Presentation – ACA & MHPAEA: Drug Medi-Cal
- PDF Document – Special Report: MHPAEA Regulations
Copies of materials can be found at UCLA ISAP’s ACA Resources Website: