An ambitious program to offer comprehensive substance use disorder (SUD) care for California’s Medicaid enrollees has shown impressive results, according to a new study published by the California Health Care Foundation. More than 80 percent of county administrators reported that the program has resulted in increased access to SUD services in their county. In surveys, adult patients rated their satisfaction following SUD treatment an average of 4.3 out of 5.
In a paper titled “How Medi-Cal Expanded Substance Use Treatment and Access to Care,” the authors describe how in 2015 California set out to become the first state in the nation to provide organized and comprehensive SUD treatment for Medicaid enrollees — while reducing overall healthcare costs. California received the country’s first Medicaid Section 1115 waiver to expand access to SUD services and launched the Drug Medi-Cal Organized Delivery System (DMC-ODS). While county participation in the program is voluntary, the authors note that uptake has been strong. As of August 2020, 37 of California’s 58 counties are implementing DMC-ODS, representing 96 percent of the Medi-Cal population statewide.
The report notes that few small counties have implemented DMC-ODS, and those that have face unique challenges. “Smaller counties are less likely than larger counties to have the resources needed to significantly expand their SUD systems of care — such as county staff and wide networks of community treatment providers — but they are still subject to the same DMC-ODS requirements.”
Five years since its inception, the number of patients accessing services has risen in most DMC-ODS counties. While an increase in those seeking treatment was expected, in some cases the demand has greatly exceeded expectations, the report notes. For example, Marin County’s increase was double what the county behavioral health department expected. Despite this large increase, Marin County’s system was able to accommodate the higher utilization without significant disruption.
The authors of the report are Allison Valentine, M.P.H.; Patricia Violett, M.P.P.; and Molly Brassil, M.S.W.; consultants with Aurrera Health Group, a health policy firm based in Sacramento. Their work is a follow-up of the California Health Care Foundation’s 2018 paper “Medi-Cal Moves Addiction Treatment into the Mainstream,” which highlighted the initial experiences of four counties — Los Angeles, Marin, Riverside, and Santa Clara — that were early adopters of DMC-ODS. For the current paper, the authors expanded the number of counties interviewed and referenced an annual evaluation of the program performed by UCLA.
The goal of the DMC-ODS pilot program is to increase the number of people receiving effective SUD treatment by expanding services and reorganizing Medi-Cal’s SUD delivery system. Counties implementing DMC-ODS are transforming their SUD treatment delivery systems by improve access to services, centering care on the individual needs of patients, improving quality of SUD services, and expanding access to medication-assisted treatment (MAT). DMC-ODS also provides reimbursement for case management and recovery services benefits that were not available through Medi-Cal in the past.
A 2019 UCLA evaluation estimates that more than 60 percent of enrollees in DMC-ODS counties who thought they needed treatment accessed services through DMC- ODS.
Improving Service Quality
The report notes that “in addition to increasing the number and scope of services, 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 counties are also required to increase coordination between physical and mental health delivery systems to aid in an individual’s sustainable recovery. These requirements work together to ensure continuity of care and improved quality of services.
San Mateo County applies a continuous quality improvement approach in its DMC-ODS program, the report says. “The county and its providers view DMC-ODS as an opportunity to improve the services they provide and to shift toward consumer-centered care. Providers are actively working to build trust with patients who have experienced stigma and negative treatment experiences in the past.”
The research for the report was concluded before the pandemic struck. COVID-19 has forced SUD providers to be creative in how they provide services, including the use of telehealth.
The Medicaid Section 1115 waiver that established DMC-ODS expires at the end of 2020. In October 2019, California released the California Advancing and Innovating Medi-Cal (CalAIM) proposal, a multiyear initiative to implement overarching policy changes across all Medi-Cal delivery systems. It incorporates most of the provisions in DMC-ODS. But when the pandemic hit, stakeholders, including managed care plans, providers, and counties, requested a delay in implementing CalAIM to focus on addressing the pandemic. California will submit a 12-month waiver extension request to CMS to ensure that programs authorized through Medi-Cal 2020 continue and are eventually transitioned under CalAIM, the report says.
