SUMMARY REPORT
MEETING 13
Date:
Time:
Hosts:
Topic:
Wednesday, May 23, 2012
10:30AM – 12:00PM
UCLA Integrated Substance Abuse Programs (ISAP) & CA
Dept. of Alcohol and Drug Programs (ADP)
What Other Large States are Doing with Reform, What
Reform’s Effects on SUD Treatment Are So Far, and other Hot
Topics and Controversies
Presenter: -- Suzanne Gelber Rinaldo, MSW, PhD
The Avisa Group
Review of ILC Meeting 12
UCLA ISAP
 The twelfth ILC meeting, conducted on April 25, 2012, involved a
presentation by Larissa Mooney, MD on Medication Assisted Treatment
for Alcohol and Opioid Dependence. Special thanks to our presenter Dr.
Mooney for her continued involvement and support of our learning
collaborative. Thank you all for your participation. A summary from this
meeting has been posted on the UCLA ILC webpage:
http://www.uclaisap.org/Affordable-Care-Act/html/learningcollaborative/index.html
Logistics
 Summary and materials discussed from the previous ILC meetings are
available at http://www.uclaisap.org/Affordable-Care-Act/html/learningcollaborative/index.html. Subsequent meeting materials will continue to be
posted on this site.
 The next ILC meeting will be held on June 27, 2012 from 11:00AM to
12:00PM. UCLA has invited Beth Rutkowski, MPH to give an
Epidemiological Update on the Prescription Drug Abuse Problem.
 All further meetings are scheduled to be held at 11:00AM (PT) on the 4th
Wednesday of every month, unless otherwise noted.
ILC Meeting 13 Topic:
What Other Large States are Doing with Reform, What Reform’s Effects on
SUD Treatment Are So Far, and other Hot Topics and Controversies
Topic Introduction – Darren Urada, PhD, UCLA ISAP
 The topic for today’s learning collaborative is to hear about what other
large states are doing with health care reform. We thank Dr. Suzanne
Gelber Rinaldo for presenting on this topic and hope this will be a learning
opportunity for those in the audience but also for the speaker. Questions
and trouble shooting among the group are encouraged.
Suzanne Gelber Rinaldo, MSW, PhD
The Avisa Group
Summary
 Pennsylvania
o Analogous to California in many ways: extremely diverse population, large
urban and rural populations, county-led state with strong substance use
disorder (SUD) county and state programs, and strong policy-oriented
provider association in substance abuse
o Pennsylvania Health Choices (started in 1997)
 One of the first states to implement their own health care reform
 Geographically phased approach (medical was done first, then
behavioral health)
 Counties have the right of first opportunity to apply competitively to be
the vendor for behavioral health (BH) and health services delivery
system for Medicaid recipients
 State has competitively selected MBHO’s in counties that did not apply
 PA created capitated program for the Commonwealth (fully at risk)
 OMHSAS successfully implemented Health Choices in 25 counties so
far (3 zones)
 Approximately 895,000 Medical Assistance enrollees covered
o PA covered SUD services:
 Services covered in plan only (no out of network but there are
supplemental services available if approved, plus varied remaining
services in counties)
 SUD Benefits:
 Crisis Intervention (including psychiatric)
 Outpatient Drug and Alcohol Treatment, including evaluation and
individual/group therapy
 Methadone/MAT
 Drug and Alcohol Detoxification (in hospital, ambulatory or
approved facility)
 Behavioral Health Rehabilitation Services for Children and
Adolescents (includes SUD, wraparound)
 Non-covered services: residential treatment for SUD – not in plan,
no approval, results in service denial



CBHNP works with other agencies, PCP’s, area and county
agencies, social services to help organize treatment and support
Minnesota
o Minnesota is a very progressive state
o Medicaid (MA) and MinnesotaCare (expansion population) both have SUD
benefits
 MA covers AOD treatment
 Dual eligibles pilot program (funded by CMS) includes full
integration of medical care, behavioral health, LTC, and community
services
 Comprehensive approach
o Hennepin County
 Largest population in state (Minneapolis)
 Long history of providing services (carved out substance use)
 Created ACO to cover MA expansion population (CMS early adopter)
 Combines BH, social services, and countywide services
 Crosses over to include criminal justice and social services for
clients who need support
Texas
o One of three states (Florida and Wisconsin) that are not formally
implementing PPACA
 SUD services are being provided in a health-reform “lite” fashion
 Unusual requirement: legislation covering new SUD program in
Medicaid states that services are tied to what is fiscally supported by
the state’s Legislative Budget Board
 State is allowed to discontinue SUD services under Medicaid via this
legislation, if providing services increases overall Medicaid costs
 They are a minimal taxation state and like California have had budget
shortfalls
o New covered benefits under Medicaid began 2010
 Covered Services in 2010: Can petition for more (medical necessity)
 Assessment, no prior authorization required
 Ambulatory outpatient treatment (135 hours of group plus 26 hours
of individual per year)
 MAT – can be provided by MD’s and by CDTF’s approved by state
 Ambulatory detoxification; only in CDTF Medicaid enrolled facilities,
must have prior authorization (electronic), up to 35 days per
episode with a limit of 2 in six months
 Covered Services in 2011:
 Residential detoxification, prior authorization, must be medically
necessary
 Special services for pregnant women and their children, not many
approved vendors (wraparound)
 MAT for adolescents, up to 20 sessions
 RTC services for adolescents
 Not covered: aftercare, telemedicine, TCM


 Retrospective review done on all claims
 Medicaid Chief is retiring – could lead to change
New York
o SUD benefit reform is part of wholesale SUD service reorganization in
NYS that created the former MATS (covered case management)
o Targets chronic cases/high fliers
 NY is phasing in Medicaid managed care geographically, now
downstate/NYC
 NY State explicitly invoked the “good and modern” system ideas from
SAMHSA
 Both Medicaid managed care and Family Health Plus (expansion
population) cover SUD services
o NY’s new Health Home program changes the SUD system again
 Existing benefits include access to full continuum of care including
crisis/detox, inpatient, long-term residential, supportive housing and
outpatient services including MAT
 Care coordination has become the key and has replaced case
management as of April 2012
 First wave of health home projects includes individuals with chronic
SUD/MH
o Managed Medicaid - New York Health Homes/UR
 Entire system is subject to SUD utilization review for level of care
determination
 State wants UR tools to determine specific clinical needs of SUD
patients, use accepted SUD assessment tools
 Issue: Court-ordered vs. MCO clinical necessity criteria
 Visit thresholds do not acknowledge differences in patterns of SUD
service delivery (ASAM criteria not adopted)
 Still are pushing but do not yet have reviewers with specific SUD
credentials and experience
 Still pushing for SBIRT as part of Health Home patient assessments
 Phase I BHO’s need to be active in Health Home enrollment,
assignment and service delivery (needs push)
NASADAD vs. Cappocia on Effects of State Health Reform (Massachusetts,
Vermont, Maine)
o NASADAD issued a 2010 statement that “after health care reform, both
access and demand rose in each state”
 Acknowledged that the uninsured rate amongst those with SUD
remained high
 Asserted that savings were realized through ASO’s (Administrative
Services Organizations)
 Pointed out challenges: enforcing parity, addressing workforce
shortages, increasing administrative costs to SUD treatment providers
o Capoccia et. al (Health Affairs 31, No. 5, 2012) concluded that the
experience of Massachusetts shows that health reform incorporated SUD
services into essential benefits for all covered residents


Analysts expected an increase in access, utilization
 The actual experiences showed SUD patterns remained stable,
large proportion of SUD patients stayed uninsured; many insured
SUD patients were deterred from treatment because of
requirements such as copayments, eligibility requirements, lack of
outreach etc.
o Co-pay deters use of services
o Homeless population can’t provide the documents
to qualify
o Benefits terminate when a patient goes to jail- it
takes another year to qualify for Medicaid
 Absence of redesign in SUD treatment may be an issue
 Ineffective outreach; needs much more of a focus
Utilization Review and Management
 Has moved in theory and practice from just say no to more
sophisticated management of care
 Requires consistent, published criteria, not ad hoc or invites lawsuits
 In place already in some counties but not fully implemented in many
 Reviewers need to use accepted protocols, have SUD training and
experience but sometimes this is not the case
 Reinforces role of medical directors
 Very confusing for some patients/families (patient navigators needed
for our population)
 Used alone does not result in savings in absence of system changes
 May be in conflict with parity law
Discussion:
Q:
Do you think SUD services are under-reported? Patients may be getting
services in primary care but since there is a stigma associated with substance
use its not being reported.
A:
This is a problem. I do believe it’s under-reported. For instance, in an
FQHC there is no additional payment for SUD services so it’s not included.
The articles demonstrated that people are worried that with health care reform
there will be an influx of patients – this is debatable. Also, how we establish
estimates of need is a problem (self-report vs. actual need). This leads to a
treatment gap.
Q:
How do you feel about managed care plans and their ability to manage
costs? Are we compromising quality of care?
A:
Key stakeholders need to be involved in this process; outcome measures
should be agreed upon; counties can apply to be providers and data is sent for
bids. At the state level the data is needed, QM skills are needed. In our state
who should do MH oversight? The SUD side needs to get more involved in this
process. We need to think of managed fiscal risk and outcomes/data.
Closing Remarks – Darren Urada, UCLA ISAP
 Thanks again to Dr. Rinaldo for presenting today. It is always helpful to
hear from experts in the field of addiction medicine. Thank you for
volunteering your time and sharing with the group.
 The next ILC Meeting is scheduled on Wednesday, June 27, 2012 at
11:00am.
 Please remember to reference the website which holds all information and
materials disseminated from the ILC: http://www.uclaisap.org/AffordableCare-Act/html/learning-collaborative/index.html.
APPENDIX 1 – ATTENDEES
COUNTY PARTICIPANTS
MBA















Amador (Pat Bartosiewicz, Jennifer Magee, Sherry Parkey)
Del Norte (Jill Fullington)
Calaveras (David Sackman)
Colusa (Deana Fleming)
Glenn (Erin Valdez, Thomas Waggoner)
Inyo (Linda Benson)
Lake (Linda Morris)
Lassen (Linda Morris, David Rothery, Anita Harsh, Sue Bandouski)
Mariposa (Linda Murdock)
Mono (Robin Roberts)
Modoc (Tara Shepherd)
San Benito (Alan Yamamoto)
Sierra (Rhonda Grandi)
Siskiyou (Randy Davis)
Tehama (Susan McVean)
SMALL
 Butte (Dean True, Marion Reeves)
 El Dorado (Shirley White)
 Humboldt (Helene Barney)
 Kings (Brenda Randle)
 Madera (Sonja Bentley, Cesar Velasquez)
 Mendocino (Leslie Kirkpatrick)
 Merced (Manuel Jimenez, Natalie Vasquez, Kathleen Reyes, Tabatha
Weeda)
 Napa (Karen McElroy, Lisa Montanez, Connie Moreno-Peraza)
 Nevada (Mary Lowe)
 Shasta (David Reiter)
 Sutter & Yuba (Nancy Lee)
 Yolo (Mark Brian)
MEDIUM
 Kern (Lily Alvarez)
 Marin (Michael Hodges, DJ Pierce)
 Monterey (Robert Jackson)
 Placer (Amy Ellis, Cheryl Renwita)
 San Joaquin (Vic Singh, Curt Willems)
 Santa Barbara (J. Doyle)
 Santa Cruz (Bill Manov)
 Solano (Andrew Williamson)
 Sonoma (Derrick West)
 Stanislaus (Madelyn Schlaepfer)
 Tulare (Michelle Reynoso)
LARGE
 Alameda (Tom Trabin)
 Contra Costa (Karen Fearn)
 Fresno (Dennis Koch)
 Los Angeles (John Viernes)
 Orange County (Brett O’Brien)
 Riverside (Karen Kane)
 Sacramento (Lisa Scott-Lee, Maria Morfin, Melinda Avey, Paul Tanner)
 San Bernardino (Dianne Sceranka, Vicki Baumbach, Gary Atkins)
 San Diego (Marshall Lewis, Angie DeVoss, Susan Bower)
 San Francisco (Alice Gleghorn)
 San Mateo (Clara Boyden, Keith Clausen)
 Santa Clara (Michael Hutchinson, Nubia Torres, Robert Gardner)
 Ventura (Patrick Zarate)
ORGANIZATION PARTICIPANTS
 ADPI (Victor Kogler)
 CAADPE (Albert Senella)
 CADPAAC (Tom Renfree)
ADP PARTICIPANTS
 Michael Borunda
 Cynthia Castillo
 Craig Chaffee
 Tina Chiginsky
 Debra Connick
 Michael Cunningham
 Jessica Delgado
 Darien De Lu
 Mary Dodson
 Jonathan Graham
 Theresa Gulley-Reed
 Cynthia Guest
 Gayle Hirahara
 Sally Jew-Lochman
 Janine LaMar
 Marjorie McKisson
 Maurilio Mendez
 Dave Neilsen
 Katrina Parker
 Nanette Rufo
 Suzi Rupp
 Gigi Smith
 Denise Wallace Warrick
 Kevin Wortell
 Marcia Yamamoto
 Angela Zamora
 Trinidad Perez
UCLA PARTICIPANTS
 Darren Urada
 Sherry Larkins
 Brandy Oeser
APPENDIX 2 – AGENDA AND RELEVANT MATERIALS




Overview of Meeting 12
Introductions
 Suzanne Gelber Rinaldo, PhD
Topic Discussion – What Other Large States are Doing with Reform, What
Reform’s Effects on SUD Treatment Are So Far, and other Hot Topics and
Controversies
Q and A
MATERIALS FOR THIS MEETING

PPT Presentation – Suzanne Gelber Rinaldo, PhD
Copies of materials can be found at UCLA ISAP’s ACA Resources Website:
http://www.uclaisap.org/Affordable-Care-Act/html/learningcollaborative/index.html.