Author: Neelam Gupta


Integrating Medical Care with Mental Health and Substance Use Disorder Services in L.A. County: A Status Report

An opportunity exists to integrate mental health and substance use disorder (SUD) services with medical care in a patient-centered manner under the Patient Protection and Affordable Care Act (ACA) and federal parity requirements. Survey results on health care preferences of low-income Californians suggest that the safety net should provide more patient-centered, responsive services to compete in an environment with significantly increased consumer choice post-reform.  Providing bidirectional integrated care, which means offering mental health/SUD services in primary care settings as well as primary care in mental health/SUD settings, will be required to meet the Triple Aim to improve the patient experience of care, improve population health, and reduce costs in order to optimize system performance.  Mental health and SUD services are fragmented and poorly coordinated with physical health services due to structural, financial, clinical, and operational barriers.  Although L.A. County faces challenges in achieving integration, it has the opportunity to lead and shape behavioral health policy in order to promote patient self-determination and dignity.  This report will review what integration means; provide information on revenue streams, the policy context, and key behavioral integration examples in L.A. County; and offer recommendations moving forward as full implementation of the ACA approaches.

Integrating services has various meanings given the differing orientations within the health, mental health, and SUD systems and other barriers that have resulted in siloed care. In moving towards a managed care environment in which decreasing costs while improving patient outcomes will be rewarded, the goal should be clinical integration.  While many people with mild to moderate mental health and SUD issues seek care in a primary care setting, individuals in behavioral health settings often experience medical and public health issues.  Addressing issues including but not limited to financing and reimbursement mechanisms, confidentiality of patient information, workforce issues, and practice settings, and using new technologies such as telehealth will be required.

California has a complicated patchwork of funding for health, mental health, and SUD services, spending $41.3 billion for Medi-Cal and indigent health care and an additional $5.5 billion on mental health and SUD treatment.  While 11% of total expenditures are allocated towards mental health, only 1% is spent on SUD treatment.  While California will benefit from significant federal dollars once ACA takes full effect, it will continue to struggle with persistent state deficits.  Counties have been facing budget deficits.  The Mental Health Services Act has been a crucial source of funding for public mental health services to create a state-of-the-art, culturally competent system that promotes recovery, wellness, and resiliency for unserved and underserved population.  Mental Health America of Los Angeles played an instrumental role in the Act’s development and passage.  While the Act’s revenue has supported integration of mental health and some SUD services into other care settings, a comparable SUD funding stream does not exist.

An overview of the dynamics currently influencing  the future role of counties in achieving behavioral health policy integration, including the interactions among these multiple forces, is provided. The state has been awaiting federal guidance on the Medicaid Benchmark Benefit and Medicaid Behavioral Parity before several key ACA implementation decisions are made; these regulations should be released by the end of the year.  Governor Brown announced to California’s leadership his intention to convene a special legislative session to address issues related the California Health Benefit Exchange and the Medicaid expansion once federal guidance is received.  While California has enacted laws that provide mental health parity, a similar requirement does not exist for SUD treatment.  The ACA presents an opportunity to upgrade the SUD benefit.  However, parity language is somewhat vague and allows considerable discretion to states.  Counties have additional revenue through the “Bridge to Reform” waiver and the 2011 realignment of financing and responsibility for behavioral health and community corrections from the state level.  It is possible that the Medi-Cal could have two tiers of benefits post-reform, one for the newly eligible and another for individuals eligible under traditional rules.  Counties will have to carefully calibrate the managing of funds for federal entitlements and construction of provider networks, while health plans will become the accountable entity for patients under ACA coverage expansions.

Background information on L.A. County’s major systems that provide physical health, mental health, and SUD services to low-income communities is provided, including the L.A. County Departments of Health, Mental Health, and Public Health; Medi-Cal managed care plans (L.A. Care Health Plan and Health Net); community health centers and clinics; inpatient and emergency services; and school health centers.  These public and private providers offer a patchwork of safety net services to different but overlapping populations.  While planned collaboration does exist, services are often provided in a fragmented and poorly coordinated manner, which will need to evolve to develop patient-centered, high quality care in an environment of increased consumer choice.  In addition, populations in L.A. County that encounter high rates of a combination of physical health, mental health, and SUD conditions are described, including the homeless, persons exiting the corrections system, and individuals with SUD disorders.  These individuals are expected to represent a significant portion of the Medicaid expansion due to the ACA’s new eligibility rules.  They will require a special focus to ensure enrollment into coverage and integrated care happens to manage their complex conditions while improving health outcomes and controlling costs

L.A. County has embarked on a number of efforts to integrate care.  Often, the focus has been on piloting approaches in certain areas and particular populations given the geographic variation throughout the county, high levels of unmet need, and pronounced differences in regional delivery systems, rather than on building an integrated system of care.  An overview of integrating care in order to improve outcomes and reduce costs in L.A. County is provided.  This includes efforts funded by the Mental Health Services Act, the Integrated Behavioral Health Project, the “Bridge to Reform” waiver’s Low Income Health Program and Delivery System Reform Incentive Pool project, integrated school health centers, emergency services, homeless initiatives, jail reentry, transitions into managed care including Seniors and Persons with Disabilities with Medi-Cal only coverage and persons dually eligible for Medicaid and Medicare, and federal initiatives.  While this review is not meant to be an exhaustive one, it is intended to bring to light major initiatives that involve cross-sector collaboration, promising results, and potential for replication.

At the crossroads of systems transformation as full ACA implementation approaches in 2014, L.A. County has the opportunity to begin the safety net transformation process towards patient-centered, bidirectional, integrated care.  L.A. County’s goal should be clinical integration that increases patient satisfaction and promotes consumer self-determination.  While significant progress made in the last few years under L.A. County’s dynamic leadership supported by financing streams such as the Mental Health Services Act and the “Bridge to Reform” waiver, additional planning and collaboration will be required to ensure that the L.A. County safety net system will be a provider of choice post-reform. Based on the review of the policy environment, L.A. County’s physical health, mental health, and SUD systems, and integration efforts taking place, the following recommendations are offered:

  • Patients should be involved in integrating and transforming safety net systems into high quality, responsive providers of choice in a post-reform world.
  • L.A. County should design a system of integrated care to serve patients regardless of the door through which they enter.
  • The expansion of managed care in public health coverage provides an opportunity to provide high quality, integrated care that improves patient outcomes and reduce costs.
  • Detection and early intervention of mental health and SUD issues should be incorporated into the primary care setting, which may be particularly important in providing care to underrepresented racial/ethnic groups.
  • Particular attention should be paid to integrating SUD services.
  • Training and practice should evolve towards integrated care.
  • Care coordination and management, information exchange mechanisms, and new technologies should be maximized to facilitate and promote the delivery of patient-centered care.
  • Financial and reimbursement incentives should be aligned to ensure the goal of achieving clinical integration.

Significant planning and collaboration efforts will be required to transform local safety net systems in order to become a provider of choice for patients post-reform. Integration may offer a chance to learn from the strengths that each of the three systems of physical health, mental health, and SUD treatment has to offer and move to a person-centered, recovery-oriented wellness model that promotes two-way communication to support the provider-patient relationship.

The full report is available for download below:

Integrating Mental Health and Substance Use Disorders in LA County Integrating Mental Health and Substance Use Disorders in LA County.pdf

ROC-MD in Los Angeles to Provide Health Care to Restaurant Workers

The Restaurant Opportunities Center United (ROC-United) launched ROC-MD recently, a health care cooperative to provide access to services for low-wage, uninsured restaurant workers, many of whom are undocumented.[1]  ROC-United was formed in New York post-September 11, 2011 to improve wages and working conditions for low-wage restaurant workforce, and has grown to eight chapters throughout the nation.[2]   With ROC-MD initiated in Los Angeles in fall of 2011, the local chapter (ROC-LA) estimates that 75,000 restaurant workers locally do not have access to health coverage due to immigration status.[3]

ROC-MD offers preventive, primary care to restaurant workers who are: 1) Undocumented; 2) Legal immigrants; or 3) Otherwise uninsured.[4]   St. John’s Well Child and Family Center, a FQHC with clinic sites throughout South L.A., provides services including annual physicals, urgent care for common illnesses, basic dental care, low-cost medications, and up to seven sessions with a therapist.[5]  Workers must pay a monthly fee of $25 to enroll. [6]   Grant funds from Kaiser Permanente Community Benefits and The California Wellness Foundation are covering the first three months of costs for undocumented workers who do not qualify for other programs such as Medi-Cal and Healthy Way LA.[7]   ROC-LA has informed restaurants and their workers about ROC-MD through door-to-door outreach in its target area of Koreatown and South Los Angeles.[8]   Workers must attend an enrollment and information session to join.  St. John’s has set aside appointment slots for ROC-MD patients to ensure access to services.[9]

Approximately 100 individuals have enrolled in ROC-MD as of May 2012. [10]    St. John’s has connected workers’ family members to health coverage programs such as Medi-Cal and Healthy Families, which assists in offsetting the cost of care.[11]  Many workers are presenting with burns, cuts, and other workplace injuries.[12]   With plans to initiate the program in other cities that have ROC chapters such as Miami, Chicago, Philadelphia, and New York City, administrators have discussed the possibility of applying for support through the ACA’s Consumer Oriented and Operated Plan (CO-OP) $3.8 billion loan program. [13] The CO-OP program will support nonprofit, member-governed plans in order to create delivery and payment models that may compete in states’ individual and small group health insurance markets.[14]   Program planners will evaluate ROC-MD as enrollment increases to inform future directions.[15]


[1] Restaurant Opportunities Center United, Membership and Leadership Development: ROC-MD, accessed at http://rocunited.org/our-work/membership-leadership-development/roc-md/,

[2] Restaurant Opportunities Center United. About Us, accessed at http://rocunited.org/our-work/membership-leadership-development/roc-md/.

[3] Gorman A, L.A. Program Offers Healthcare for Illegal Restaurant Workers, Los Angeles Times, May 3, 2012.

[4] ROC-MD –health care cooperative for restaurant workers, accessed at http://roc-la.blogspot.com/2011/09/roc-md-health-care-cooperative-for.html.

[5] Ibid.

[6] This fee includes $20 for ROC-MD and $5 for ROC-LA membership dues.  See Restaurant Opportunities Center of Los Angeles, ROC-MD –health care cooperative for restaurant workers, accessed at http://roc-la.blogspot.com/2011/09/roc-md-health-care-cooperative-for.html.

[7] Personal communication with Cathy Dang, Restaurant Opportunities Center of Los Angeles, May 15, 2012.

[8] Ibid.

[9] Personal communication with Jim Mangia, St. John’s Well Child and Family Center, May 7, 2012.

[10] Ibid.

[11] Ibid.

[12] Ibid.

[13] Personal communication with Cathy Dang, Restaurant Opportunities Center of Los Angeles, May 15, 2012.

[14] Gray BH, Consumer Operated and Oriented Plans (CO-OPs): An Interim Assessment of Their Prospects, Robert Wood Johnson Foundation and Robert Wood Johnson Foundation, August 2011, accessed at http://www.rwjf.org/files/research/72784qscoopfullreport201108.pdf.

[15] Personal communication with Jim Mangia, St. John’s Well Child and Family Center, May 7, 2012.

Los Angeles Is Moving

Learn about the  progress in Los Angeles County’s safety net systems transformations from the 2011 LA Health Collaborative executive summary.  Key points include:

  • Striving to create an integrated delivery system and become a provider of choice, LADHS aims to serve 500,000 patients by 2014 with a payer mix that includes 30% Medicaid coverage and services provided by county-operated health centers and the contracted community clinic network (Community Partners).
  • As the county’s safety net health plan, L.A. Care developed a new managed care partnership with LADHS, enrolled the SPD population in mandatory managed care, was awarded a federal grant establish HITEC-LA to assist providers in achieving meaningful use of EHRs, and established eConsult as an innovative peer-to-peer physician communication and referral system for county safety net providers,
  • Community clinics implemented a high level of innovation., such as pursuing PCMH accreditation from NCQA, developing benchmarks for PCMH elements to determine impact on patient outcomes, creating HIT infrastructure to advance quality improvement, improving patient flow and cycle time, and using patients as secret shoppers to evaluate and improve the patient experience and satisfaction.
  • Hospitals are expanding while becoming leaner operations, attempting to remain informed of ACA rules and regulations, and collaborating to identify ways to improve efficiency and work with scarce resources, such as collaborating with other agencies on developing a countywide health information exchange (LANES).

The full summary may be found here.  In addition, a fact sheet is available on a group initiated in the fall of 2010 to create strong, effective L.A. County partnerships to prepare local safety net institutions for federal health reform.

 

LADHS Primary Care Capacity Update

One of LADHS’ key accomplishments in 2011 was empanelling nearly 240,000 insured and uninsured patients into a medical home.   For the first time, these patients had an assigned primary care provider.  LADHS Ambulatory Care Network staff presented on the department’s primary care capacity set against a backdrop of future expansions.

LADHS empanelled 236,499 patients as of March 1 in the department’s health centers, comprehensive health centers, and hospital-based ambulatory care.  Having 140 FTE providers and using a panel size of 2,000 patients per physician and 1,500 per nurse practitioner, LADHS may serve up to 250,800 patients presently.  Estimated growth in demand for 2012 includes SPD beneficiaries (5,000) and Medi-Cal managed care assignments (27,000) through the relationship with L.A. Care Health Plan with 8% disenrollment rate (-2,560), which totals to 29,440 new patients.  However, the exact number of GR recipients that will convent to the local LIHP (Healthy Way LA Matched) is unknown, with this population having differing utilization patterns.  LADHS plans to begin auto-enrolling 82,000 GR beneficiaries into Healthy Way LA Matched starting in June with approval granted from State DHCS and DRA verification to be completed.  LADHS plans to expand current primary capacity by achieving systems efficiencies, implementing an in-house registry, and recruiting 10 new primary care providers by the end of the year, which will result in an additional capacity of 14,861 patients.  Therefore, LADHS will be close to meeting the projected increase in demand, with the exception of GR recipients.  Regional capacity differences exist among the ACN facilities, with empanelment ranging from 99% of overall capacity in the Antelope Valley’s High Desert MACC/health centers, 71% capacity in the MLK MACC/Humphrey Comprehensive Health Center, and 78% capacity in Roybal/Hudson/El Monte Comprehensive Heath Centers.

However, two significant barriers to hiring exist.  A shortage of primary care physicians nationally and statewide persists that results in a small pool of candidates.  LADHS loses many qualified candidates to Kaiser Permanente, which offers substantially higher salaries and an incentive bonus for additional language capacity.  With an acute need for bilingual Spanish-speaking physicians, LADHS’ planned strategies include providing a more competitive compensation package along with loan repayment, enhancing recruiting methods by effective advertising, and streamlining the application and hiring process.  While the numbers of patients assigned to a provider panel are typical of a managed care setting, LADHS’ panel size may require readjustment based on patient acuity and demand.  The panel size used by teaching hospitals and the VA is 1,500 patients per physician and 1,200 per nurse practitioner.  It is important to note that Community Partner clinic capacity is not factored in, although the billing and payment issues faced with Healthy Way LA Matched may preclude many CPs from hiring new staff and increase capacity.  Primary care residents training in programs specializing and located in underserved communities tend to select the public health care system and FQHCs as a place to work upon graduation.  The question regarding what will primary care look like in two years when full ACA implementation takes place is one with which LADHS and many other providers are grappling currently.