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Typology: Summaries
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Darren Urada, Ph.D., Anne B. Lee, LCSW, Brittany Bass, Ph.D., Cheryl Teruya, Ph.D., Valerie P. Antonini, M.P.H., Vandana Joshi, Ph.D., Howard Padwa, Ph.D., Elise Tran, B.A., David Huang, Ph.D., and Isabel Iturrios-Fourzan, M.A.
Executive Summary
The Drug Medi-Cal Organized Delivery System (DMC-ODS) 1115 demonstration waiver was created by the California Department of Health Care Services with the intent of improving the way substance use disorders (SUD) treatment is delivered in the state. As of July 1, 2020, DMC- ODS had been implemented in 37 counties containing the vast majority (95.9%) of California’s population, but 21 small or small/rural counties are not participating. In participating counties, the DMC-ODS waiver has improved access to treatment, treatment quality, and coordination of care, but many challenges and opportunities lie ahead.
Access to Care
Compared to State Plan counties, the introduction of the DMC-ODS waiver significantly increased the number of people receiving DMC-funded services in waiver counties by 18.3 percent. Across all funding sources, there was not a significant effect on admissions immediately upon implementation, which suggests some of the initial increase in patients receiving DMC-funded services may have been attributable to existing clients changing funding sources to DMC. However, seven or more months after the introduction of the DMC-ODS waiver, the number of unique patient admissions did significantly increase by nearly 30 percent. Some evidence also suggested an increase in the number of treatment providers occurred from 2016-2020. County administrators and patients generally gave positive ratings to treatment access under the DMC-ODS waiver. Still, treatment penetration rates (5.0%) decreased somewhat due to an increase in estimates of treatment need. However, the penetration rate among those who think they need treatment was estimated at 55.2%. Data suggest access challenges specifically for youth and narcotic treatment programs. Use of the DMC-ODS recovery services benefit seems to be hampered by confusion over the benefit.
Recommendations
all have the capacity to collect this data and analyze it. Providers indicated that starting early, getting client buy-in about engaging in the continuum of care, eliminating the concept of “graduation,” and having formalized relationships between providers are significant factors toward successful transitions. In addition, having staff conduct warm handoffs, facilitate the communication/information exchange, and complete the required paperwork are also essential.
Utilization of the case management benefit remains low (9.5%). Consistent with this, stakeholders report that case management is often delivered but not billed due to confusion over billing and documentation requirements. Case management may be a useful tool to facilitate better integrated and coordinated care, but technical assistance to better utilize and bill for this service is needed.
Recommendations
COVID-19 and Telehealth
The COVID-19 pandemic caused a rapid shift from in-person services to telehealth. Both counties and patients reported high satisfaction with its use. However, significant barriers exist, specifically patient access to reliable internet services and tablets/phones. Also, early data suggest flexibilities related to take-home medications may have increased retention among methadone patients without increasing fatal overdoses. Counties want to continue this service, plus the use of telehealth past the COVID-19 pandemic. Furthermore, DMC-ODS waiver counties indicated that COVID-19 had an impact on the need for recovery residences, with counties citing the lack of availability to insufficient housing and bed supply.
Although these recommendations require funding, the COVID-19 relief bill passed in December 2020 provided expanded funding of the Substance Abuse Prevention and Treatment Block Grant that could be used to implement these recommendations.
Recommendations
Lessons Learned for Future Regional Models
Stakeholders appreciate that the Partnership HealthPlan of California’s Wellness and Recovery (PHC W&R) Program covers all three service systems (PH, MH, SUD) and can do rapid triage to each with much-improved ability to follow through on care coordination. They are finding the program facilitates timely access to the most appropriate level of care. However, PHC W&R program administrators struggle with the varied regulatory requirements for SUD, MH, and PH. Additionally, there are challenges with perinatal services as perinatal services must be delivered in the county of residence. Stakeholders also appreciate the flexibility to provide contingency management and provider incentives under the program. An additional benefit of the program is that it offers significant administrative support for all the requirements of the DMC-ODS waiver. Importantly, discussions with PHC suggested a regional model like PHC W&R is only feasible in one-plan counties or County Organized Health Systems (COHS). In counties with multiple managed care plans, it is likely that the coordination required would be overwhelming.
Recommendations
What State Plan Counties Would Need to Join DMC-ODS
State Plan counties have a perception that there are many unfunded requirements in the DMC- ODS waiver, which has prevented them from joining the DMC-ODS waiver. Also, most State Plan counties do not have a full continuum of SUD care within their counties.
Recommendations
Stakeholders report that insufficient funding for recovery residences (RR) and transitional housing (TH) create challenges serving PEH, as does the limited availability of RR/TH beds in their communities. The dearth of housing options for patients when they transition out of care (and are no longer eligible for RR/TH) remains a challenge as well.
Recommendations
DMC-ODS Stakeholder Feedback on Current Waiver Requirements
Based on county and treatment provider feedback, major implementation challenges include clarity of guidance, requirements and funding, and consistency of policies between counties.
Recommendations
Figure 1.1 Map of California counties participating in the DMC-ODS waiver as of January 1, 2020.^1
(^1) DHCS and the EQRO use county codes which assign a number to each county ordered alphabetically. For consistency with this convention, maps within the report use this numbering system.
DMC-ODS waiver counties – non-PHC (n=30)
DMC-ODS Waiver counties – PHC regional model (n=7) 1 Alameda 12 Humboldt (PHC) 7 Contra Costa 18 Lassen (PHC) 9 El Dorado 23 Mendocino (PHC) 10 Fresno 25 Modoc (PHC) 13 Imperial 45 Shasta (PHC) 15 Kern 47 Siskiyou (PHC) 19 Los Angeles 48 Solano (PHC) 21 Marin 24 Merced 27 Monterey State Plan counties (n=21) 28 Napa 2 Alpine 29 Nevada 3 Amador 30 Orange 4 Butte 31 Placer 5 Calaveras 33 Riverside 6 Colusa 34 Sacramento 8 Del Norte 35 San Benito 11 Glenn 36 San Bernardino 14 Inyo 37 San Diego 16 Kings 38 San Francisco 17 Lake 39 San Joaquin 20 Madera 40 San Luis Obispo 22 Mariposa 41 San Mateo 26 Mono 42 Santa Barbara 32 Plumas 43 Santa Clara 46 Sierra 44 Santa Cruz 49 Sonoma 50 Stanislaus 51a Sutter 54 Tulare 51b Yuba 56 Ventura 52 Tehama 57 Yolo 53 Trinity 55 Tuolumne
Darren Urada, Ph.D., Vandana Joshi, Ph.D., Cheryl Teruya, Ph.D., Brittany Bass, Ph.D., Anne B. Lee, LCSW.
Evaluation Questions and Hypotheses
Evaluation hypotheses are organized into the following four categories:
Access to Care
Beneficiary access to treatment will increase in counties that opt into the DMC-ODS waiver compared to access in the same counties prior to DMC-ODS waiver implementation and in comparison to access in counties that have not opted in.
Quality of Care
Quality of care will improve in counties that have opted into the DMC-ODS waiver compared to quality in the same counties prior to DMC-ODS waiver implementation and in comparison to quality in counties that have not opted in.
Costs of Care
Health care costs will be more appropriate post-DMC-ODS waiver implementation compared to pre-implementation among comparable patients; e.g., SUD treatment costs will be offset by reduced inpatient and emergency department use.
Integration and Coordination of Care
SUD treatment coordination with physical health (PH), mental health (MH), and recovery support services will improve.
Evaluation Design
The evaluation uses a mixed-methods design that takes advantage of different comparisons based on the measure in question.
As discussed in the approved evaluation plan, administrative data from Drug Medi-Cal (DMC) claims and CalOMS-Tx was used for a difference-in-difference design (conceptually equivalent to a multiple baseline approach) to account for different county implementation periods, consistent with CMS recommendations for strong evaluation designs.^5 This approach essentially combines pre-post comparisons and comparisons across counties to test whether changes are detected when counties “go live” but not at the same time in other counties. In other cases (e.g.,
(^5) Reschovsky, J.D. and Bradley, K. (2019). Planning Section 1115 Demonstration Implementation to Enable Strong Evaluation Designs. Available at: https://www.medicaid.gov/medicaid/section-1115-demo/downloads/evaluation- reports/enable-strng-eval-dsgn.pdf
Evaluation Period
The first DMC-ODS waiver counties began implementation on February 1, 2017, and new counties continued to join through July 1, 2019. The implementation period being evaluated is therefore best described as February 1, 2017 through the end of the DMC-ODS waiver, currently scheduled for December 31, 2021. A pre-waiver period extending back to CY 2015 is used where data sources allow (administrative data, County Administrator Surveys).
Evaluation Measures
The following measures are included in this report. For a fuller description of these measures, see the Evaluation Plan.^6 Due to data availability, not all measures described in the evaluation plan are included in this report. In particular, cost measures are not included because Medi-Cal Managed Care/Fee for service data was not available in time for this report. In other cases, additional measures that were not originally in the evaluation plan have been added.
Access Measures
Quality Measures
(^6) California Drug Medi-Cal Organized Delivery System: Proposed Evaluation for California’s Section 1115 Demonstration Waiver. http://www.uclaisap.org/dmc-ods-eval/assets/documents/DMC-ODS-evaluation-plan- Approved.pdf (^7) MAT is commonly referred to as Medication-Assisted Treatment. Wakeman (2017) argues this contributes to stigma by treating addiction medications as secondary, and different from medications for other conditions. We therefore use the more neutral term Medications for Addiction Treatment. Wakeman (2017). Medications for Addiction Treatment: Changing language to improve care. Journal of Addiction Medicine. 11(1):1–
Coordination/Integration Measures
Each measure draws on different data sources, described below. UCLA is generally the steward of these measures, except for engagement (NQF #0004).
Special Topics
In addition to the main evaluation measures above, this year’s report focuses on several special topics that add additional context around current practices and which can potentially help improve future implementation of the DMC-ODS waiver. Interviews, survey items, and administrative data are used to provide information on:
Data Sources
Administrative data sources
CalOMS-Tx is California's existing data collection and reporting system for all patients in publicly-funded SUD treatment services. Treatment providers collect information from patients at admission and discharge and send this data to DHCS each month. CalOMS-Tx provides
