SUMMARY REPORT

MEETING 19

Date: Wednesday, January 23, 2013

Time: 1:15 PM –2:15 PM

Location:CADPAAC Quarterly Meeting in Sacramento

Hosts: UCLA Integrated Substance Abuse Programs (ISAP) & CA Dept. of Alcohol and Drug Programs (ADP)

Topic: ADP-UCLA Integration Survey Results for 2012

Presenter:Darren Urada

UCLA Integrated Substance Abuse Programs

Review of ILC Meeting 18

UCLA ISAP

  • The eighteenth ILC meeting, conducted on November 28, 2012, provided a preliminary look at hot topics from the Integration Survey. Special thanks to those who participated in our open-table discussion and contributed theirthoughts to the group. We appreciate your continued involvement and support.

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 February 27, 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 19 Topic:

ADP-UCLA Integration Survey Results for 2012

Topic Introduction

  • In today’s learning collaborative, Dr. Urada will discussthe results from our recent 2012 Integration Survey, conducted by UCLA and ADP as a follow-up to the 2010 Integration Survey. Surveys were sent to one AOD administrator in each county and asked about the integration of SUD services with mental health and primary care.We saw an increased response rate in 2012 over 2010, so thank you to everyonefor your efforts in completing the survey! Your responses will help us determine training needs and evaluate progress towards integration across the state.

Definitions and Abbreviations

  • Substance use disorder (SUD): Refers to problems with alcohol and other drug (AOD) use that have been diagnosed and require treatment.
  • Behavioral health providers (BHPs):County or county-contracted individuals who provide mental health (MH) or AOD prevention, treatment, or recovery support services.
  • Integration:Any type of routine or standard AOD/SUD screening, referral, intervention or treatment conducted in a primary care setting, any primary care services conducted in an AOD/SUD setting, or bidirectional referrals. May also refer to the inclusion of AOD/SUD primary prevention or recovery support services in primary care settings.
  • Primary care (PC): Routine health care focusing on the prevention and early detection of health problems through regular physicals, blood pressure tests, mammograms, and similar procedures. Services may occur in a physician’s office, health center, or other locations. Primary care is the first (primary) point of medical consultation for patients, but may result in referrals to specialty care.
  • Federally-qualified health center (FQHC): Community-based health centers that receive grant support through the Health Resources and Services Administration (HRSA) and can receive enhanced Medicaid rates.
  • FQHC-lookalike: Community-based health centers that meet all of the requirements of an FQHC and can receive enhanced Medicaid rates but do not receive grant support through HRSA.

Darren Urada, PhD

UCLA ISAP

Survey Findings: General Ratings of Integration

  • AOD integration with PC or MH:In 2010, 57% of respondents agreed that behavioral health providers (BHPs) in their county were currently working to integrate AOD services with primary care or mental health. In 2012, 90% agreed.
  • 2012 Breakdown: Integrating with whom? Most respondents agreed that BHPs in their county were working to integrate with both primary care and mental health, while smaller percentages agreed that they were integrating with just primary care or just with mental health within a primary care setting.
  • 2010/2012 Comparison: If no integration, any planned? Among counties in 2012 that reported no integration, 3 stated that they were planning to integrate in the future, 1 said they were not, and 3 did not know. Compared to 32% of counties who weren’t doing integration but were planning to do integration in 2010, 43% in 2012 stated that they weren’t doing integration but were planning it in the future.
  • PC services in SUD programs:In 2012, 31% of respondents agreed that primary care was being integrated into AOD specialty treatment. This was defined as SUD treatment providersother than narcotic treatment programslicensed to have an on-site medical professional who provides primary care services such as physical exams to patients. In 2010, only 25% agreed to the same. The increase from 2010 to 2012, while present, was small.
  • AOD services in PC settings:In the other direction, we asked whether AOD services were being provided in primary care settings. These services included SBIRT, primary prevention, or recovery support services. The percentage of those agreeing changed from 23% in 2010 to 45% in 2012.
  • 2012 Breakdown: 31% agreed to treatment being provided in primary care, while smaller percentages agreed to primary prevention and recovery support services being provided in primary care.
  • Distribution of AOD services in PC settings: A lower percentage reported that AOD services were provided in no primary treatment services in 2012 than in 2010. A higher percentage reported that AOD services were provided in more than 25% of primary care settings in their counties.
  • Types of PC settings providing AOD services: A great majority of primary settings providing AOD services were FQHCs and FQHC-lookalikes. Some non-FQHC community health centers were reported as providing AOD services and small percentage of private physician offices and private clinics were reported as offering AOD services.
  • Types of AOD services offered in PC settings: Most common services are routine screening and brief interventions for drugs and alcohol, as well as case management.
  • PC in SUD versus AOD services in PC: In 2012, a greater percentage of respondents reported integration of SUD services into primary care (45%) than those who reported integration of primary care services into non-narcotic treatment program SUD treatment providers (31%).
  • Ratings of PC and AOD integration: In general, ratings of AOD/PC integration activity increased in 2012 over 2010. Many more respondents reported actual engagement in integration initiatives, while fewer reported no integration-related activity whatsoever.

Survey Findings:Funding, Service Delivery, and Barriers

  • Funding sources: MHSA/Prop 63 funds were the most commonly reported source of funding for integrated AOD services in primary care, while Medi-Cal and self-pay were the most common sources of funding for primary care services in SUD treatment.
  • Private insurance billing:In 2012, half of respondents reported that 25% or less (or none) of their county’s SUD treatment providers were currently billing private insurance for AOD services, showing a possible increase in private insurance billing over 2010.
  • Service delivery models: The pattern of responses showed that, where SUD services were present in PC settings, they tended to be better-integrated, with a fully integrated model. Medical services provided in SUD treatment settings tended to follow a co-located model rather than full integration.
  • Structure of county BH and physical health services: No notable changes were apparent between 2010 and 2012. The majority of counties in 2012 had BH services (MH and SUD) under one department/agency and health services in a separate department/agency. In about a quarter of counties responding, all three services were served by a single department/agency.
  • Barriers to integrating AOD with PC:The same pattern of problems were found in both 2010 and 2012. Financing remained the largest barrier, followed by documentation and partnering with primary care providers.
  • Safety net programs: A majority of respondents agreed that their counties were involved with safety net programs in preparation for 2014. Projects included CMSP, LIHP, Path-2-Health, Dual Eligibles, and others.
  • Training needs: Respondents were very interested in trainings on the topic of integration with health care: integration strategies, chronic disease associated with SUD or MH, and working in the health care system. These survey responses will be used to help guide the PS-ATTC in developing its training offerings.
  • Integration Learning Collaborative (ILC): A majority of respondents were interested in participating in further discussions through the monthly ADP/UCLA learning collaborative. Many volunteered to present their own experiences in future ILCs.

Conclusion

  • While a few counties have not yet begun the process of integrating AOD services with mental health and primary care, many others have reported progress in their integration initiatives. Going back to our main questions: have everyone’s efforts paid off and are we now ready for integration and health care reform? Maybe not quite yet, but we’re moving in the right direction. ADP and UCLA are prepared to offer training and technical assistance to aid counties every step along the way.

Discussion:

Topic – Billing

  • Percentage of SUD treatment providers billing private insurance:CADPAAC attendees discussed and interpreted this survey question. Due to the complex issues involved, the results from the survey reflected educated guessing from respondents. Some of these issues are described below.
  • A new requirement from Drug Medi-Cal requires providers to first try to bill private insurance even though they may not be paid.
  • Though they may not be reimbursed, SUD providers still must attempt to bill private insurance in order to receive the denial necessary for them to bill Drug Medi-Cal. This practice was referred to as “waterfall billing”.
  • Kern County found another related issue in that, due to parity laws, private insurance companies would often be reluctant to issue the denial which would allow providers to bill Drug Medi-Cal. Instead of choosing to pay or deny the claim, the companies would simply not respond.
  • Overall, private billing presented a large challenge for providers.
  • San Mateo County providers have been working to increase their capacity for private insurance billing and trying to learn how to request authorization, demonstrate medical necessity, etc. However, not being part of the preferred provider network presented substantial challenges and few were successful. Many providers found that their staff lacked the proper licensure to bill for service, which was another barrier. Overall, it took a lot of effort to get limited benefits.
  • Another county’s providers were able to get the right staffing in order to do private billing. The providers also had contracts with Kaiser and were part of the network, which enabled them to bill. Still, others were unable to bill or were only able to get a few things reimbursed.
  • A few providers who have been able to successfully bill private insurance included some in Los Angeles and Sacramento.
  • Tarzana, the largest provider in Los Angeles County, has contracts with the insurance companies (Kaiser, Anthem Blue Cross) that allow them to bill private insurance. The other providers in the county are working with Tarzana in order to learn how to become part of a network, but it’s still difficult.
  • Sacramento County has providers that are very large and provide many levels of service. Some of these have been able to apply to become FQHCs, which makes it much easier to bill due to their FQHC status.
  • Smaller providers, however, particularly those that are only providing one type of service, continue to struggle with insurance requirements.
  • Billing Medicare for AODservices: A small percentage of survey respondents (9%)reported that their countieswere using Medicare to pay for AOD services in primary care. Medicare does pay for certain AOD services by covered providers, although some of those servicesare not provided in primary care. In inpatient acute and acute psychiatric hospitals, Medicare covers detox and treatment of drug abuse. In outpatient settings, it covers SBIRT, group or individual counseling by qualified clinicians, sub-acute detox in residential programs, intensive outpatient services, extended-release naltrexone, and Vivitrol.

Topic – UCLA/CiMH Collaboration

  • It was recognized that greater collaboration is beginning to occur between the mental health and substance use fields and has positive implications for integration of care. Both fields recognize the importance of the other and both could benefit from having shared discussions to learn from oneanother.Dr. Urada regularly participates in the CiMH learning collaborative and has spoken in one of their learning sessions about SUD.

Topic – Survey Comments

  • County department structure: Although county structure was used in the survey as one indication of PC/MH/SUD integration, a consolidated county department does not necessarily mean that services are integrated. For example, in one county, primary care, mental health, and AOD all fall under a single department, but remain in separate silos and do not generally communicate. Mental health and AOD are working on integrating with each other first before approaching integration with health care services.
  • Potential survey bias: With greater political and economic pressure on counties to integrate PC/MH/SUD, while lackingstrong guidelines for what that integration should look like in practice, respondents may be subject to agreement bias when asked whether integration is occurring in their counties. Counties also vary in size and structure, with some depending heavily on contracted services and others not, which could affect the knowledge and perceptions of survey respondents.
  • A suggested improvement for future surveys was to ask multiple individuals in each county and try to get consensus from their differing perspectives, which could allow a more accurate picture from each county.
  • Because the current survey used a broad definition of integration, however, the definition was more flexible to fit the needs and resources of California’s diverse counties. It is still important to incorporate multiple types of integration activity because what works in some counties may not work in others.

Topic – Integration Models

  • Integration of PC into SUD treatment settings:In the survey, 31% of respondents agreed that their counties have integrated primary care into SUD treatment settings. These include San Francisco County, Los Angeles County, and others. Their providers are separately but simultaneously licensed to be treatment programs and community health centers.
  • These efforts show support for use of thehealth home model for patients who regularly receive services from these specialty clinics.
  • Continuing care:Several aspects of designing integrated models for continuing care were discussed and are listed below.
  • Screening and brief intervention in primary care
  • Determining levels of needed care (Four Quadrant Model)
  • Referral to and continuing importance of specialty treatment
  • Emergency care crisis support services
  • Documentation and confidentiality
  • Case conferencing and care coordination

FinalNotes

  • Thank you to Dr. Urada forgiving us an update on California’s counties as we continue to movecloser to health care reform and AOD, mental health, and primary care integration. We would also like to thank our survey respondents for their time and effort, and we especiallyappreciate the thoughtful comments and suggestions of everyone who contributed to the discussion.
  • The next ILC meeting is scheduled on Wednesday, February 27, 2013 at 11:00am.
  • Please remember to reference the website which holds all information and materials disseminated from the ILC:

APPENDIX1– Agenda and Relevant Materials

  • Overview of Meeting 18
  • Introduction
  • Topic Discussion – ADP-UCLA Integration Survey Results for 2012
  • Q and A

Materials for this meeting

  • PPT Presentation – Integration Survey Results

Copies of materials can be found at UCLA ISAP’s ACA Resources Website: