Legislators consider status of Medi-Cal mental health delivery system

In the first of a two-part series of informational hearings, the Assembly and Senate Joint Health Committees heard information on Tuesday about the status of the Medi-Cal Mental Health Delivery System. The purpose of the hearing is to unravel the workings of the complicated system and assess its strengths and weaknesses to find opportunities for improvement.

Catherine Teare, Associate Director, High-Value Care, of the California Health Care Foundation, began with an overview of mental health prevalence in California.

According to recent California Health Care Almanac Data, she explained that about 15 percent of California adults and experience some form of mental illness with up to 1/3 of those experiencing a co-occurring substance abuse issues. This incidence has been fairly constant over the last several years.  However, for children and adolescents the rate of serious emotional disturbance is higher than that for adults at 7.6 percent, and the occurrence of major depressive illness among adolescents has risen by around 50 percent.

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Speaking about access to mental health services, Ms. Teare laid it out bluntly:

 “I will say that the numbers are not great.”

She explained that only about one-third of adults with mental illness received treatment by some form of mental health professional during the prior year, which is lower than the national rate. Much more than any other types of health care services, mental health services are provided through public funding.

 

 

“I think we can all agree though that our system does not always make it easy for people to access the care that we need. And that California can do better and can do more,” said Teare.

The Committees also heard information on the Medi-Cal Mental Health Delivery System, including financing.  Jennifer Kent, Director of the Department of Health Care Services (DHCS), explained that the state’s 24 managed care programs provide services for 11 million Californians with mild to moderate mental health needs and interact with 56 county mental health plans, which also provide care through specialty mental health plans for more serious mental health diagnoses.  All of this is financed through a variety of fund sources which are often “braided” together.

 “There’s a lot of complexity [to mental health funding]. I cannot stress enough that this is probably the most complex areas of the programs that we administer,” emphasized Kent.

The Legislative Analyst’s Office (LAO) explained that the bulk of mental health funding, approximately $7.9 billion, goes to county based mental health services for more severe mental health services, wrap around, and safety-net services, with an additional approximately $2 billion applied to Medi-Cal Managed Care and Fee-for-Service programs. Of this, a little less than half, or $4.3 billion comes from federal funds and the remainder comes from a mix of state and local funding sources.

 

Source: County Behavioral Health Directors Association

 

Dr. Amie Miller, BH Director for Monterey County and CBHDA President Elect, spoke to some of the complications in coordinating and funding mental health treatment. She highlighted a major difference between mental and physical health as the difficulty measuring severity, which is linked to billing/funding, as people often fluidly move through the continuum which shifts funding sources available.

Jennifer Kent also noted that since California instituted the mild to moderate mental health benefit in Medi-Cal Managed Care plans, DHCS has been tracking utilization and the uptake has been huge. Since 2013, youth and adult utilization has grown by over 550 percent or from 32,000 adults to close to 187,000 and 13,000 youth to 73,000.

Kent and Miller continued to discuss quality of care measurement within the system, including information on Quality Improvement and Performance Metrics as well as network adequacy and timeliness of care. As a county mental health professional, Dr. Miller explained that important questions she asks revolve around whether her programs inspire hope, increase safety, reduce inequity, reduce stigma, and empower families to meet the needs of the most vulnerable people in California.

Active questioning from the Committee including questions regarding management or tracking of patients as they move through the continuum of care, the prevalence of telehealth usage and policies, and how the quality of care and patient satisfaction data is collected and measured.

Assemblymember Jim Wood summarized by asking Director Kent,

“So from your perspective what are the top issues that you see consistently?”

Kent responded:

  1. Child psychiatrists are excessively hard to access, which is concerning from both an access and prevention standpoint.
  2. Transportation – which she hopes is being addressed now that Medi-Cal managed Care Plan have been directed to pay for transportation regardless of whether they are actually paying for the service, or not.
  3. Crisis stabilization and intervention since often the services provided county-by-county don’t sync up with the times when mental crises most often occur and services are not always mobile so as to best serve those in most need.

The next round of hearings is scheduled for Tuesday, March 5th at 1:30 pm. Legislators are scheduled to hear more about suggestions for improving the Medi-Cal Mental Health Delivery System moving forward.

You can view the entire hearing here and access materials, including slides and reports, here.