Senate Standing Committee on Health

Say I need to give another 10-second warning for those who weren't paying attention the first time. So 10 more seconds, then we'll start. The Joint Informational Hearing of the Senate Health Committee and the Senate Budget and Fiscal Review Subcommitee No. 3 on Health and Human Services will convene. Today, we will be reviewing the state's progress on reforming Medi-Cal's behavioral health delivery systems through the CalAIM Behavioral Health Initiative.

As all of you know, I'm certain, the CalAIM initiative was originally proposed in about 2019 and was ultimately launched around 2022, contained a variety of policy changes designed to improve quality outcomes, reduced health disparities, simplified the process, and achieved behavioral health payment reform, among other changes. This afternoon, we will hear from representatives from DHCS who will provide updates on how the implementation of the CalAIM initiative is progressing.

We will also hear about the implementation, its successes, and its challenges from the perspective of counties, from providers and healthcare consumers. We will also provide the public and welcome the public and provide access, public participation and access during this process. Before we begin with the actual presentations, I want to give the opportunity to those to my right to present their perspectives. First, the immediate past chair of this Health Committee and someone who knows infinitely more about CalAIM and a variety of other healthcare subjects than I do, Senator Susan Eggman.

Thank you, sir. Senator Roth is very generous, but I'm glad to be sitting here by these two folks' side today as we talk about--I think one of the biggest things that we're doing in California, especially as it relates to behavioral health care, is the CalAIM program. So I'm excited to get an update about it. I'm excited to hear both from the department's perspective, how things are going.

I know we've just done a lot of data collection, and as it relates, of course, to the access criteria. How is that coming along, as it relates to...? I'm especially interested--and as I have, I've been talking a lot about mental health, especially around the state. And as we talk about CalAIM as being a central component of our entire continuum of care, specifically, how is that no-wrong door working out?

We keep hearing things about people not being in the right place at the right time or not understanding how to bill for certain services. And as we move into talking about SB 43 as well, and that implementation, we've heard a lot from the counties about not having enough direction about how to do those kinds of things. And I'm wondering where no-wrong door comes into that discussion and dialogue. Want to know about how the screening tools are doing, and of course the billing.

As somebody who's been a practitioner for a long time, and we know everybody's complaints about billing and documenting every couple of minutes. So as we did this massive transformation, how is that actually going? Are we actually seeing more people? Are we actually having better outcomes? And are providers understanding the requirements that they need to follow in order to get reimbursed for those services? So I know the department is prepared to talk about all those things today.

We're just excited to hear both from you, as then as well as those who are on the ground trying to implement at the same time. So I'm looking forward to the conversation today and the information that we'll receive. Thank you.

Thank you, Senator. And now our Chair of Budget Sub 3, Senator Menjivar. Any comments?

Thank you so much. I'm just happy to be in this sandwich of-

-Out members. That's what she means.

-legislators who really set the foundation for this to my left and to my right. And I think here in the Senate on the health space, this trio has been really at the forefront of a lot of these issues. And I'm looking forward to, I think on the billing, what Senator Eggman mentioned, is one of my key points also and additionally CalAIM and how we're going to take advantage of this and helping the needs of our juveniles and the justice system.

I know that's something that's going to be tied in directly to help further move towards a care versus a jail first model and then addressing the recidivism rate. During tours of my district with providers, the billing thing is what came up often. And then I'm also interested as to how we are in different counties where some counties are offering one service and the other counties are offering another service.

I'm excited when I got the numbers that the number one service being paid out is housing navigation, which is really phenomenal. I'm also excited about the amount of money that we've helped on deposits for housing deposits and so forth, and looking to see how we can further expand that, seeing as we know that these are helping with preventative measures. So with that, kick it back to you, Mr. Chair.

Thank you, Senator. Let's welcome our first panel, Michelle Baass, Director, Department of Health Care Services and Brian Fitzgerald, Division Chief, Local Government Financing Division. Welcome. Thank you for joining us. Look forward to the presentation.

Good afternoon, Chairs and members. Michelle Baass, Department of Health Care Services. And thank you for the opportunity to provide an update on the behavioral health components related to CalAIM. As you know, CalAIM is a multi-year effort to improve the quality of life and health outcomes of our Medi-Cal members by implementing broad delivery system reform and payment and program reform across the Medi-Cal program. The behavioral health components of CalAIM are designed to support a whole person integrated care, move the administration for some of the behavioral health to more consistent and streamlined approach, reducing complexity and adding and flexibility for our county partners, thereby improving quality and reducing health disparities.

The initiatives collectively aim to ensure that counties and providers are able to effectively and efficiently coordinate care s members really are not in the mix there. They really have access to timely care and really have kind of the provision of streamlined care as well.

Many of these initiatives launched in 2022, however, we know that implementations will take us through 2027. This is a multi-year effort, really fundamentally changing the delivery systems, both the county behavioral health side and the managed care side as well. We've comprehensively engaged with our stakeholders--and as I go through through each of the components--really came out with some policies at the beginning and have taken in feedback to iterate and do continuous quality improvement as we continue to roll out the policies and further implementation. All of the initiatives-

Mr. Chair, is it all right if we ask a question here or there?

Absolutely. I actually prefer that, if you don't mind.

Yeah. I think just in our very assumptions of the county's handling some and the plans are others. Right? Is that part working? Right? Is that the best that we can do? Are we finding through this implementation?

Well, I think a lot of it is really having conversations on some of these specific policies--like no-wrong door, for example, the screening and access criteria--having really specific policies to work through, to build in some of those partnerships and really kind of the transitions or the hands-off and kind of really trying to take the member out of that experience.

And I will say even just through our conversations, we have a member advisory committee that we started last year, and just hearing directly from our members about those experiences and then bringing those experiences to our plans and county partners about: this is still happening. Right? We still have issues to address and just trying to continue to work through it. It's not going to be solved overnight. It's going to take time because these processes are so entrenched, but really trying to even use just live examples that we hear and try to triage with our partners.

Okay, so, so far we think that's the best delivery model; separating those two things as we have?

It's kind of the model that we have today, and so how do we best kind of implement those connections and partnerships?

Okay.

So maybe I'll start with documentation redesign. This is one of the key components of our behavioral health initiatives as part of CalAIM. This included efforts to streamline and simplify documentation standards for our providers. Really, prior to launching this effort, requirements for assessment, treatment planning, and documentation varied across delivery systems and funding sources as well, and across different facility types.

Some of these are really outdated processes and procedures that have been in place for many years and hadn't been revisited in a long time. And so part of that was we initially provided guidance in 2022 regarding this redesign, and again, the goal was to really reduce that kind of administrative burden and several actions were implemented. We worked with our stakeholders to provide that initial feedback. Again, that was in 2022.

And as we were tracking implementation efforts and just kind of understanding areas that maybe we weren't tracking, for example, some federal requirements that really also were burdensome to our providers, we continued to kind of iterate through this, and we ultimately received two federal waivers, essentially, from federal agencies to further streamline some of those federal requirements.

We continued our discussions with our providers and our plans and then implemented additional guidance in 2023 to really kind of re--what we've learned and how we've addressed some of those changes. It represents really over three years of feedback as the counties and providers continue to implement that. So we, again, continue to take in feedback, but really are trying to learn as we are changing some of these fundamental principles and policies that have been in place for a very long time.

And when you say we, right, this is from the department, and how are we measuring the integration down to the county levels?

I have kind of a little about, we did a qualitative survey of our counties, our plans and our partners, and maybe I'll go through all of the findings after I present. Does that work? Okay, but we have some qualitative assessment, and we are also trying to work on quantitative using data, claims data, for example, in some of these areas to understand, but we don't have that data yet.

Okay, Director. And you spoke about perhaps some of the providers using antiquated process for documentation and so forth. So I would like to ask, because I'm still hearing some providers, that some of the documentation, they still are collecting it manually, for example, like the behavioral screening is done manually, it's causing further burden to then upload it. So I'm wondering what TA we're providing and if we're really standardizing across counties where we're still hearing some providers on the local level still having difficulty with.

That document, this is going to take a while to fully implement. Right. For us to be able to get down to every single provider, it's not really feasible for the state to take on that role. And so really working with our counties and some of our TA assistance folks to kind of help on that.

But it is a matter of, as we learn, we do try to address, but it is one of the big things with CalAIM, it's reaching communities and kind of different CBOs and partners who haven't, and this may be a little bit different, but haven't necessarily been part of the healthcare delivery landscape. And so building out those connections and building out kind of the lines of direct communication on how to do that, we are thinking about how do we build out our TA?

It's something we're not really resourced to do, but how do we build out TA, really the direct engagement with the Department and providers?

My second question regards data collection, and I'm barely diving into all of this and please educate me on this aspect. And as we standardize documentation and potentially maybe we're assuming that we're removing some extra things that's not needed, trying to make it as streamlined as possible.

But what, if any, have we heard regarding some documentation that is hard to obtain that is impacting providers when they need to submit that up because it requires them to do human effort, or better known as man hours, to find this information from their clients staff hours?

I'm not tracking that concern, so maybe I can follow up if you have more information on information that we're now requesting that maybe we hadn't requested before.

The reason I bring this up, sometimes the numbers aren't correct in either screenings or the medical profile of the patient. That is requiring a lot of providers to have to go really literally investigate where they are to get more information to submit on some of these documents.

Okay, maybe I can follow up with you. I'm not tracking this issue, Madam Director.

My backgrounder indicates that some of these new standardized procedures don't apply to some aspects of the behavioral health system. Fee for services. Did I read that right?

So the documentation redesign piece that I just mentioned. So just this piece right here applies to county behavioral health departments. So the county essentially managed care plan, this does not apply to fee for service.

Does that create any difficulties?

It's a different delivery system. Essentially. Medi California is kind of in the behavioral health space, and the line essentially is non specialty behavioral health. So mild to moderate. And in the specialty, it's kind of more severe in the mental health side for adults. And then in terms of substance use, managed care and fee for services, really, besides some high level screening, it's really provided in the county side, and that's.

Why I asked before, is that the best way for us to be providing this? And I think they're still finding out.

The split between specialty and non specialty has been in place for a while now, and this is all part of realignment and how we've obligated counties to be part of the specialty mental health and drug medical side of the delivery system.

I got it. Thank you.

Okay, so the next policy to maybe quickly talk about is the No Wrong Door for mental health services. We implemented this, what we call just the No Wrong Door, but it is for mental health services, really to clarify the responsibilities between, again, the county mental health plans, which is more the specialty side, more the severe kind of side for the adults, and the managed care side, which is the mild to moderate non specialty services.

And so this policy seeks to facilitate the coordination between these two different delivery systems so that an individual, no matter where they show up, has access to services, really regardless of where they show up initially seeking care. So under this policy, members can go through the assessment process even before a diagnosis is established. So it really shifts the policy so that members receive timely mental health services as soon as possible and not really dependent on a diagnosis or kind of being in the right delivery system.

Again, really, the goal of this was to streamline the experience for the ,ember so wherever they showed up, they could get the services and treatment they need. Part of this is really clarifying, and a lot of this is about the kind of the financial responsibility between the two systems. So we clarified that services are covered and reimbursed even when they are provided prior to someone being determined what the diagnosis codes might be and prior to determining kind of medically necessary criteria.

Again, this means if someone receives an assessment from a county mental health plan for specialty mental health services, all services provided during that assessment period will be reimbursed even if the member does not meet specialty mental health criteria. So again, really trying to take the member out of the split between the two delivery systems. As noted above, we allow for concurrent treatment from both delivery systems. So again, county mental health and managed care for members who meet the criteria for both of the systems.

And so, just as an example, if a member has been seen a therapist through their managed care plan and their needs continue to escalate, and they receive a referral to the county behavioral health plan, they can continue to see the provider with whom they've had built that established relationship so long as the services are coordinated and not duplicate.

And this is really in particularly important for our children and youth, where kind of that bright line between the services is not necessarily as clear as it is for the adults. This policy also clarifies that mental health services are covered and reimbursable even if a member has a co-occurring substance use disorder need, as long as, again, they are coordinated and not duplicated. So we issued what we called behavioral health information notices outlining these policies back in 2022.

And again, we continue to revise and really think about these policies as they get implemented and trying to learn as counties and managed care plans have these experiences.

If I may, sir. Director, looking forward or not even looking forward, we feel like we're getting to the place where even if you're having some emotional issues, you want to go for counseling all the way to being admitted to a secure facility. There doesn't need to be any pre ops for any of that. So again, I'm getting a lot of questions on the implementation of SB 43 and how people are going to be able to bill for that, right?

So if we're talking about No Wrong Door, wouldn't that applied in the same.

No Wrong Door really was specific to mental health because of the specialty mental health criteria versus the mental health, the non specialty mental health criteria, substance use only is really county behavioral health plan kind of responsibility. Again, managed care plans have very light, more assessment or screening obligations there. And so I think inpatient, that is especially mental health criteria, and they need to make sure that they meet the kind of the criteria to achieve inpatient admission.

Okay, I think we'll talk more. Okay.

How is the reimbursement actually working? Because there are different funding streams. So is that working smoothly, seamlessly?

I haven't heard any issues with the funding to this initiative.

Okay.

The next initiative is our adult and youth screening and transition care.

I thought you were. Sorry, Director. I know you mentioned wrong door behavior health, but I don't know if you heard. Have you been hearing feedback regarding, we announced a new service, eligibility, and a constituent a person is like, oh my gosh, I'm eligible for that. Or, this is a new eligibility, I'm going to go to my local clinic, FQHC, or what have you, and say, hey, I'm here for this service. However, the guidelines have not been distributed yet. I'm wondering if we've put it into thought.

Did I lose you? Did I explain it correctly? Where, instead of announcing a new eligibility before we have the guidelines for providers, if we can align that announcement so our providers are better prepared to provide this new service instead of having people go to their locations and say, I'm here for XYZ and them not really being fully prepared with the guidelines and so forth.

Appreciate the comment. I would say we've heard that for some of our other initiatives, this one in particular just related to kind of county understanding of these obligations and our Medi-Cal managed care plan understanding.

I think we issued the guidance prior to the policy going live, but I hear your feedback on some of the other items that we've rolled out in terms of ensuring we generally communicate with our medical managed care plans, and then the plans are obligated to really provide the guidance to the providers that they contract with.

And it is something that we are trying to do a better job at is the direct relationship to the providers, but our obligation is with the Medi-Cal managed care plans and not every entity that they subcontract with in terms of some of these new things, we are trying to do better there, but it is kind of understanding who are all the networks, who are all the providers out there that our medi Cal.

Managed care plans in our responsibility are part of, just part a where we share with the plans new eligibility services and so forth. Are we providing some time for them to then do the legwork for their contract services versus us? We share with the plan, say, hey, that's our responsibility. We are now going to announce it to the state or are they given some time?

I think some yes, some no. I will be honest with you, I think some. There's been lots of engagement ahead as the policy gets developed. And then there's other things. I would say with just CalAIM, we implemented a lot very quickly, and so the runway may not have been there for everything that we all would have hoped for, but that's why some of these things, it's just going to take a little bit of time till they're fully implemented and fully scaled.

As we're looking towards the future of adding potential new things, other counties adding new services, are we taking that into consideration now and perhaps creating a longer runway?

Yes, and it is definitely feedback we've heard from our plans, too. I mean, we all want this to be successful, and so the more the Runway we can provide, the better. Sometimes we're under deadlines and it is the push to roll out and then kind of continue the engagement after the policy rolls out. Okay.

Not a huge fan of that process, but okay.

We are working to do better there. We understand. The next one is the adult and youth screening transition of care tools for Medi-Cal mental health services. So under CalAIM, we implemented standardized statewide screening and transition care tools for our mental health services, and this began January 1, 2023.

County behavioral health plans and our managed care plans have been using these tools to make timely and accurate referrals to the appropriate delivery system, regardless of which county a member lives in as well, or what plan they're enrolled in. From the managed care side, we previously had multiple screening and transition tools that were used for our members across the state, which led to inconsistencies in terms of how members were referred to county behavioral health and how they were referred to our managed care plans networks.

So to ensure and to really try to foster the access to care for our members, we've streamlined the process by developing or really kind of standardizing the screening tool. We have a separate tool for adults and a separate tool for youth, and so the purpose, and this is, again, for when individuals are coming to these systems for the first time, otherwise they're in their delivery system of care.

These tools provide a referral to the appropriate mental health delivery system so as they contact either plan on the behavioral health side or the managed care side, that initial assessment is a tool that kind of evaluates the individual and then makes kind of an assessment on which delivery system they should be referred to as part of getting those services.

These screening tools are not required for use for members who reach out to mental health providers directly to receive services, so this is if they show up at someone's door, nor the screening tools required for members who are referred to a mental health provider by another provider, such as their primary care provider.

Mental health providers who are contacted directly by member syncing mental health services are able to begin the assessment process and provide services during the assessment period without using the screening tools, again consistent with the No Wrong Door policy.

In addition to these screening tools, we've developed a transition of care tool to ensure that members who are receiving services from one delivery system are transitioned to the appropriate delivery system as necessary so that we ensure that kind of the capacity and the mobility of each delivery system is maintained to serve kind of the members that fall into those criteria for their system.

The design of the screening and transition tools we undertook an intensive two year period of research, stakeholder engagement and testing in partnership with some of our clinical leadership from county mental health plans and managed care plans, advocacy organizations and provider groups, and we issued guidance on these processes and tools back at the beginning of 2023. And we've implemented many public webinars and FAQs on this.

And so again, really the goal of these is to ensure that the members are receiving services in the appropriate delivery system, as that is, how kind of their models are developed.

And how have these tools been received by your customers?

So I will say some counties and plans, it's definitely different by the state. Very consistent, the way the screening tools have kind of identified members going to manage care plans and county behavioral health plans is kind of very consistent with how it's been running for the last x many years. And some plans or some counties, it's been a little bit different.

And so that's fostering conversations between the plans and the county behavioral health plans in terms of really identifying what is the appropriate setting for the member, where should they be receiving services. For example, county behavioral health really is not lead on mild to moderate services. Right. And so individuals who maybe have on a path to recovery and are stable, maybe they should be transitioning to their Medi-Cal managed care plans and really fostering that conversation.

So the appropriate delivery system is really providing the care because we want to ensure access and we don't want individuals who may not need a higher level of care being in the system that supports the higher level of care. So it's definitely based on county kind of, there's no statewide. It's definitely based on some of the county relationships. I do think that it's fostering conversations that haven't happened to date.

Thank you.

I wanted to provide just in terms of your question about how are we doing in the evaluation. So just a couple of weeks ago, the last week of February, I believe we released a report highlighting some of kind of the feedback we've received with regard to these policy implementation. So this kind of covers the policies that I just mentioned. And we conducted a statewide survey of our managed care plans.

And our county behavioral health agencies had deep dive interviews with a few plans and counties just and consumer groups and provider organizations just to get kind of that qualitative understanding for how things are going in terms of the rollout of these policies. We do plan to, and it's already started, but we just don't have the data conduct claims analysis as well to have an understanding of how are things different, how are things changing.

And as Brian will mention, as part of payment reform, we've also changing the way we actually claim for these activities because we're really going to get down to a really more refined understanding for what behavioral health services are provided at the county level. But just kind of these are the things that we're thinking about.

I would say most of our managed care plans and county behavioral health plans report that the greatest successes of CalAIM include really that improvement and coordination between the two systems, supporting members by providing better and faster access to care, by removing some of the barriers that we were attempting to address, particularly increase in access to care for youth.

And I would say in particular our foster youth, just given some of the changes in the criteria for access for our foster youth, making it easier for members to get services in those transitions, and then the care coordination between plans, I think the feedback we received, that's just not enough time has passed to really understand the impact of these initiatives.

But I think at the local level, continuing to revise their workflows and just kind of that kind of change management at the local level that is needed to really fully implement. Struggling with the pace of all of these efforts and how quickly these things have rolled out. It's a lot of work. And so I think it's just going to take some time to settle and get through it all.

And then the workforce challenges that I think we are all tracking as part of the behavioral health space and then kind of some of the limited administrative capacity to continue to implement these.

Is that on the state side or the plan side or the county side?

This was feedback we heard from our managed care plans and our county behavioral health Department.

No, I mean the capacity to do the things.

County behavioral health and managed care I think particularly county behavioral health. Okay, let's see here. I think the referral tracking and referral coordination is something that I think we all need to work on. And I will say as part of our managed care contract, that is a provision that will also go live in 2025, just that kind of closed loop referral, just really a better way to track referrals between systems.

I will say I think we have about 91% of survey respondents reported that members are being now directed to the appropriate delivery system for the initial clinical assessment based on the screening tools.

And some of the most constructive feedback that we heard from both our managed care plans and our mental health plans is that the screening tools can sometimes lead to members, as we talked about, going down to the wrong system, depending on how they kind of had established their program before and where they are today.

So again, we are continuing to monitor these and want to make improvements as they continue to roll out and are really, I think for the first time ever, at the end of last year, we convened all of our Medi-Cal managed care plans and all of our county behavioral health departments. It was a big kind of almost at a summit.

And really, I think part of this is about those kind of those links and those conversations and knowing I can pick up the phone and call you to really facilitate those conversations and relationships. And I think by doing that, I think we're going to just continue to improve. So with that, I'm going to turn it over to Brian to do a really deep dive in the payment reform piece.

Thanks, Director Baass. First off, I'd like to say thank you to the Committee for allowing us to discuss behavioral health payment reform. It's near and dear to all of our hearts and a really large initiative, just as background, especially mental health services and substance use disorder services are rendered through the county behavioral health delivery systems. Prior to payment reform, counties were financed for those services through a certified public expenditure process.

This process and financing model was extremely administratively burdensome, oftentimes taking years to reconcile cost reporting and close out the books. Very challenging for counties to budget and forecast under that model. Similarly, counties didn't have this incentive for productivity nor providers because of the cost reconciliation. Regardless of how many Members a provider or county saw, they would always be reconciled the cost, the cost it took to render those services. Similarly, under cost based reconciliation, there was no ability for counties to reinvest any surplus funds.

Those surplus funds, in a cost based world, would be recouped by the department and sent back to the Federal Government. So under payment reform, we're moving away from cost based reconciliation. We've implemented a fee for service model with our eye towards a value based purchasing model in future years. On top of that layer of financing, we've also asked counties to transition their coding structures, which is a similarly large lift. Specifically, we're moving from HCPCS level two coding to CPT coding.

And that's just a fancy way of saying that counties prior to payment reform were using about a dozen codes that were very broad. As Director Baass had said, we didn't get a lot of great information off of it. We weren't really able to set great financing mechanisms off of a dozen codes. We moved them to CPT coding July 1, 2023. And that's hundreds of codes, very granular, and we're much better positioned to actually see what care is rendered.

On top of that, it's a federal mandate where we can move to CPT codes. We should. And then it also positions county mental health plans to be on par with our commercial industry, our Medicare industry, and then also our Medi-Cal managed care plan. So now we'll be able to actually see the data in a much better apples to apples comparison.

And it's easy enough to be able to do that. Hundreds of different codes.

It's a challenge. This is complicated. Coding is complicated. There's an actual industry just on coding. That is actually one of the things that I think our teams underestimated is the lift on EHRs for counties and the amount of money it takes to update them. The variance between electronic health record systems between the counties, because they get to choose the vendor, and then also the ability for providers to make that transition. So that has been a big lift.

While we focus a lot on the money side of things, coding is equally as challenging. Okay.

And that's on the provider or that's on the plan?

Both. So we set a code structure throughout the Department that the county must submit claims. In this code structure, the county then also uses those same codes and requires providers to bill those codes to them. And that can vary as well from plan to plan.

Can we ask a question?

Absolutely.

Thank you. So tell me a little bit about the providers and their transition. I know that I kind of stepped out and came back in, but give me a little bit more in terms of, are people catching up? Where do you see it? I mean, are they stepping up to the plate? Are they behind? Give me just the big picture.

Yeah, it's a good question. And I think there's varying levels of aptitude and ability in the state. I think that it varies county to county, provider to provider. We've tried our best at the state, along with our joint Powers Authority, CalMHSA and CBHTA, to kind of wrap our arms around the provider community and ensure that we have technical assistance provided to them. We've trained them through webinars and things of that nature.

I would say some providers, typically the more resourced providers or larger providers, do better because they're able to make that transition quicker. And this is an ever evolving process. So we are on iteration five of our billing manual for coding since payment reform went live. So there's lots of iterations and movement in this.

So follow up to that. So do you find any that are, I'm just going to say resistant, like are having a hard time getting there, just resisting the change?

Not from a coding perspective. I think people understand that there's benefit in this. I think change is hard. And again, varying aptitudes and ability and financing really shake out to make it challenging. I think that there's variance between counties, and I'm sure our provider partners in the gallery will attest to this. There's variance between counties. So if you operate between counties, it can be a challenge if they have two different coding structures.

Again, we meet with providers and provider associations in our counties every other week or so to try to suss these things out, whether it's a systemic, statewide issue or if it's a county specific issue, to try to make it a little more seamless. Again, CalAIM payment reform specifically, we're trying to make this easier, not harder, but that transition is going to take some time to smooth out.

I would say once we start to focus on value based purchasing, it'll be nice to have those codes in place so we can actually look at what's happening and provide a better financing structure, and then that next transition won't have a coding component to it. So we're kind of moving two trains at once.

Thank you.

Do the codes, the codes themselves change? The CPT codes themselves change county to county, or is it just to transition between the old system to the CPT system? That's the problem.

Both, yeah. So it depends on how counties can implement their coding structures. Typically, they're the same going forward or backward. But say, for example, a provider is cross county and they have one set of services that they render in one county A, and another set of services, likely same or similar. There may be a paring down of codes based on the county that's an industry standard that where the actual payer themselves can pick the coding structure.

As long as those codes that are built to DHCs are in alignment with what our billing manual says.

Shouldn't we have standardized codes, though the state is delivering, I mean, providing the codes for them to be able to use? Correct.

They're largely the same codes, but counties can provide different modifiers to those codes and also add ons to those codes in order to track financing and other localized things that they need for reporting.

Certainly must make it difficult for you to do an analysis if that was the whole purpose for transitioning to CPT codes. If you can't rely on having the same codes county to county.

Well they'll have the same codes when they come to DHCs. There's back crosswalks from the provider to the county, county to the state. The county will actually crosswalk the codes that they've given the providers to the mandated standardized codes at DHCs.

Yeah. Why wouldn't we just not allow that and just have a complete.

We don't have the authority to do that under current contracts and that we don't do that now in other spaces like our physical health managed care plans, and that's not an industry. So if they bill, say they have to build commercial insurance, Blue Shieldis going to be different than Kaiser or Medicare. While we're all using CPT codes, there's different ways to bill. This is an industry problem, not a payment reform issue. But we are meeting with our provider associations.

They've been kind enough to really track a lot of the variances and do a really good job of saying, hey, this is the problem for our providers, especially small providers that are between like 1 and 2, 3, 4 counties. What authority does department have and what TA can we provide to counties? This is something that we're actively looking at and one of the highest priorities.

How is the payment negotiation process working with respect to providers?

That's a good question as well. So I would like to take it just a step back and give some context to how we set rates at the state. Along with our partners at the county, CBHDA and CalMHSA, we took three years to develop a rate structure that wasn't a one size fits all. We developed 12 different rate methodologies that really tried to get at maximizing federal funds to get at, what are the local drivers of cost?

Because California is more like a country than a state, and so Northern California and San Diego may not have the same cost driver. So really trying to parse that out and then also segmenting our services out to say, okay, inpatient services really, the costs and payments for them really aren't like outpatient services. Those are two different worlds.

And so we spent a very, very long time in being mindful of those developments, and we've got some really great talking points about what we've been able to achieve in that sense. All that to be said, it took longer than anticipated and we gave counties rates very late in some instances. So say, for example, payment reform went live July 1, 2023.

Some of the last rates that we gave them were in March and April, and so they had to turn those around, model them, and then negotiate those rates with their provider group. I would say overall, counties are understanding that this is a very short runway for them, but overall they're getting a great rate upfront from the state to the county.

They've committed in general to really being mindful about the rate discussions with their provider groups, and they've also committed in general to reassessing those contracts every six months, every year. I've seen some really creative financing, like 1/12 contracting, where they have a contract, say, for $1.0 million for a year, each month you're going to get the 1/12 of that $1.0 million and then we'll true it up at the end of the year. Just so you know, you have revenue streams.

They're also seeing alternative payment models like through LA, where they're incentivizing certain activities for providers to become, provide additional services and really be robust in their services when the member is there in their offices. But I would say first year we're just getting this off the ground and it's making sure that the providers are in a position to stay solvent and that we're really working towards maintaining those provider networks.

And then next year we're really focusing on how do we shift our best TA towards those creative financing models that really maximize coverage and care.

So just a quick question, sort of a twofold one. Have you received complaints from providers about the payment reform?

Yes.

And two, have you noticed, even though we're early into this, have you noticed any diminution in the panel of providers available at the county plans? A decrease?

We have seen decreases. That's typical, though. Decreases, increases. What we have seen is that whenever we get a claim, somebody raises their hand to say, hey, we're going to close line of business or our business is going to close altogether. They typically cite payment form as an issue.

We investigate all of those, whether it's with the county or the provider or both, and we find some underlying trends with that, where oftentimes the issue is predated payment reform, and that the transition to a fee for service model exacerbated the issue. A lot of times this centers around direct patient care time. And so what we've seen with some providers where they've raised their hand saying, I have to exit the Medi-Cal system, it's because they have, say, for example, 15% productivity.

And so that means that 85% of their time they're not seeing members, and 15% of the time they are. Not to say that that's bad business practice, but under a fee for service model, that you can't stay solvent that way. A lot of it centers around staffing issues. That's an industry issue. That's not just a medical issue. Trying to find clinicians is just impossible. And then our system is the most challenging to provide services in.

So they're competing with school districts and commercial plans with mild to moderate, and they're making more in those areas, too. So payment reform is trying to address those concerns. I would also say that we have some standards within the mental health contracts that require them to notify the department of any significant network changes since payment reform went live we've had seven of those. Three of them have cited payment reform. The department has investigated all seven of them.

But again, that's kind of just par for the course. You have providers exit and enter the program oftentimes. What we're also seeing is that counties are switching utilization from contract providers back to the county providers. And so while a provider may exit because there's low productivity, there's no profit there, there's no margins there. The county will then absorb the, or provide, or send it to another provider that may be able to provide a little bit more efficiency.

Well, regardless of the complaints, can you tell me how the fee for service rate compares generally to, on the average, to the cost reimbursement?

Sure. We haven't done an analysis of that. We are working with CalMHSA to define an analysis of how well people are doing pre and post payment form. It is not apples to apples yet. And I would also like to say our data isn't there. There's this thing called claims lag. So we like to think of claiming as real time service is rendered, it gets billed, it gets paid that day, and then we know exactly what's happening.

If it's a hospital, it's probably 90 days or more, right?

Yeah. And counties are about six months at times. So we are eight months into payment reform. So we were finally seeing claims data come in.

Okay, thank you.

Similar, but not within the payment reform could we talk about. I can imagine this is adding an additional layer of difficulty regarding our recent publication of rates on our statewide and then providers seeing that not matching up to what they're getting.

Sure, it's a really good question and a point of contention for a lot of folks. From the county perspective, it puts them at a disadvantage from a leverage perspective to say, here's what the county is being paid. Providers want to have a large, what they call a pass through of that rate. But what I think what gets missed in a lot of this is that counties are paid one rate for a service, and the county has to budget a global budget for all services.

There may be a loss in there somewhere, and where they have a profit, they need to actually take some of that profit and apply it to the loss. We're seeing that between outpatient services and psychiatric inpatient services. So while the department is working with CMS to try to resolve the loss component of this, they're reducing their rates over here with one provider to accommodate for this other issue.

And I would also say that at times, even within a specific set of services, the counties are really trying to say, okay, what does your business need to have financing wise to remain solvent? So say, for example, a clinic based provider who has lots and lots and lots of patients come through on a fee for service basis, they're going to do great.

Therefore, their rate might be a lot less than what the department is paying the county, because the county also has to pay the provider that's primarily field based, that's only going to see one or two patients during the day. So their rates may be much, much more than what's published on the DHCS website and what we pay to the county.

Do we have any insight on moving forward to a capitation system?

We're looking forward to that. Again, we are in the infancy of payment reform. I call it 1.0, and 2.0 is as complex when we move to risk based capitation, similar to our physical health managed care plans, it requires actual soundness. There's a lot of other things that go into it. So we are many years out from that. So this is not going to be next year type thing.

Okay, well, this is almost capitation. If the county's balanced risk and you've got a plan that has certain fees for certain CPTs or whatever, but the county can say, well, I'm losing money over here on this for this fee that you've given me, I'm going to take it away from this one and shift it over here that's risk based capitation, sort of, isn't it? As I understand it.

So risk based capitation tends to be a per member per month.

Right. Except what we're doing is the county is going to get a bunch of money for services and they just move it around.

Yeah. I think that fee for service is fundamentally different than risk based capitation.

But if it weren't, then the fee that is in your plan for a particular service would be received by the provider less an administrative cost, whatever that is. And that's not what you're suggesting is happening.

We take the administrative cost out. That's paid separately in and above those rates.

Well, then why isn't the provider receiving the fee that's in the plan that you have issued? Well, what you've suggested is if the county plan is losing money on a particular service, they might negotiate a lower fee than is covered in your plan with a provider to use the excess to cover the loss on the other service. Am I missing this?

Yeah. And then the state tries to resolve the loss component of that, which we're doing now in one of our sectors, inpatient.

I think it's kind of a hybrid, a little bit of, kind of pure capitation, which is based on kind of the members criteria, seniors and persons with disability versus children. That's a little bit different than kind of pure fee for service. But the flexibility that is provided under payment reform gets to the point of a little bit of the flexibility that a capitation provides for.

Which is probably why the providers don't understand it.

Right. Well, you see the providers, the haves and have nots, kind of in their eyes. So they say when it comes to the fee schedule, they say, okay, the department is paying $100 for the service that I render, I'm getting $70 of that. But you don't hear the other provider that's getting $140 because their pro cost profile for the services, the same sets of services are largely different. So the county has to balance all of that.

Yeah, it's interesting because you already rake off the administrative, the county gets paid for the administrative service of managing the program. So it's sort of strange that there would be rate manipulation within that process of negotiation. Right. Okay, that's a- question from Senator Rubio.

Thank you, Mr. Chair. I think I was thinking along the lines of what he was just saying right now. When I heard you say that you paid less here and then more there, that's what I heard right now, like money. That's, and forgive me for saying it, this almost unaccounted for. Like, how do we keep track of? But you try to explain it to Mr. Roth, and I was having a hard time, so that's just.

No, but I was thinking just along the lines I heard, you know, because we don't get paid enough here, then we pay it over. You know, I thought that we paid for whatever the reimbursement was, but I'm going to say it the way he said it.

Right. A payment manipulation. But I don't know. Can you go deeper into that, help me understand that? Because now I'm having trouble understanding how you take it from one and give it to the other one that was in the reimbursement for that particular item.

Sure. So the rate paid to the county by the state is always going to be the same. So there's no rate negotiation. The CPT code and the practitioner type, they get that rate. That's been said and done. When the county looks at the providers rendering that service, they have to actually look at the lines of business. So while it might be the same service from a coding perspective, it really isn't.

So the actual assessment or critical treatment or crisis stabilization, where it happens, and the costs associated to render that have to be accounted for. So counties are obligated.

Can you give us an example?

Fuel based services versus a clinic service.

They'ee both paid the same amount, or you're saying they're not?

From the state to the county? Yes. And then the county has to negotiate rates, and the state delegates that contracting authority and rate negotiation to the county mental health plan.

Okay, so you're saying, like, one, somebody's coming to office, they have a visit scheduled every 50 minutes. The other one, somebody's out in the field, and they might have to go down a hill to an embankment to provide that same service?

Yeah. Outreach and engagement is a huge loss leader for those types of providers, and we want to make sure that we ensure that, because wherever the member is, the county is still obligated to treat them. And so while it's more efficient and financially viable to have somebody in a clinic, a homeless person likely isn't going to go there. So we have to contract with these providers that really don't have the volume of services to render those mandated services, and that's expensive.

So while it may be coded the same way, it's really not the same service.

That make more sense for everybody now? Yeah.

Okay, let's continue the conversation. Thank you so much.

Anything further, sir?

I think I've actually tackled my whole agenda. So thank you for that. And I'll turn it back.

The socratic method is fabulous.

I actually prefer this. Further questions. Senator Menjivar, Director.

Yeah, I'd like to come back and tell me if this is appropriate in this space here. Maybe we can dive more into sub three issues. I'd like to learn more about how we're addressing behavioral. Let me back up. I remember there were certain populations that we were focusing on under CalAIM as a whole, and I'm wondering how well CalAIM is meeting the needs of underserved survivors of violence. I'm hearing some from some providers. It's not an eligible category for these services.

So I think you're referring to Enhanced Care Management, which is a Medi-Cal benefit by population of focus.

Talk about this in sub three, then.

Sure, perfect.

If I can just ask one more question on contracting, because as you're providing all these new services, I'm interested in the navigation services and the community health worker and all of those things. Are the plans able to contract with enough people? Do we have enough providers?

So community health workers is a managed care benefit at this time under BH Connect, the waiver we have before the Federal Government that's adding it as an optional benefit for county behavioral health. So today only Medi-Cal managed care plans are able to bill for community health workers.

And so, you know, I think we are continuing to build out our community health worker benefit in the workforce and also recognize that as part of Enhanced Care Management, a lot of community health workers are actually doing the outreach and engagement. It's one of the core seven services of Enhanced Care Management. So they are doing that work.

And I think as we continue to build this out, it's kind of one of the things that I think we think is critical to really addressing some of the kind of the quality and metrics that we're trying to achieve. And I think you one other.

Colleagues, other questions. Excellent. Thank you for the presentation. You're not leaving, though, right? No. Well, you can stay there. We can bring the next panel up, but let's bring the next panel up. That's up to you, Michelle.

I'm learning how to run a hearing.

You're a pro.

Okay. Welcome. And here's how we're going to do this so I don't butcher names, we're going to have you introduce yourselves for the record. Starting to my left, your right, ma'am. Yes, ma'am.

Kiran Savage-Sangwan. I'm the Executive Director of the California Panethnic Health Network.

Thanks for coming. Yes, ma'am.

Hi, Adrian Shelton with the California Alliance of Child and Family Services.

Welcome.

Hi, Dr. Leandra Clark Harvey, CEO of California Council of Community Behavioral Health Agencies.

Good to see you again.

Good afternoon, Chair and members. Michelle Cabrera with the County Behavioral Health Directors Association.

Ok. Thank you for joining us for shareholder perspectives. You've heard the first panel, so take it away. Who wants to be first?

I will take that honor.

Thank you, ma'am.

Hi, good afternoon. So, as I said, I am Michelle Cabrera, Executive Director for CBHDA, representing the county behavioral health directors for all 58 counties responsible for the delivery of medical specialty mental health and substance use disorder services, both as prepaid inpatient health plans for specialty mental health and through drug MediCal and drug medical organized delivery system plans for substance use disorders. CBHDA, along with other stakeholders, engaged in early conversations with the state related to CalAIM starting in 2019.

At that time, we were trying to solve for a number of problems outlined in your background paper and also highlighted by Director Bass and Brian on the earlier panel. We lifted up the overly burdensome documentation and payment requirements that resulted in an overemphasis on compliance, self-denials, or recruitments for services that might expose us to audit risk rather than orienting our system to the delivery of medically necessary services for beneficiaries.

For example, CBHDA highlighted the overly restrictive eligibility criteria for kids and in particular for foster youth. The old specialty mental health criteria led to federal and state audit denials of legitimate MediCal services when providers were unable to adequately document that children met the diagnostic and severity requirements set by California.

A diagnosis was the golden ticket to entry into county services, but it also boxed providers in and didn't give them enough room to update and change their understanding of the child's conditions over time without risk of losing reimbursement for the services they were delivering. These challenges, associated with documentation and reimbursement, have contributed to driving providers out of our safety net at a time when we need them the most.

However, the ambitious vision of CalAIM and trying to measure the impact of those reforms to date, cannot be viewed in isolation. First, CalAIM was initially put on hold for two years due to the pandemic. Trying to stand up broad, sweeping reforms while still coming out of the pandemic has put additional strain on an already shaky foundation of workforce shortages, along with increased demand for services resulting from the pandemic.

In addition, CalAIM reforms have happened alongside a whole slew of other new behavioral health reform initiatives, including the Children and Youth Behavioral Health Initiative, the BH Chip Care Court, LPS Reforms, the new mobile crisis benefit, just to name a few. We've counted 13 new specialty behavioral health benefits that are coming on board between 2022 and 2024 for county behavioral health, and that's not even counting those other reform initiatives that are happening in parallel.

Since 2022, DHCS has been laser-focused on implementation of CalAIM and with good reason. The new granular code set we heard about earlier with respect to medical billing has actually been a federal requirement and industry standard through most of healthcare since the 1980s.

Fee-for-service payment reforms will bring our system into the late 20th century ways of financing health care, and by developing a fee-for-service rate structure, we'll be able to help prepare our system, lay the foundation really for capitation and other value-based payments moving forward. So think of these as sort of necessary foundational pieces that can help us sort of modernize and get in line with the rest of how healthcare works.

And to some extent, as Mr. Fitzgerald was mentioning, some of the sort of kinks and challenges and problems are really inherent to how modern health care works. Today we're far enough into implementation of these various CalAIM reforms to have a sense of how it's going so far, even if many of those reforms are still in their early infancy. I will focus my comments on three main areas of CalAIM that are flagged in the background paper payment reform, documentation reform, and no wrong door.

But I'm happy to speak to other pieces of the reform. The first wave of reforms included the new eligibility criteria, no wrong door, and documentation reform. When CBHDA and providers provided feedback to DHCS on the need to continue to streamline documentation requirements. Going further than the state's initial guidance, DHCS engaged us in a month-long process, resulting in updated guidance issued this past December.

While expanded eligibility criteria have increased the number of children and youth eligible for our services, the new screening and transition tools that also went live around the same time have also identified a number of children and youth who are more appropriate to be served through MediCal Managed Care's mild to moderate benefit, meaning the counties have not seen a huge net change in the number of children and youth we're serving, although the children and youth who are being screened into our system do have those more complex needs, which is appropriate.

Overall, from the provider and county perspective, we've received the following feedback from one of our counties. The largest impact has been through documentation redesign, updated criteria for assessing specialty mental health, and the ability to serve clients prior to assessment, or no wrong door. We've seen positive impacts on our clinical staff. They're starting to feel the impact of documentation redesign and feeling less pressure on documentation.

Access to care for clients has improved due to our ability to serve clients prior to their assessment, and clients are getting services they need when they need them instead of us having to say we can't help them until you do XYZ. With respect to payment reform, we're less than a year into implementation.

Counties partnered closely with the state in developing the plan-based fee-for-service rates, and despite a strong partnership with the state and rate development, we have encountered a number of issues that have made implementation more challenging. First, counties, as mentioned prior, did not receive final rates until about a month before implementation, which limited their ability to appropriately model and negotiate rates with contract providers.

This was strictly a matter of the aggressive timeline we were on, and we gave our providers a heads-up that the first year would be a challenge for these reasons. In addition, multiple counties and providers have had to contend with changes to their electronic health records, also mentioned before, that in the short run have complicated coding as well as payment transitions.

We've dug into the specifics on issues raised by counties and providers, sometimes learning that the EHR transition, more than anything, has been a bit of a drag on payment reform and coding transitions as well, along with across the multiple EHR vendors. So this is like many, many different EHR transitions happening all at once.

We do expect that these issues will resolve over time, though, as the sort of coding issues get worked out and as folks become more comfortable and familiar with those EHRs and they're able to report out better data. Each county received its own rates as well, which was really important and part of what made this such a heavy lift.

Because there was limited time to model and negotiate rates with our providers, counties did take different approaches depending on how their system set up and what kind of data they had going in. In counties where providers were willing to collaborate with us, we were able to develop tiered rate structures which, with incentives built in on top to provide those providers with opportunities for extra funding beyond direct services to encourage things like EHR upgrades or value-based payment approaches in other places.

The county paid for actuarial consultants to model the impact of payment reform for those individual providers, as well as providing cash advances to their contracted providers. Some counties went with a straight percentage of the county rate, which has been passed along to providers, and still others agreed to make their providers whole for the first year of payment reform. Of the varied approaches, we have learned quite a bit.

CBHDA partnered with DHCs and our joint Powers Authority, CalMHSA, to develop a whole range of free training and TA before, during, and after payment reform implementation to support both our counties as well as our providers. CBHDA has requested that our provider associations bring specific concerns with counties to us so that we can help sort through those concerns alongside our providers and counties.

I want to in particular thank the alliance for the strong partnership with our county members in issue spotting and caseworking problems that have been raised with CBHDA through this process. Throughout, we've been consistent in emphasizing the need for counties to ensure that they are maintaining adequate networks that is a core pillar of the Medi-Cal program. In the best of scenarios, there is tremendous opportunity for counties and providers alike to benefit from a fee-for-service rate structure.

I know of several counties that are taking contract amendments to their boards because their providers who have really leaned into payment reform have been so successful that they're now exceeding what has historically been the contracted amount for that provider. For the first time ever, neither the county plan nor providers will be limited to the cost of their services. This means that counties and providers alike will be able to make new investments to grow their programs as well as improve quality.

That's kind of the hope or the promise here. CBHDA is doubling down on our efforts to support providers and counties as we head into year two of payment reform with some of these lessons learned under our belt. First, we're bringing in our own actuarial consultant to offer targeted training in TA to counties and contract providers on how to develop a tiered rate structure and to help providers succeed with different program models.

We want to be sure that we support our field-based and home-based services that make our system so unique and effective for individuals in MediCal, while offering strategies for counties and our providers to increase direct service time and maximize these opportunities.

We're also tracking individual counties' performance along with data from DHCS to ensure we can distinguish which counties can be helped solely through training and TA, and which may need to adjust rates to better reflect the cost of doing business in their county or region. It's too soon to tell, however. In many cases. Finally, rates will need to continually be adjusted over time to reflect new services and statutory requirements, such as the mandated increase in minimum wage with SB 525 signed into law last year.

We're grateful to the goals of CalAIM and to our partnership with the state and our providers and working to expand access to specialty behavioral health services for MediCal beneficiaries. Remember at the top I talked about sort of the problem we were trying to solve for really, it was trying to bring our system into the late 20th century of healthcare delivery, trying to remove some of those really onerous documentation and other requirements that put us all at risk.

And we are working towards that goal still, it'll take some time because these are a lot of changes and they're all happening at once. And happy to answer any questions you might have. Thank you.

Thank you very much. Please proceed.

Yes, thank you. I'm Dr. Leandra Clark Harvey again, a psychologist and a CEO of CBHA. We're a statewide advocacy organization representing mental health and substance use disorder clients across the state. As described earlier, CalAIM has great symbolism and promise. It's an innovative approach and a huge opportunity to address a multitude of disparities that exist for behavioral health clients in our state by promoting integrated models of care and addressing social determinants of health in a very new way.

That's why we believe it's so imperative that we counties, providers, and the administration really works together to get it right. Despite the promise of CalAIM, this panel has been asked to discuss some of the mechanics that need to be fine-tuned, including implementation of payment reform, a threat to the livelihood of many of our behavioral health providers, which my colleague will discuss next, and also including administrative burden, which is whittling away at the productivity of our behavioral health workforce.

So what is this administrative burden that keeps being tossed around? Well, simply, it is excessive and unnecessary requirements. CBHA has been surveying our members for decades, and the top administrative burden identified has and continues to be varying clinical paperwork requirements from the numerous counties that they contract with. This is why we commissioned a study eight years ago that found that it takes California Clinicians approximately five times longer to complete paperwork than Clinicians in other states.

It's been eight years since this initial study, but the problem continues to persist, even with CalAIM. It's not just a study. It's not just anecdotal testimony that we hear from our providers. I speak from firsthand knowledge. When I practiced at hospitals in Southern California, I was a part of integrated care teams, but my physician trainees and counterparts did not experience the same level of paperwork requirements that the behavioral health clinicians did. That was 14 years ago.

The issue persists, and worse, as my colleague has said, our providers today have had to also brave a pandemic that has exacerbated mental health needs, causing a crisis in the workforce, and much less capacity for tracking varying and excessive paperwork requirements. We literally cannot afford to burn out our workforce due to administrative burden. Hiring teams of individuals to manage varying paperwork requirements, as many of our agencies do across counties, is just untenable, especially when Amazon and FedEx are paying more than clinical positions.

Imagine going to school for a master's degree and having comparable pay. Now as Director Baass shared DHCS has attempted to solve this by providing guidance and trimming down documentation requirements. They've had BHINs, but we must contend that without required standardization, we're in the same spot with uneven paperwork requirements across counties. In fact, out of 70 CBOs that we surveyed just last year, only one said that they were receiving relief because of the changes made in the past year.

So while we appreciate the help and we appreciate the work groups and we appreciate all of that, it's getting to the point where we have to look at other remedies. There have been productive conversations.

If I could ask a question? Sure.

No, I encourage the questions, if you'll permit.

Sure, of course. Yeah.

No, just this issue because we asked. I'm sorry. Mr. What's your last name, Mr. Sir?

Fitzgerald.

Mr. Fitzgerald. Because I think it's the same issue. You're talking about that counties code in different ways. Is this the same issue we're talking about?

It's related.

It's what?

It's related.

Okay, so, Ms. Cabrera, why don't we have standardization across counties?

Well, for starters, on the coding side, as Mr. Fitzgerald mentioned, it is industry standard meeting common to all healthcare for there to be different coding. And typically the coding stuff happens on the back end. It's in the EHR, it's how that's programmed. Why do counties have different coding requirements? Oftentimes it's because they've got different kinds of grants and other programs that they need to attach different modifiers to.

An example of this would be if you're trying to track how many of your clients are homeless because you've got reporting that you need to do for LPs purposes, then you might require that as a part of that clinician's code set so that you can see, okay, how many of my clients who are coming in are homeless. So the more complexity you're managing, the more grants, the more different entities you might be contracted with if you're a subcontractor to a managed care plan for ECM purposes.

Is this what you're talking about Ms. Leandra Clark?

It's understood that there's going to be additional requirements based, know as Michelle is describing, some of the other grants. That's not what we're talking about. Initial paperwork at the base could be helpful. Just standardizing forms could be helpful. Those are very simple things to do. And there has been work, there has been work groups, there have been conversations. But how long are we going to be expected to do that? How long do we keep doing that?

And the work with the counties and the department has been productive, but if a county just decides that they don't necessarily want to adopt that because it's not mandated. It's a suggestion, right? Strong suggestion. We're still in the same place.

And so being in the space where I'm representing providers and hearing day in and day out about how these things that seem very little right, and it seems like, well, 58 counties, they should have flexibility in how they do this, it really does trickle down and impact progress and practice, especially with some of our members that have clinics in varying counties.

We know people that are dealing with fights with their counties or have been, because it was on the yellow paper versus the green paper or things like that. And there has been work to reduce some of that, but it's not solved. And until it's solved, until we have someone that's willing to say this is what we have to do at a base level, we will continue to have uneven requirements pile up across different counties. It's just human nature, but it's not helping the provider.

Dr. Can you give an example of some of those initial forms you're speaking to?

Intake forms, my colleague can also, they've done,

Don't we have those now with the more standardized forms that we're using?

I was going to say if there's a county that is requiring a certain color form and that's part of this concern, we're happy to track down where that concern is and talk to that county and see what's going. That seems like a pretty easy, straightforward fix.

It's been decades, though.

Well, but that's what I'm saying. The problems of the prior decades are exactly what CalAIM is attempting to resolve. And the new documentation standards and requirements ask Clinicians to put in progress notes into their EHRs, which is part of where that record should live for multiple Clinicians to be able to do.

We have a standardized intake form?

Again, the assessments are standardized and then we have progress notes in the clinician.

I'm getting a yes and a no here.

Yes. There are things that the BHIN, the info notice that the DHCS has put out has said, you need to do this. My point is that until there's something that says you have to do it, you have to do it this way. And this is the base. We will continue human nature to create things. And there's different reasons for that. Traditionally it's been because counties have, you know, we're because of audit risk. Right. And so we want to do more to cover ourselves.

But what that's led to is over here, this county heard that this county over here got dinged, so we're going to add more. And DHCS has responded and said, ok, well, this is what you have to do. At the end of the day, if there continues to be an autonomy across all of these multiple different counties, there will be differences and that will impact the workforce. And we are seeing that day in and day out. Yes, with CalAIM, has there been some standardization?

I've acknowledged that, yes. And I'm also acknowledging that I hear from providers directly and we survey them and the results are not that everything's going well. Are there a few? Yes, very, but not the majority at all. And so we have to be honest about where people are, at least those that I represent and talk to.

So these aren't the CalAIM forms, the screening, the transition of care. We're talking about local option, county tracking logs, intake forms that are not prescribed by the CalAIM process.

These are basic. We can keep it as low. And we've had legislation in the past and we have a bill right now around basic intake forms. That's one way to start. Is there documentation streamlining that needs to happen in other areas, too? Yes. We're saying if you could at least do this basic intake form, level of documentation and streamlining, it would be very helpful to members.

Thank you, ma'am. Senator Rubio.

Thank you, Mr. Chair. I mean, I guess that's why we're here, right? We're trying to figure out how we best support the system, the infrastructure. But I hear your frustration about having just different requirements for different counties. But I guess if I can ask you here, we're trying to solve a problem and you have concerns.

If you can give us your top two items besides just basic intake forms, can you give me the top two items that you'd like to see us focus on so that we can make things a little bit more better system for you guys.

I know it's not my turn, but happy to jump in.

Sure.

Adrian Shelton. I'm with the California Alliance of Child and Family Services. I would say one of the biggest pain points for our providers right now is the fact that many of our providers have to actually input a different code that does not match the DHCS billing manual, CPT codes. And we have been bringing these issues, this is not a surprise, to CBHDA or DHCS. We have been bringing that issue forward.

And imagine for a provider that has to navigate 15 plus counties and having to navigate the different codes that don't match the DHCS billing manual. So I would say for us, for the alliance, that's one of the biggest pain points in terms of this additional burden, this additional sort of documentation, administrative burden.

Can you speak to Mr. Fitzgerald's point about, say, for the example that we use for that, somebody coming into a clinical office receiving 50 minutes, somebody receiving that down in encampment, the person is going to have different methods and everything to get down there. So is that what you're talking about, that same example, if we can keep using that, Ms. Shelton?

Well, I was going to add on that example. There's also an element here around the time that it takes to get to a homeless encampment.

Correct.

Right. There's community-based services, and that's something I was going to get into in my comments around making sure that that is adequately financed because sometimes our members are traveling hours. Right. Our people, the MediCal population that we are serving, they're not coming into clinics by and large, we are going out to community, and this is ours in some cases. So we want to make sure that this is adequately financed, the community-based, field-based delivery system.

I'd like to add that some counties have been in communication with providers around travel time, and even though initially the experience was that travel time just isn't going to be reimbursed. There have been some improvements with a few counties, but again, it's a nice example of it's uneven. Right. So you're in one county providing the same service to maybe the same population. Travel time might. Now that county might say that we're able to help with travel time. Another county isn't.

So I think the base of this is creating as much standardization as is possible because providers operate across multiple counties.

So that granular level we're talking about, it still might be the same service, but you have to look for so long, that would be a different code. That makes sense. So the 50-minute hour, right. We go into a clinic for that. That would be one code, the same service, but it's provided in the field. It would be a different code you're suggesting, which adds to the problem of. Right, or am I incorrect?

I think what I was talking more about is you could have the same service, let's say one of our providers who's actually here in the audience, Pacific Clinics who have services in multiple counties. Right. You could provide the same set of services, but if in one county you're told that you're maybe reimbursed for travel time and the other you aren't, all of that goes into the bottom line of are you going to be able to provide those services to that population?

And you don't want to have an uneven provision where in one county you can. In one county you can't.

Okay, if I may, I'll just note that on the travel time issue, there's no CPT code currently for travel. And so that does need to be factored into the overall contracted rate for that provider.

Which is why we're saying, to your point that some providers will be paid more if the program model is such that they've got more high-intensity and more field-based services, which is part of why the coaching and the TA and the training that we're providing to counties is how to set up a tiered rate structure.

So basically, the high volume clinic-based versus the more field-based and home-based providers and providing different rates to providers depending on the kind of program that they have and the complexity, acuity, and challenges associated with bringing in clients and doing direct face-to-face services, right. Because fee for service is all about, you deliver a service to somebody, you get paid for that service. Right. The more people you see, the more money you get.

And so the modifiers though are part of what is varied across different plans. And that's just true of all healthcare plans, whether it's commercial, Medicare, MediCal, managed care, or county behavioral health, will have the option to set up different codes. And some of that might be varied because things are new and people are trying to figure out how to do this the right way.

Some of it is about those modifiers, like I said, and we're really all just sort of learning together about what the best approaches are. But the idea that the plan would set codes according to what works best for them, that is industry standard.

Doctor, with your example with service providers saying, hey, we're working in different counties, I get it here and I don't get it here, then are they opting out to not do it, to just make it even maybe evil, even too?

It feels evil. Some are, yes. And I think you're seeing that there's been a series in Cal Matters, which is the voices of providers saying this is an issue, this is how it's impacting us. And this isn't just one or two, and it's not just the small ones. There's been lots of things said about that. There are some very large agencies that have been at risk and had to cut workforce.

And this isn't just, we only have this much workforce, so we can only do this much service. We are cutting workforce. Right. And that's not because we don't have enough service. Oftentimes that's just the rates that are negotiated aren't good enough to sustain operations.

I'm not a data analyst, but if I were slicing and dicing data based on the CPT code, and if the amount paid is different based on where the service is delivered as opposed to the service itself, I don't know what that data point would give me if I wanted to do some analysis. I don't know if that's important in your business, but certainly the data is not particularly useful I would think.

So, would seem to me there would need to be at least a subcategory of the.

I think part of this, and it goes to kind of a bigger point beyond calam, is like the more detailed data reporting we want out of these systems, the more requirements are going to fall on counties and our providers to collect that more granular data. Right.

And so there is a balance here between expanding the granularity of data but also wanting to make things simple enough on providers that it doesn't become that tipping point of administrative burden. Right. And I think part of what you're hearing from our providers is we want things to be the same exactly across all plans. And part of what you'll hear from us is that's not quite how healthcare more broadly is working.

When you contract with a managed care plan for ECM or community services, those plans will each have their own different ways of doing business and their own unique requirements. Part of what's different for us is with our providers, we're covering a much broader range of services and a broader range of service types and programmatic types. And so there's just inherent complexity in the broader range of services that we are able to contract with these providers for.

And I'd say with ECM and CS in that example, we're not seeing, yes, there is complexity there. We're also seeing a lot of problems there because of the varying rates and the very low rates that they offer our providers. So even though that's been set up as a catchment for other services and populations, that's not necessarily working incredibly well either.

Senator Rubio?

Yeah, I want to just touch on what you just said right now. And the more that we require data, the more complex it becomes. But it would appear to me that you'd want to capture the most important part that impacts reimbursement. So what we're saying is service in the office versus service out in the field. I think to me that's a big part of understanding the reimbursement. And so I don't know how we fix it, but it goes back to what I said here.

We're here to fix a problem, and I guess how do we get a report in terms of what would be, like the top 10 items that you need to figure out in terms of making it equitable to reimburse I mean, I imagine hair color. I'm not making this up, of course, it's such a minor thing, but how many hours you spend on the field, I mean, that's critical. Right.

And so even though it does add a little bit more complexity and more time, it's critical. Like, we need to know that information, no matter how cumbersome it becomes to gather that data, I think it's important to figure out what's the most important in terms of reimbursing. And I heard you also said, I'm sorry, Doctor. I think I heard you say that because the negotiations, it doesn't cover operations, then you have to cut people.

And that kind of diminishes what we're trying to do here, which is provide quality service so it's interconnected. But I think we need to. Forgive me, but get past the burdensome of reporting. But if it's necessary, it's necessary. We need to report what's necessary. But I guess it's just more of a comment. Thank you.

I just wanted to add something to this conversation I think is really important, which is a letter that DHCs sent to all of the county behavioral health directors in December and something that we at the alliance and members are looking forward to, which is targeted provider rate design.

Yes, ma'am.

So DHCS has said this to the counties strongly and unequivocally recommends that counties implement provider rate development strategies that incorporate these adjustments, assumptions, inputs that one size, all fit rates do not account for field based and in home models. So there is an expectation of the State of DHCs that this happened, that there would not be a one size fits all rate approach, and it didn't happen this year in this first year of payment reform.

So we are really looking forward to this idea, and we'll continue to uplift examples that are working across the state. But this is a central recommendation in this letter to the counties.

And is the intent that there be a separate CPT code then, for field services?

So, Senator, there are modifiers for each of the CPT codes that go on top. This is part of what we were talking about. Right. That talk about the location of service. So that's already built into the code.

Oh, okay.

Yeah.

Thank you. Doctor, we cut you off.

It's fine because we got into a little bit of all of it. I think we're well prepped to go to my colleague Adrienne at the alliance. So I'll just end by saying, like, it's dire times. We get it. We're appreciative of the work that DHCs, the counties, all of our providers are trying to do together, and we have to do more. Our workforce is lean and our administrative burden is just way too heavy. So thank you for convening this conversation about this important issue.

Obviously, there's lots of complexities and lots of perspectives, and it's going to take all of us being willing to work to come together to solve it. Thank you.

Thank you. Shelton.

Hello, Adrian Shelton with the California Alliance of Child and Family Services. Thank you, Senator, so much for having this important hearing today. Alliance members are the nonprofit organization serving children and youth and families in our safety net programs in all of the 58 counties. The alliance members contract with both the counties and the managed care plans to provide behavioral health services to vulnerable youth and young adults and adults and their families. So changes to the medical program have a profound effect on the populations that we serve.

And so we're very grateful to be part of this important hearing. So I just wanted to draw a couple of examples about who alliance members are. Children come into our members programs having experienced often profound physical and emotional abuse. So alliance members with extensive and specialized training and staff stabilize children in crisis and work to rebuild their trust, often with the goal of reunifying the children with their families. And so, as you might imagine, this is intensely emotional work requiring highly trained staff.

And youth are also referred to our members'programs, from schools. So alliance members are also really critical to academic success as well. We wholeheartedly support and agree with the goals of CalAIM having serving the medical population, our members are keenly aware of the unifying physical health, behavioral health and social supports that is vital to our community's well being. And so for children and youth in particular, CalAIM is an opportunity to both expand access and improve quality of care.

A robust network of community based organizations deeply rooted in the populations that we serve is a foundation for CalAIM success. So it's also important to recognize that many of our programs are really struggling right now as they are caught between soaring costs and payment rates that don't necessarily match. And in many cases, this does have to do with how the counties are setting their rates for their nonprofit providers. And this was done, as CBHJ mentioned, this was done very quickly, right?

There was not a lot of room for negotiation. So this first year has been very tumultuous, to say the least. And so in some cases, payment reform under CalAIM has really accelerated the financial threat that our nonprofit members have. And there are some examples, and we just did a recent survey about our providers that are, because of the losses that they're taking, are considering downsizing or in some cases leaving the county altogether.

And again, we are in constant communication with CBHJ and DHCs about these issues. Like we bring these issues right away. We do not let them fester. So we bring the crisis or bring the issue and really try to problem solve, and that's actually worked in a number of cases. And again, we have an enormous opportunity to address the challenges that we have, the behavioral health crisis that we have among our children and our youth.

But to just raise these points, again, CBOs are often caught between low payment rates in the county contracts and the surging housing prices, as an example, and the funding that's needed to attract a highly specialized workforce. So we also greatly appreciate initiatives that have been rolling out in our state under HKAI and others around workforce. But we have to fundamentally address the structural issue around rates to truly make a difference. My colleague mentioned documentation. So just to say we have seen some relief. Absolutely.

There has been a second round of guidance that has come out to the counties, to our providers. We have seen some relief, but there are still some issues we're problem solving. We brought up the codes issue earlier. That's a big one. So in partnership with the other provider associations do have a legislative proposal on the table around these issues. And then also to achieve our state's goals around equity and responsiveness to the needs of our most marginalized communities.

California is going to be even more reliant on community based organizations that are rooted in the diverse communities that they are serving. These communities that our members serve lack transportation. They are mistrustful of government for good reason. They're not coming into clinics. We are going out to serve them in homes, in schools and communities. And our members succeed because they build trust, because they are going to the streets. Your example? It was right on to serve the most underserved.

And again, going back to this really important letter that DHCs initiated, we're very grateful for it that this payment models based on the one size fits all just are not going to work for our members and the communities that they serve. So again, we're very grateful for the partnership that we have with CBHDA and with DHCs. We have to get payment reform right. We're looking forward to the future. We know this first year was rough, but we're trying to problem solve. We're looking forward to that.

And I just want to thank the committee because I know individually you all work on bills that address the behavioral health crisis, address our foster youth crisis. And so we're looking forward to being a resource. Please consider the alliance and our membership a resource as we problem solve. We would love to suggest a follow up calm hearing soon as we are getting into the next fiscal year. So thank you so much for your leadership.

Thanks for your presentation, colleagues. Any questions? Madam Executive Director, you're next.

Great. And I feel a little out of place on this panel. I'm not a provider. I'm not a county. I'm not DHCs. Yeah, I'm with you. So I was a little, I'm not getting in the middle of that. But my organization, the California Pan Ethnic Health Network, or CPEN, we're a statewide health advocacy organization. We work with the consumers, medical members, and our focus really is on eliminating, reducing and eliminating racial disparities.

We have a big focus on behavioral health because I think we really understand what a significant concern it is across the state and how important behavioral health is to all of us in our lives. We talk to communities across the state every year. We do listening sessions, we do surveys, we do focus groups. We really want to understand what's happening from the member and the consumer perspective. And the key themes really haven't changed that much in terms of generally what people experience

behavioral health at a very high level. Behavioral health services are almost universally difficult to access. The services that are accessed rarely align with the cultural and linguistic needs of our medical members. And more often than not, people of color, actually, when they get into care, don't necessarily find the services to be useful or helpful. We actually see a lot of drop off among communities of color who maybe access one first service and never go back. And so that's a real concern for us.

I think the consequences of these situations are quite grave for communities of color. And so I really appreciate the CalAIM efforts. I appreciate the efforts of the counties and the providers, I think really trying to improve our system of care. And with regard to the three sort of subsections of CalAIM that are the topic today, I think our view is they're necessary, but far from sufficient. Right. And particularly far from sufficient when we're thinking about racial equity specifically.

And that's because racial equity, while it was sort of in the air as part of CalAIM, isn't the specific focus of these initiatives. And we think it should be if we want to achieve that impact.

So I have much less to say on payment reform than my colleagues, other than to really, you heard the discussion from DHCs, and we think it's really important that we're moving in this direction of value based payment, not only because it's what the rest of healthcare does, but because we really care about the outcomes. We care about the outcomes for people and we care about how to get there.

And we don't necessarily have the systems in place based on how we pay our providers, how we work with our counties to really incentivize that kind of value and those good outcomes and those reduced racial disparities today. Right. So this is a painful step, but we can't get to that place without going through this. Right. So for that reason, we are optimistic about it and we hope the state continues to move actually somewhat quickly towards a more value based system.

I will say some of the folks we work with are your very small community based organizations, the ones who are very deeply embedded in communities, who are not part of the medical program today. They're even smaller than Adrienne's and Le Ondra's providers. Right. And a lot of the conversation about CalAIM in behavioral health as well as in ECM and community services has been about how do we actually bring some of those providers into the system. Right.

Sometimes we're talking at community health workers, sometimes we're talking at other kinds of providers. And I think we have not seen that happen yet. Right. And I think part of that is this is really challenging. And I don't think the emphasis has been on how do we set up a payment structure that will work, that will help people build a foundation, that will help organizations really build the infrastructure needed to be part of the medical system.

So we would really encourage the legislature to think about how we can do more of that as we think about payment on no, wrong door. I mean, of course it's a good thing to not have people bouncing back and forth and losing their provider between systems. But our bigger concern really is that MediCal members are not getting to any door at know this policy is helpful for people who find the door, but that is not most people with a behavioral health need.

And that's clear through so much data that we have. Right. Well over half, close to two thirds of people who have a mental health need in any given year don't get any kind of care. Right. There is a huge gap there, and that's really where we hope there'll be increased focus going forward. And all of you have been champions on this issue, so I know you deeply understand it.

But just to put sort of a fine point on it, if we look at the data that DHCs reports in 2022, less than 4% of Medical members had continuous engagement in the managed care plan services. Right. And we look at that in particular because those rates are actually really low. Like, it's low on the specialty side, but it's really, really low on the managed care side.

When you think about actually how large that population is of people who need a mild to moderate service, the fact that it's 4%, I think, is incredibly troubling. And when we look at that across racial groups, it's less than 3% for Latinos, it's less than 2% for Asians and Pacific Islanders. So we're talking people really not being able to get into this system. And we looked into a little bit. Why is that? Right. We talked to consumers.

We actually also talked to primary care providers because I think on the non specialty side, the primary care providers are a really important referral source for behavioral health. That is the door that people have right now. And actually, what we found across consumers and across primary care providers, they didn't even know that you were supposed to be able to get this suite of benefits from your managed care plan.

And so they were all under the impression, if you have a mental health condition that is severe enough, you can go to the county, and otherwise you're out of luck. Right. And so this is concerning to us. This has actually been a benefit for 10 years. Right. On the managed care side, we actually sponsored legislation to require the plans to do culturally and linguistically tailored outreach, both to members as well as to primary care providers. To my understanding, it hasn't been implemented yet by the department.

Perhaps they can give an update. But we do think that's one initial step that would be really important, because even if we.

So we know currently that folks who receive treatment in the MHSA. Right. That oversight Commission only tracks that funding.

Correct.

Is it possible that a lot of the folks that we're missing are going through that system and we just don't have any accounting of them? Through a Medi-Cal system, people are.

Getting MHSA paid for services. I think those services, while they are broad, are part of the county system. And so really what we're missing is the people who have that non specialty need who should be able to get care from their health plan. And that's where we see the really low numbers. And we understand that's actually a big population, that's most of us who maybe have a more occasional need or a less severe condition, who are not getting anything, really, if we're in the medical program.

Okay.

Does data exist with respect to our managed care plans, as to how many patients are referred from primary care provider to a behavioral health provider?

That is a good question, I don't know the extent to which the state tracks that.

Or even how many referrals they get from their counties?

Right. I don't know the answer to that. Yeah. I don't know if Michelle knows the answer from the counties.

Well, I think an important sort of link back to the Cali and behavioral health initiatives are these screening and transition tools. Right.

So one of the things that we've encountered in implementation of that, which is a plan to plan conversation, to Kiran's point, somebody managed to find the door. Now, where should they go? Right. And one of the things that the screening and transition tools have done is they've more appropriately sorted people who ought to be served under Medi-Cal managed care. They end up going over to Medi-Cal managed care.

And that actually has had an impact both in terms of our contracted providers, our county direct provided services as well as the beneficiaries. So it's changing, as I mentioned in my comments, the severity of who we're seeing. And it means that in some cases, some of our contract providers were actually seeing quite a number of people who should have been seen by the Medi-Cal managed care plans.

And I asked our county in one case where there was a provider who was closing down a program as a result of this, I said, did you put them in touch with the medical managed care plan to see if those less severe folks could, who they've been seeing, who should have been covered under the managed care plan, if they can contract with that provider that county was contracted with?

They said, yes, but the managed care plan doesn't pay well enough, so the provider is opting to close the program rather than continue under a contract with managed care plan.

And I think that is one of the issues that the managed care plan tax is trying to resolve, is bringing those non specialty provider rates up so that they can better build better networks, basically, because if they don't have true networks or networks that are appropriate to meet the needs of the Medi-Cal population, then people aren't going to be able to get to them. But this issue about sort of primary care and referrals is super important and really appreciate that.

And let me just ask you, what's the door? Is the door the Medi-Cal primary care provider? Isn't that the door when you get to your plan and it's your primary care?

So it can be, and because that's where so many people seek care. Right. And where they first express their mental health symptoms, it can be. But people in Medi-Cal can go directly to behavioral health services.

They're not going anywhere. So I'm just trying to figure out, so if the door is the primary care provider and there's some screening tool, I guess, is it applied?

Well, typically. So people will call the county access line if they know that county is a thing. Right.

So if you know county has behavioral health services, you'll call county access line. County access line will do the assessment. They'll screen you. They'll tell you your managed care plan is XYZ, you should call them. And let's help you out. Right. In some communities, people are aware that Medi-Cal managed care has a mental health benefit. But based on the data, it looks like those folks tend to be the white beneficiaries in Medi-Cal that have that awareness about that.

It's interesting how the demographics sort of line up there, and then you have to think about other sort of entry points for people into our systems. Right.

For us, as county behavioral health, we're very tied in with child welfare, we're very tied in with justice involved individuals, with unhoused individuals. And so we've got different sort of communities that are naturally feeding into counties, and then we've got partnerships with schools. And so I think one of the questions is, through CYBHI, are things going to change? But really getting the primary care folks to better understand, to CPEN's point, whether the benefit exists and how to access that benefit, it's actually not that hard.

In theory, it's a specialist referral if they need specialty care, and if not, it's to whomever the managed care plan is contracted with to deliver those services. But it's that lack of awareness that's sort of driving the confusion.

Well, because I assume you could report to your primary care provider with some physical ailment, but during the process of dealing with that, the primary care provider identifies a potential mental.

Exactly.

Issue that needs to be addressed. And so my concern is, how are we measuring whether that provider, whether it's IEHP or Molina or one of the other contract providers, sends that person to either the county because they don't know anything other than county mental health or someone within the managed care plan who handles behavioral health issues? We need to figure that out.

That's where we see a big, I mean, the primary care providers we spoke with, and we're not the holders of the data. Right. Maybe DHCs can share more about the data they have. But we know what do you do? You screen a patient and you find they have a behavioral health need. And they almost universally said, we tell them to call the county access line. Right. That's often not the right place.

And at least now if they call the county access line, we can help them get to the right place. But I think the point being. Yes, it delays treatment. And even when consumers are actually trying to seek the services directly from their managed care plan and know about it, the other barriers that we found, you can go on the website, you can't find half the websites. You can't figure out who is the behavioral health provider in network.

And we actually tested it in non English languages. That provider directory does not exist for a lot of plans. Right. And so it's really, really difficult. The system has not been set up to be consumer facing, I think, and to really help people find the services, particularly on the managed care plan side.

Thank you.

And then there's a same day billing issue.

Right. I just want to talk about one more thing, if that's okay.

We apologize for derailing your presentation.

No, that's fine. I'm really glad we're talking about this issue. I think it's an important one. But just on the other topic of the hearing, which is the documentation and the screening and assessment tools, I think one specific issue that comes up for us around screening and assessment tools, this is a historic issue. It's not a new one with the standardized tools, but is translated tools.

And I think we recognize in behavioral health, a literal translation of a behavioral health screening tool can give you very wrong information. We talk about mental health symptoms very differently in different languages and in different cultures. And so this has been an issue historically. We've talked to, in particular one community that speaks a Mexican indigenous language on the central coast. Their folks have been routinely turned away from county behavioral health services because it didn't line up with the assessment how they would describe their symptoms.

So counties, previously, some counties had changed things, understood their local communities, been able to change things. But our concern is when DHCs created the standardized screening tools, they did a lot of consumer testing and then they translated them. They did not consumer test, to my knowledge, the translations. And so we really feel like that's a missed opportunity, but one that we could still correct if we really wanted to go out and make sure those tools are going to work in different languages and in different communities.

So I hope that can still happen. And I'll just sort of, in conclusion, say, I think we often expect equity to be a byproduct of changes that generally lift all boats. But some of our boats are sinking so fast that we really have to be intentional and focused on those issues that are particularly concerning to communities of color. So happy to answer any more questions.

Well, thank you, colleagues, questions?

I just want to make a statement that for all of you and for the departments and for the counties, I just want to acknowledge how much work has gone on the last few years and will continue over this next decade. And it's huge. And I just think that bears stating.

Was an excellent presentation. Thank you all for joining us. I suppose I should see if Director Baass or Mr. Fitzgerald want to come back up and offer any final comments or would you prefer to stay there? That's okay.

In the comfy chair.

Do colleagues any questions of. Unfortunately.

I guess I just like to ask each of you, what was your impression hearing from people? I'm sure it's some of the same things you've heard. You're in conversation with these folks. What do you see as your biggest challenge going forward and what are you most excited about?

So I will say, I mean, very clear the balance between state directive and local flexibility. And we hear it here, we hear it with our managed care plans as well. And so it is a balance of providing locals or managed care plans based on their region, kind of the flexibility to design their programs to meet their needs, reflective of the other revenue sources that they may have.

And so I think it's something that we continue to work through of what is the right balance there in terms of a statewide, this is what you must do and what federal law allows us to say as well. And kind of this flexibility at the local level.

What are you most excited about?

There's a lot in flight and I think getting there, it's going to take years to really realize all of this. But I think we are really fundamentally rethinking what health means. And so recognizing all the contributors to a person's well being is, I think, the vision, and I think, you know, we have a roadmap to get there, but it's going to take time. And so just kind of seeing where we'll be in a few years is pretty exciting.

Thank you, Mr. Fitzgerald.

So thing I'm most excited about it again is I echo Director Baass. There's that integrated care and really thinking about people holistically. I think we've developed things in silos for so long, and now we're starting to realize that a person can be treated with one thing and another, not in another.

And so really kind of marching towards that, treating somebody as a whole person, whether it's housing or justice or health care or an education, I think that's a great way to approach just making people better in society. As general, I would say that the things that were set up here today from our colleagues are things that we deal with on a weekly, monthly basis and don't disagree with just about any of it. But I would say that I appreciate their partnership.

I think over the last three years, at least in the payment reform space and a few other tangential spaces that I've been involved in, the relationships and the communication are there. And so while we're not always on the same side of the table, I think we come to the table with good faith efforts and really try to resolve problems actively. I think we're all trying to be proactive instead of reactive.

I would also like to echo that there is a lot of things in flight, and it is a challenge at every level. When we continue every few months, get another great idea, and it's like, okay, here's your good idea today, and we all go in a vacuum.

Yes. Really agree with that idea. We will do that in five years. How about that? So that's where I would.

And as a departing member, I just want to say that I really respect and appreciate all you do, and I understand what it says, that everybody's got a good idea that they think should be done yesterday.

We see that every day. I want to thank you. Excellent presentation. What was your thought with regard to how we deal with primary care providers in the Medi-Cal context, with our managed care plans and access to behavioral health services, and making sure, or track one way or the other, either tracking and finding out they're not, or tracking and finding out they are, and making sure that those with behavioral health issues are referred on a timely basis?

That is one of the things we're working on with the closed loop referral. That's going to be part of kind of 2025 requirements, so we can track some of those referrals and see the results of them.

I will also say we are working with our plans to monitor underutilization of primary care as well, to design from like a population health management perspective, where are their cohorts of individuals or populations of focus who maybe are not utilizing primary care, and what interventions do we want to kind of develop so that it is that upfront intervention, it's the earlier engagement as possible in terms of making the connections of what might be needed and then finally I would just say last year we came out with some really focused materials for our families and children with regard to EPSDT and kind of the obligations of what that means, particularly in the behavioral health space of what children and youth are, the, it is an obligation of the state and kind of our various delivery systems to provide services.

And so thinking about how do we educate our members and our families, and also as part of our new managed care contract, we're requiring our plans to educate their providers with regard to EPST and what it means, if you're not familiar, early periodic screening and treatment. So it's this federal frame with regard to what children, it's like whatever it takes to impact or ameliorate a children's need. And so there's broad kind of abilities with regard to kind of what is available for children and youth.

And so just in terms of the space of kind of how we're thinking about provider education as well, in terms of what does EPSDT mean and kind of the obligations of what a provider can do, and it can be creative there a little bit in terms of what they could authorize for a child. So thinking about that more broadly with regard to behavioral health and provider education as well.

Any other questions? Thank you very much. Thanks for stepping back up to the bat a second time. We were kind. Right?

Okay. Well, that concludes our panel presentations and apparently our committee questions. So we're going to open it up to public comment. Anyone wishing to make comment on the presentation today, please step up. State your name and affiliation for the record and you may proceed.

Thanks very much. Good afternoon. Erin O'Brien. I'm the CEO at Community Solutions, one of the community based providers. We've been providing behavioral health services for over 50 years. We do it to all ages, zero to five, up to older adults, all the levels of intensity, outpatient, up to crisis residential. So we've been very deeply immersed in all of this for a very long time. And I want to start by thanking you for holding this hearing today.

I think it is really important and also to all of the parties engaged. I know everyone is working really hard to make CalAIM implementation and payment reform a success, and it is no easy thing to do.

I also want to give a special thanks to DHCs because they gave me my best Christmas present this year, which was the letter that they sent out on December 14, which was to the behavioral health directors talking about their expectations in terms of how payment reform was going to be done, which was not doing a peanut better approach, which way too many counties did, and talking about how their rates were set.

And I think part of what CalAIM has done is set an interesting and perverse incentive that wasn't present before between how the counties are reimbursed and how their providers are reimbursed, because now counties are reimbursed at a certain rate, and DHCs was very thoughtful in how they set that rate. But then the providers, how their rates are set, how we are reimbursed, is entirely up to the counties.

And so it creates an interesting and perverse incentive because the delta between the revenue that they're earning through our services and what they're paying us becomes theirs to use within the system as needs be. And that was referenced, but it becomes a little bit problematic because I think that the providers are highly incentivized to serve. We are mission driven organizations, and so we are going to be doing everything we can to maintain the services to the best of our abilities.

But agencies will get to places where they're out of that ability. And so the conversations that we're having now in terms of how do we reset the rates are incredibly important and urgent because as I'm up here this week for the alliance conference and talking with colleagues around the state, literally not a one, is sustainable. And so the conversations that we're having with our counties are really important. The county's alignment with DHCS's direction is incredibly important for our agency.

We serve primarily four populations, kids, adults, the seriously mentally ill, homeless, previously homeless, and the carcerally involved. If our county, which is an active discussion with all of the providers to amend, but if they weren't doing that, we would be down to one division left. We would only be able to serve the adults. That's not what anybody needs. So these conversations, your attentions that matter, is just incredibly important, and I'm very grateful for it. Thank you.

Thank you, ma'am. Next please.

Good afternoon. Eva Terrazas, chief public policy officer at Pacific Clinics. Pacific Clinics is a statewide behavioral health agency operating in dozens of counties throughout the state, delivering integrated behavioral health and social services for children, adults and families. So we serve the full age spectrum. We are Members of both the California alliance and CBHA. And I just want to say ditto to everything that Erin just said because it's exactly the concerns that we have.

We are also very appreciative of the leadership of the senate committee to hold this hearing on CalAIM implementation. You've all heard that community based agencies are a central partner in ensuring we are meeting the needs of a very vulnerable population. We share the concerns raised by the provider associations on this last panel, particularly ensuring that we have a financing system that adequately covers the cost of community based care.

Pacific clinics would like to be a resource to this Committee as CalAIMs continues to be implemented and their future discussions about how CalAIM is being implemented locally and statewide. Thank you.

Thank you, ma'am. Next, please.

Good afternoon. My name is Marika Collins. I'm the director of public policy and advocacy with Didi Hirsch Mental Health Services in LA County. We've been around for over 80 years providing mental health services, substance use services, and prevention services across the age lifespan from zero to five children, youth adults, transition age youth.

And I really want to commend and say how much I appreciate you holding this hearing because CalAIM is something all of the providers here are living and breathing every single day and really trying to make the best out of it. So thank you for holding this hearing. As you've heard from all of our associations that are present today, CBOs are really and truly the lifeline for service deliveries in California for our most vulnerable, challenging, difficult to treat children, youth, adults.

And as Eva just mentioned, we're mission driven. I'm also at the alliance conference, and it's a matter of what's your deficit this year? What's your deficit? zero, you're only 1.5. We're 2 million. I'm not speaking for my agency, but those are the conversations we're having. So this rates discussion is not about how much in the black are you? And we just want to cover our costs. We just want to be able to serve the children and the community members.

So I really wholeheartedly appreciate you holding this hearing, and I would just encourage you to continue to ask questions, continue to really just advocate on our behalf, and we'll continue to provide you with the information that you need. So thank you very much for your time today.

Thank you. Thanks for coming. Thanks for what you do. Next, please.

Robert Harris, on behalf of SEIU California, we have members who work for provider service agencies and who work for the counties. And so we've been engaged in discussions about the rates and how they affect individuals. Right. And trying to help everyone find solutions. We like Le Ondra, we like Adrienne, we like Michelle, we get along with them, and we're trying to solve that particular problem. I think the other problem that exists right now in the system is the stigma problem.

And it isn't stigma against mental illness, it's stigma about SUD. In fact, we're really encouraged by the department actually bringing up the fact that kids with SUD are entitled to EPST by the federal law. It was never treated like that. The counties didn't want to do it, the plans didn't want to do it and the state didn't want to do it. So that's important because if that stigma is going to still exist as we try and integrate everything, we aren't going to get integration.

So that's one thing. The second thing is if you look at the sud workforce or if you look at the whole behavioral health workforce, no one looks like the people getting services. No one except for sud counselors. And because of the Low rate structure, they stay about two years, but they're the only people who look like the people getting services. So we've got to figure out some way to fix this rate structure where it isn't disproportionate, it isn't unequal. We don't think mental illness is.

Mental health issues don't include SUD because they do. And it's really important that we pay attention to that because that's where the rate inequity happens the worst. So that's all. We really appreciate you doing this sharing. We'd like to see more of them and we appreciate everyone's trying to work together, even though it's a difficult situation. So we'll keep working on making it happen better. Thank you.

Thanks for working together. Thanks for coming. Next, please. Yes, ma'am.

Good afternoon, Mr. Chair, Madam Chair and members. Jolie Onodera, with the California State Association of Counties, representing all 58 counties, wanted to thank you for the robust discussion today and for your leadership in this space.

Really just wanted to take the opportunity to acknowledge and to appreciate, as Dr. Eggman had said, just the immense amount of effort that has been done by the department, counties, our county partners, providers and all of our community partners that are really essential to actually make this very significant and multi year initiative a success with that and just look forward to continued partnership with you and with all of our partners. Thank you.

Thank you, ma'am. Next please.

Good afternoon, chairs and members. Trent Murphy, speaking on behalf of the California Association of Alcohol and Drug Program Executives, also known as CAADPE. CAADPE's members provide SUD services at over 400 sites throughout the state and constitute the infrastructure of the state's publicly funded substance use disorder network. CAADPE is continuing to work with DHCs and provide providers effort on efforts to ensure adequate payment rates for behavioral health services and to ease paperwork and documentation burdens on our providers.

Thank you.

Thank you, sir. Any other public comment? Well, with that, I'd like to thank our panelists for an excellent presentation. Members of the public who attended and who provided comments, my colleagues who attended, staff who helped some of us prepare, and to my right, my superb colleagues for providing their experience and the questions that they asked during the hearing. So with all of that, see you next time. This hearing, Joint Hearing, informational hearing is adjourned.