Assembly Budget Subcommittee No. 1 on Health and Human Services

Good afternoon. We are going to call Subcommittee One on Health to order. We can call roll.

[Roll Call].

Today we will be doing an overview of the public health behavioral health system here in California. We are going to start with Mister Will Owens from our Legislative Analyst Office for his presentation. Thank you.

Thank you for having me Chair Weber. As you said, my name is Will Owens with Legislative Analyst Office. And today I'll be presenting some information found in our handout on the overview of the public behavioral health system in California. So we're going to be discussing three primary areas in this presentation. The first is the various behavioral health delivery systems found in the state. The second is broadly the continuum of care for behavioral health services.

And finally, we'll discuss some recent behavioral health initiatives and how they generally fit within the state's overall behavioral health efforts. So on the first page of your agenda or the third page of our handout, find a high level graphic which shows the different delivery systems provided throughout the continuum and the different services that can range from everything from prevention and wellness services to acute care services and facilities. So the graphic itself, as you can see, is fairly straightforward.

However, the behavioral health system in the state is quite complex. There are multiple delivery systems, each providing services of varying acuity, and individuals often move up and down the continuum as their needs change and across delivery systems. So this figure is meant to be illustrative and doesn't really capture a lot of the overlapping levels of service that can be found across delivery systems in between levels of care. But it's more just to give you a broad conception of the system as a whole.

So, first, with our discussion on the various delivery systems, public health, or rather publicly funded behavioral health services are typically provided through either counties or state funded managed - Medi-Cal managed care. So counties are primarily responsible for the funding and delivery of behavioral health services for individuals enrolled in Medi-Cal with the very highest needs. The state, on the other hand, typically funds individuals enrolled in Medi-Cal with mild to moderate mental health needs, and these services are delivered primarily through managed care plans.

So while not necessarily the focus of this hearing in particular, we'd just like to touch on that. Behavioral health care is also provided in other publicly funded settings, particularly in state run institutions, specifically the Department of State Hospitals and the Department of Corrections and Rehabilitation. Also, behavioral health is provided within the educational system, both in K-12 schools and institutions of higher education. Our handout describes some of these institutional settings and education settings and some of the services they provide.

But I won't be touching on them in this presentation. So next I would like to talk briefly about the continuum of care. As mentioned, this ranges from prevention and wellness services all the way to acute care services and facilities. So behavioral health services are provided on this continuum based on the needs of an individual. We provided a high level breakout of these types of services on page seven of our handout. And so the different levels of the continuum we describe aren't all encompassing.

For example, there are crisis intervention services that you could consider prevention, as well as outpatient services or even an acute care service kind of continuum. So the actual services provided range on the spectrum, and there's quite a bit of overlap, I think, in your agenda there's also a continuum of care demonstrated by the Department of Healthcare Services. And as you can see, there's some flexibility there with how you define some of these. But just to give you an overall impression of lower acuity and higher acuity.

So putting this all together, want to touch on briefly some of the recent behavioral health initiatives that have happened in the state. And so there have been a number of recent behavioral health initiatives. And, for example, the Children Youth Behavioral Health Initiative. This is something that cuts across multiple departments and includes multiple service delivery systems.

This can make it difficult sometimes, maybe, for the Legislature to evaluate the outcomes and to make future budgetary decisions, as a lot of these programs touch on so many different parts of this continuum. So in our handout, we discussed broadly the different areas of the behavioral health system that are impacted by some of these initiatives, from behavioral health services for children and youth, behavioral health services for adults, behavioral health infrastructure and behavioral health workforce, which I know was a subject for another hearing.

But all of these things kind of tie together. So to kind of give a high level takeaway of a number of the recent behavioral health initiatives and how they've impacted the system, we kind of have two main points. The first is that many of the initiatives include efforts to increase capacity broadly across the behavioral health system.

These include efforts to improve behavioral health infrastructure, increase bed capacity, things of that nature, as well as improve and expand the workforce, as well as improve the pipeline of behavioral health workers. So much of the funding for the behavioral health system in recent years has been limited or one time funding. And given that the nature of these funds were one time, using them to efforts to increase capacity rather than fund ongoing services, our office is generally found reasonable.

The second kind of overarching message that - or theme that we've kind of found with these recent behavioral health initiatives, is that there's been a large focus on connecting new or underserved populations with services in new ways. So, for example, efforts like mobile crisis services, these efforts not only connect to individuals who may have been lacking access to behavioral health services, but also provides these services in a new way in the community and not in traditional, maybe office or doctors settings.

In addition, initiatives like the CARE Act create a new process by which individuals may access behavioral health and wraparound services. As I discussed, these are just some of the main takeaways, and in our handout we go kind of breaking out the various initiatives. These aren't all encompassing. There's a lot of components of a lot of these that we don't touch on. But these are just to give you a broad overview of the different ways that these initiatives have impacted not only the behavioral health system, but kind of how they fit along the continuum as well. With that, that concludes my presentation and available for questions.

Thank you so much for your presentation. One of the things that you just touched upon was that what we're trying to do here at the state level is very diverse and touches a lot of different areas. And that, of course, is important because behavioral health shows up in a lot of different areas. But I guess my question to you is, do you, when you're analyzing and when you're looking at the programs and where they have been placed, do you feel like they are too spread out and too broad that it's hard for- that it would be hard for us to really determine the effectiveness because we're touching so many different areas.

I think that speaks a lot to maybe outcome evaluation for a lot of these programs. Right. I think, as you say, a lot of these kind of span across the spectrum, not only in service delivery, but in infrastructure, bed creation and workforce. I think when you are evaluating something like behavioral health broadly, it's a little hard to conceptualize what that means is, you know, what is good behavioral health. How is the state making improvements upon it.

I think the way we approach it when evaluating is we look at maybe the programs a little more discreetly and what are the outcomes for a specific program. Are the beds that were projected to be created with a new proposal, are they being created? Is the money getting spent? Is it being used? And that's kind of through kind of budgetary means like, that is kind of the way that we evaluate these things. But I think a broader question on are all these things together improving the behavioral health outcomes in the state is a very valid question and something the Legislature should really evaluate when looking at these proposals.

Thank you and I think along those lines because the state is investing a lot of money, as they should, in the behavioral health space. But there have been times when the state has invested a lot of money in a variety of different things, and we really haven't seen the outcomes that we're hoping for. What advice would you give to the Legislature as far as oversight? How often should we be asking for the data to show whether or not some of these programs that we're funding in all of these different areas is actually improving our patients, our residents that have behavioral health issues?

Yeah, so I'll say specifically in recent years, as I mentioned, there's been a fairly large investment in behavioral health services, a lot of this one time or limited term in funding. So I think especially when you look at things that have to do with workforce, with hiring, with infrastructure building, these things can take some time to kind of work through the system.

I think the Legislature should always take the opportunity to ask and work with the Administration regarding specific outcomes of funding, regarding how the funding is being spent. Is it being spent in a timely way? These are all things that we try to look at and evaluate throughout the budget process and even outside of the budget season, is kind of evaluating these programs on a budgetary basis. And any opportunity that the Legislature has a particular interest in a specific initiative or specific part of initiative, I think is an opportunity to perform oversight and to ensure that it is meeting legislative expectations and objectives.

Thank you for your presentation. I do think that from a legislative standpoint, we are going to have to do things a little different. And I think one of the things that we've addressed here on this Committee deals with the loan repayment program for the psychiatry division. So as we talk about increasing workforce, and I noticed that was also mentioned about loan repayment payment, we allocated those fundings, and yet it was never actually implemented.

So I do have concerns because it is so broad at this point whether or not we'll be able to really, truly wrap our arms around everything to make sure that all of these things that we're funding and we're trying to do are actually working. And if not, where is the area that we need to tinker. But it is definitely something that we, the Legislature, need to do a better job of, and I'm sure we will in the upcoming future.

So with that, I want to thank you so much for this overview. We are going to now turn to our panel. And I'm going to ask Toby Ewing from the Mental Health Services Oversight and Accountability Commission, Michelle Cabrera from the County Behavioral Health Directors Association of California and Doctor Alexis Seegan from the California Association of Psychiatrists. Thank you. And you can begin.

Thank you very much, Toby Ewing, on behalf of the State's Mental Health Commission, really appreciate the chance to join you and that you're focusing on behavioral health in this way. This high level overview. As you stated earlier, the state has made significant investments, yet we've also struggled to figure out how we can most appropriately understand the impact that those investments have had and more importantly, understand the mechanisms that those investments are supporting that lead to the outcomes that you're looking for.

We look at what happens around California and around the country and in other countries, and the good news is that we've made substantial progress in prevention, in early intervention, in tailoring care to be responsive to needs, in understanding how we can better do peer and community empowerment, peer and community engagement to really shape the programs and policies that are impacting the lives of people we're trying to serve. We're leveraging schools, the workplace, the talents and capacity of community based organizations.

There's been hundreds of millions of dollars in innovation investments across the state. The State of California is far ahead in terms of the progress we've made to meet needs. Yet at the same time, we have just profound challenges. We're often not outcome based per your comments. Too many people continue to be to make contact with behavioral health services through law enforcement or jail or prison or locked settings. We have profound delays in access to care.

We have over reliance on deep end care because our systems and strategies to do the early intervention often are not as robust as they need to be. We also don't have sufficient opportunities to learn and scale around best practices. We see very strong patterns of learning and scaling, of research and investment in incentive financing and other aspects of healthcare and other areas of public policy. But the behavioral health system is new. Those strategies are new to the behavioral health system.

In the last five years, we've seen just tremendous progress and leadership from our county behavioral health partners in that area. But the potential to actually expand those opportunities is tremendous for this state. Fundamentally, public understanding of our behavioral health system is challenging. I receive phone calls, often in the middle of the night, from people who don't even know where to turn.

And that is highly unusual in other aspects of healthcare, where people have a really clear sense of the of way the system is organized, how they access that system, how it's being paid for. And behavioral health system that is a huge barrier. Stigma certainly is a continuing challenge, and disparities must be an area of focus and an enduring commitment, something that the state has made some progress on, but it continues to be very difficult.

We really must do more to engage early on to reduce the deep end - utilization of deep end services, but also to reduce the costs associated with that level of care. The state has an opportunity to redesign and rethink, to really pull resources out of deep end care and make them available through more upstream, much more cost effective strategies. Again, I'd say, you know, California is leading the country. We have - we're very optimistic, optimistic about opportunities to really do this well. But as we can see from the news every day, from what we see when we walk down the streets in most communities in California, we have a lot of work to do. Thank you for the chance to join you. Happy to answer any questions you have.

Thank you.

Good afternoon, Madam Chair. Michelle Cabrera with the County Behavioral Health Directors Association of. California. And today I'm going to speak to the behavioral health continuum, and we've prepared a one page handout to help provide a visual aid for my talking points. And I'm sure you'll hear quite a number of consistent themes across the various speakers today. We know that our communities have faced increased need for behavioral health services in this pandemic era.

Along with climate change, political unrest, social media, and with the arrival of Governor Newsom's Administration, California has embarked on a significant number of reforms focused along multiple delivery systems, including commercial plan parity laws and enforcement, new investments in rates for Medi-Cal managed care plans, mild to moderate benefit, the payer agnostic CYBHI school based fee schedule and virtual services platform in schools, the rollout of our 988 crisis hotline and numerous other major reforms in the county behavioral health safety net, including, but not limited to, payment and billing system reforms, as well as an overhaul of our Mental Health Services Act and LPS involuntary care laws.

These things are happening virtually simultaneously. I will note that the vision of the continuum that I share with you today, one that starts at prevention and moves all the way through outpatient, intensive outpatient, acute, and the highest levels of involuntary treatment in state hospitals, are quite unique to county behavioral health. No other behavioral health system stretches so far to meet the community needs so comprehensively.

And although counties do serve the whole community to the extent that they have resources, our primary obligation stands with the Medi-Cal population. Within Medi-Cal, counties are managing an entitlement, meaning that we have to serve any Medi-Cal beneficiary with the complex need for specialty mental health or substance use disorder services. The behavioral health continuum is also inclusive of a range of programs and services that are today not eligible for any sort of insurance reimbursement.

For example, prevention is largely not funded by any insurance payer, and until Medi-Cal started paying for short term housing and supports, no payer covered housing in a medical model. What is or is not covered varies tremendously by payer as well. But those gaps are significant in either creating or exacerbating conditions into preventable disability and premature preventable mortality outcomes.

In fact, behavioral health conditions are the world's leading cause of disability, and this is why, in our discussion of the continuum, we're inclusive of individuals with commercial insurance as the underinsurance that they experience is and can be a significant driver of disease outcomes as well as recovery. For too long, commercial insurers have treated behavioral health conditions almost like an elective, forcing their beneficiaries to pay out of pocket if they can afford to, rather than providing ready access to the very benefits they pay for.

In fact, one study showed that commercially insured consumers pay are six times more likely to pay out of pocket to meet their behavioral health needs than for other physical health conditions. It also means that for the vast majority of consumers who lack the financial resources or or wherewithal to navigate accessing the appropriate care on their own, their lives can rapidly spiral to the point of hitting emergency departments and the criminal justice system, or worse.

In Medi-Cal, many of the essential functions that county behavioral health services provides cannot be funded, even through Medi-Cal. California is pursuing an 1115 waiver to waive the rule that Medicaid will not typically pay for residential or inpatient mental health treatment in facilities larger than 16 beds. This law recognizes that larger settings historically were not places of healing. It dates back to the establishment of Medicaid and was meant to reinforce the deinstitutionalization laws signed by then President Kennedy.

Prop One provides the resources for us to pursue housing and facilities needed to - but it shifts funds from mental health to try and address those housing and substance use disorder needs. The net impact on our system is that the most acute levels of care for Medi-Cal are largely not covered by the state or the Federal Governments.

Waivers like the DMCODS for substance use and the pending BH Connect waiver under Medi-Cal for mental health services may allow us to provide limited federal financial participation, but those initiatives both come with many strings attached. Similarly, outreach and engagement services, especially those needed to reach people who are unhoused, are essential in identifying individuals who need our services and bringing them in, but outreach and engagement is not covered under Medicaid.

The reason the continuum of care matters so much is that we know that when individuals have awareness of what behavioral health conditions are to the point of our anti stigma efforts - and thank you so much for your Bill on that topic, Chair - and how to address them, they can advocate for themselves and their loved ones to get care early. When outpatient and specialty care services are readily available, individuals can most often heal, saving individuals, their employers and the government, potentially hundreds of millions of dollars.

One study found that individuals with behavioral health conditions are among the medical systems most costly. But more importantly, we can avoid the unnecessary suffering that ripples through families and communities, quite literally intending to access the appropriate, medically necessary care that's necessary to save their lives. In order to do this work, we all need a robust continuum that starts at prevention and works as hard as possible to ensure access to comprehensive, quality outpatient and early intervention for specialty care needs. This is the mission of county behavioral health. We see consumers achieve recovery every single day and very much appreciate the opportunity to discuss this important topic with you today. I'm also happy to take any questions.

Thank you.

You know, one of the things that's been so, you know, we've seen so profoundly in the last few years is that the most trained psychiatrist, the individuals with the most training for mental health treatment are actually treating the least ill. You know, the people who are NPs, PAs are now going... They're going to the places where, basically, psychiatrists aren't financially enticed to go. Why is that? Because...

And they're treating our most ill individuals when really the individuals with the most training we would think should be treating the people with refractory schizophrenia, refractory depression. And part of that is loan repayment. Part of that is Medi-Cal and Medicare reimbursement. It's just not financially solvent for individuals to be able to often go and do those jobs where they can make more and not have to deal with insurance. So that's part of an issue.

But, you know, working with people, I primarily work with individuals with serious and persistent mental illness. And one of the most profound things that you see is this idea that people have to fail upwards within the system. When we identify them as having a severe need, somebody we identify is going to be ill and need higher levels of care, we can't always get them that initially. They have to go through whatever county system.

And that's the other problem, is that the counties have vastly different ways of handling intakes and even the criteria for some different programs, which makes it really difficult when you're in one hospital in one county and maybe you live in another county, even if that county happens to be five minutes away.

But the, you know, individuals are not able to get those higher level services that we think they're going to need, and then they have to essentially waste time, waste another hospitalization, you know, their own potential disability, in order to gain access. I worked with a young man who had schizoaffective disorder and basically bounced between inpatient jail settings until, at one point, he ultimately tried to take his eyes out while he was in jail in the midst of a psychotic episode and was permanently blinded.

And that was actually the only thing that landed him in the hospital for long enough for us to be able to fully stabilize him. And now he's doing quite well, has a wife, has a baby. But unfortunately, it took him doing something that severe for him to be able to get the care that he needs. And that's the problem we're seeing. It's this revolving door.

We, people there, the continuum that we've been promised of care that's going to exist with CARE Court, those types of things, is just not coming to pass. We need a true continuum. A lot of these housing options that people are having available do not fit the unique needs of our population. Some can be much more independent than others, and we're really missing that, and that's leading to this repeated revolving door hospitalization.

The number one goal we, as psychiatrists, have for our patients is to see them functional, having, you know, working within the community, having families. But, you know, the current system kind of misses lots of... There's gaps where a lot of our patients don't fit. And so I think that's the challenge that we see is that we're always trying to put school square pegs into round holes and find what can we help our patients get to and what can we, and what are they not able to get because they don't have a referral from a particular agency.

And it's, you know, I think in the end, this is why you have a lot of people not wanting to work within agencies, for instance, the healthcare agencies or, you know, ones that are dealing more with a larger population or a more Medi-Cal population because it's just frustrating. It's frustrating.

And the other, I would say, issue is that the support staff in a lot of these programs are not particularly... There's a high level of turnover, which I do think speaks to potentially the reimbursement or the pay, amount of stress that those individuals are under. Because we know that we as physicians cannot operate in a vacuum. We need our support staff. We need social workers, we need therapists. And so if none of those people are available, it's extremely challenging. And so, you know, I will say, having worked in Orange County for a number of years, things are a lot better than they used to be. But we also know that there can be a lot of improvements. So thank you.

Well, I definitely want to thank you all so much for your presentations and for being here today. Do have a couple of questions for each of you. You spoke about learning and scaling up. Can you elaborate on that a little further and also kind of give examples for whoever may be paying attention, how we do that in the other areas of healthcare?

Absolutely. Probably six years ago, we commissioned some research by UC Davis to look at access to services for folks in the very early stages of psychosis. So there's a national research study that documents an evidence-based practice. The research was done with people who have had their first episode of psychosis was within 18 months of receiving these services. And the federal government has documented that this package of service, referred to as coordinated specialty care, is highly effective.

It can result in as much as a 74% reduction in justice involvement for the people that are served. But when we asked our subject matter experts to look at programs across the state, there's huge variation in the type of care that people receive. Many families don't even know what to ask for. Right. And if you compare that to stroke or heart attack or diabetes or obesity, people have either a strong understanding of what the expectations are or they know where to get that information.

But psychosis is different. Most of us actually don't have good guidance on what that means, what to look for, who to call, and then how to advocate to receive evidence-based practice. Most families don't even know if the care they're receiving is evidence-based.

When we meet with families and when we talk with practitioners, they'll tell us that families will say for their children, it's typically children, late teens, early twenties, that they would rather their child had cancer than schizophrenia, in part because they know what to expect, in part because there's hope. When in fact, we have an evidence-based practice. It's highly effective, but it's a roll of the dice in a given community if you will receive that. There are huge wait lists.

There are profound barriers to care, in part because of how we pay for it, because of how we train our practitioners. So many practitioners don't actually know if they're delivering an evidence-based practice based on the diagnosis. So Dr. Tom Insel, former Director of the National Institute of Mental Health, he's written and shared multiple times that the quality of the care, the care you receive is often based on the training of the person in front of you, not your diagnosis or your need.

So we have a long way to go. We know what the practice is. We know how to deploy it. The good news is through the Child Youth Behavioral Health Initiative with MHSA Innovation Funds, the State of California is standing up strategies to develop more evidence-based first episode psychosis programs across the state. We're working with the private sector. We're working with the federal government. We're working with lots of partners, including our county behavioral health partners, to really scale that. But it's swimming against the current. It's very difficult to do.

So maybe you can help me understand how this could even be possible within the realm of healthcare space. Because we have national standards, we have national guidelines which are evidence-based, but why are we seeing differences in how that is delivered?

I think for specifically the first episode psychosis, one of the major issues is the funding. A lot of that comes from that. It's not just medication that has the evidence-based, it's all the other interventions, the psychosocial interventions, the family interventions. And clinics are not always, you know, a random, you know, clinic may not be able to deliver that.

If there's an issue with reimbursement, how are they, and there are some newer codes coming out, but how are they going to actually obtain reimbursement for those services that are essentially collaborative in court and going above and beyond the actual facetime, seeing the patient. So that's why those types of things, it's really hard for people to implement them within a clinic.

It's much easier to say just go and see somebody. Sit in there for a half hour or whatever, maybe, hopefully not 15 minutes, but maybe a little bit more. And to have them. But to have them actually be able to see these other people be part of occupational and occupational academic supportive services, those are all the things that take part in, for instance, that type of a program. And those are the types of programs that are just hard to access. They're more expensive.

Insurance, a lot of times these are run through the county, and so insurance doesn't often know how to reimburse private insurance. So it can be actually sometimes difficult to know where to refer somebody based on their insurance. And so I think practitioners try to do what we can to be within evidence-based care. But a lot of these evidence-based care guidelines for mental health are not just the medication. It's this supportive network that you really need to have.

And that's going to depend on the quality of the training of those individuals. Kind of, I was talking about, like, if there's turnover, language barriers, and so a lot of our individuals, their families may speak other languages, and so are you having those services as a family of services in their language? And so it can be fairly complicated. And so a lot of clinics honestly have shied away from doing this.

Is this an issue that we're seeing across the country, or is this unique to California?

If I may jump in on this overall question. And you know, first episode psychosis programs have largely been built up by our county behavioral health safety net system, and with support from funding through the MHSA, as well as different federal grants that we get. And the way that I like to put it is that we have a system that has patchwork by design and that starts at the federal level when the federal government decides to do grants, right, instead of standardized benefits for services.

And the effects of that sort of piecemeal approach policy-wise are compounded by a lack of comprehensive, quality, accessible coverage for people with commercial insurance, which is like half of the market. And this is a warping of market-based healthcare that we don't really see in physical health in this way. Which is why I said people with commercial insurance six times more likely to go out of network and pay out of pocket.

So if you can't get what you need from your private insurance plan, yeah, you're kind of sort of left to your own devices. And that's true for both the individual as well as their providers who say, gosh, it would be really great if you could access this program. And that program may or may not exist in your county, and it may or may not be available to you as a person with commercial insurance. Why is that?

Because the safety net is not currently designed to cover every single Californian with a specific diagnosis, regardless of insurance. Right. We don't have a single payer behavioral health system. We have insurance-based. And the safety net may step in and expand a little bit and open its doors to people with commercial insurance because we see that sometimes if we don't step through that door and let them in, that person might die.

And that's, you know, that's unfortunately the reality with many of these conditions. Or they may become very sick and then eventually qualify for our services. And so we have sort of a moral obligation. We have a desire to be helpful when we have something that doesn't exist elsewhere. But I think part of the question needs to be, how can we get all of our systems to provide that more comprehensive coverage so that the safety net isn't sort of holding everything?

And I think if we got more payers in and improved the reimbursement and overall funding for the safety net side of things, we might start to get to a point where things are sort of turning around more broadly. But it has to be an all in approach. Right. The full set of payers have to be at the table. The providers need to be supported so that we can build out more of these programs so that it's not so scarce.

Thank you for that. You know, along the lines of payers and Medi-Cal and commercial insurers, we know that Medi-Cal reimbursement rates are horrifically low within the realm of behavioral health. And unfortunately, many providers just don't take any kind of insurance either because of reimbursement or because the paperwork is just too onerous to try to get those funding back.

Dr. Seegan, maybe you can answer this question. Because I have asked many times and no one seems to be able to tell me, how many psychiatrists, board certified psychiatrists, do we have here in the State of California?

That's a good question. I know we, part of our organization is about 3000, so we don't represent all of them. I can get back to you on that though, definitely.

Okay. Because one of the things that I have asked multiple times is how many psychiatrists do we have and how many of them actually take insurance. Right.

You know, I will say I think the tide is turning a little bit with, you know, my residency year and residency, you know, classes that have graduated since. I think more individuals are being enticed to go into the county systems because of loan repayment, stay in academic systems. Some go to the prisons. That's actually been a, they've done a very good job of enticing physicians and psychiatrists there. And so I do think that there is movement in that direction.

But I would say, we, at our University clinic, we have a waitlist of several months for, because we take Medi-Cal, Medicare, and commercial insurance, and we're just one clinic. But we have a waitlist of several months for both sides, psychiatrists and therapists.

Wow.

And Chair, I want to say, with funding from Kaiser Foundation of Southern California, CBHDA worked with UCSF Center, Workforce Center and Dr. Janet Coffman. And she did an analysis in a report that we published, and I'm happy to share it, that shows that in California we currently have roughly 6000 psychiatrists that are licensed to practice in California. Now we have asked for more data on sort of payer mix and those sorts of things, and we've made those recommendations to HCAI as they're rolling out the various initiatives that they have.

Thank you for that, for at least giving me a number, because no one in the past has been able to. But I do think that is significant. As we talk about workforce challenges, training, the question is, do we have the providers out there but they're just not seeing the patients because of reimbursement. Right. Or do we need to increase the number of providers that we have. I know a significant number of providers do not take insurance, any insurance.

And so it is very challenging for individuals to be able to see these people because they do have to pay out of pocket, and it is not inexpensive, especially if you need to go and have multiple visits. What are we doing to ensure that, as we're rolling out these different programs, that we are rolling them out in a way where a variety of communities will have access and that we are ensuring that we are providing equity as well?

There's a lot in that question. Thank you. California, through work that started in Solano County, really has been pioneering strategies to really elevate community engagement to support discussions about what should be funded, how it should be funded, where programs should be located, even really looking at redesigning services, even the language that we used. We've seen dramatic improvements in public trust, in access to care, particularly among underserved or inappropriately served communities.

In partnership with the Commission, but mostly through the work of the County Behavior Health Directors, we've really been able to expand some of these approaches. This is part of this. We support learning collaboratives. How can we learn and share many of those best practices? But I also would say that we have a long way to go in making sure that we are being responsive to the needs of people. Right.

You know, my comments earlier about, you know, the public not having good pathways, good guidance and understanding where to turn to. I appreciate the in depth on the early psychosis strategy, but that's one of, you know, three dozen examples. Right. I think, you know, we have to do a better job on the community engagement side, and we also have to do a better job on our capacity to learn around how these programs are working or not working.

We have to get better at understanding what's driving these impacts and really thinking about our system systems design, particularly in areas like criminal justice involvement. Right. The state supported and many counties adopted what's called the Sequential Intercept Model. Do everything you can to help someone move away from the criminal justice system when there's a behavioral health need. We've sort of lost some focus on that, and we've lost some intensity in that area.

And that's an area where we see profound disparities, we see profound challenges around public trust, and the costs are enormous relative to what we could do. So, you know, we're very excited about some of the new conversations that are happening under Prop 1 around workforce, around an elevated role for the Department of Public Health on prevention, an elevated role for the state in partnership with the counties around early intervention.

There's a lot that we can do, and other states are actually doing a bit more, in understanding how to think about where areas of early intervention should be sort of the focus of our investments and what those early interventions should be. This system of scaling, it is very much a patchwork by design.

But in order to sort of move towards more consistency, more effective services, and more ability to learn will mean us thinking about how can the state provide more technical assistance and support for our local partners, both on the public sector side and the commercial insurance side from this sort of broad population health lens. So, you know, the good news is, you know, we actually know how to do so much of this.

The challenge is resources, kind of, you know, workforce capacity, and it's going to be really important to align and line up those investments in ways that help us think strategically. Your question about how many psychiatrists do we have versus how many do we need relative to how can we meet that behavioral health need through a much more diverse workforce strategy, which we've seen in, for example, nursing, where we diversified the field pretty dramatically. The new behavioral health coach component of our workforce is essential.

Really leveraging our schools, really leveraging our community based organizations, particularly in rural communities, in communities that are suburban or diverse language, diverse ethnicity. It's not a simple question. It's actually a pretty complicated question. But I think it's the key challenge that California has to do better on.

Madam Chair, if I may also, I want to give a couple of specific examples of the way that we can really maximize and leverage the state's one time investments, in particular on the workforce side. We know, as Mr. Ewing stated, that it is really possible to turn workforce shortages around. This is a simple formula of expanding slots and increasing pay so that people have a living wage on the other side of that schooling. Right?

Currently, county behavioral health is losing staff to the fast food sector oftentimes, and so we need to be far more competitive than we are. And in terms of expanding slots, our workforce report also looks at geographic regional differences and disparities. The San Joaquin Valley by far outpaces the rest of the state in having the biggest need.

So if we expanded slots in the Central Valley, we would draw from a more diverse population of students and help to ensure that more of them stayed in those communities to practice where they're so desperately needed. We also need to change the quality of the education, so the curriculum needs to be far more oriented toward safety net rather than some of those self pay, private practice kind of orientations that so many of the schools currently have, unfortunately.

They're training people for a single shingle rather than for working in high touch, crisis oriented, field based, home based. Our directors are seeing that, and they're dismayed. If these public dollars are rolling out, we can attach strings to it to say this is what we want in terms of curriculum. So simple formula, expand the slots. We would suggest, put those slots in places where it's more diverse and necessary, and then attach some strings to those dollars.

Similarly, on the continuum side of things, we have some extraordinary county behavioral health directors who say, I hardly need to conserve anyone because I've invested so deeply in my outpatient services and in my upstream interventions. The goal should not be for us to get bulky on the high end of the continuum. It should be for us to bulk up on the early intervention and outpatient side of things.

And so I think we need to look at that as we're building out what we're building out. Because if you build it, you then need to sustain it right over the long run. And what we don't want to see is a ton of crisis services, a ton of acute and inpatient. But that means we need to bring a bunch more people into the discussion and the conversation about accountability and ensuring that access to quality outpatient early intervention services.

And there needs to be that monitoring across multiple payers, also delivery systems within Medi-Cal, so that when people present with a need early, not just the individual, but their primary care doctor knows what to do. Too many primary care physicians, unfortunately, don't know what to do when presented with those issues.

Also about, with regard to kind of diversity, I think we know that there are better outcomes when people have a physician that looks like them, that speaks their same language. And so there's a couple of things. I mean, at the very top, we need to be recruiting and continuing, continuing to support people who, you know, speak Spanish, speak, you know, in Orange County, Vietnamese is a large minority, who speak these languages to stay within community settings.

The other thing we need to do, and this goes as more of a federal issue, is how do we, actually, we need, we're short on physicians. There's going to be multiple people retiring. Even if we're not, we're short now, but we're going to be even more short as things come in.

And so having Congress increase the amount of residency slots is essential because we can't make more doctors without more residency spots and also having, and then we can have med schools work on recruiting into more, you know, there'll be more med schools, we can recruit a more diverse applicant pool. Because right now, you know, this goes down to, you know, where people are born and how likely they are to get into medical school just from the moment that, you know, where they're born into.

So that being all said, I think we need to help people stay where they're needed the most. And we do know that a lot of people do stay where they train. I will say, I think from the psychiatrist standpoint, the single shingle is actually a lot less common than it used to be. I think it's just a lot harder to do. Yeah, it's apps. So, yeah, going to apps is one thing people do. Doing, like through... Yeah, but at least they take insurance, which is better than just nothing. But I think there is a pull, again, I think a lot more people are going into community programs, but we need to make it entice them to stay there. And then with regard to the...

You can kind of mentioned just as a side point, the continuum and where we should invest. I do want to make sure, having worked in inpatient, that we're not forgetting that there is a group of individuals that no matter what we do, they are going to be ill and need higher levels of care. And right now, at any given point in time, we have up to 50% of our inpatient beds utilized by people who are waiting for a long term care bed.

And so that's another aspect of bottlenecking. That's. And that goes, again, also to part of the federal, the IMD Exclusion Act and everything. But, you know, there, it's hard. Again, we have different populations with very different needs, and we're trying, this is a system where we're trying to meet the needs of all these different populations, and some are going to be much more reliant and have a lot of benefit with the outpatient. Some people need the continued structure of, not even necessarily inpatient, but of a support supported living. So we talked for a long time about this.

Yes, I understand psychiatry is a very broad, behavioral health is a very broad field. I do tend to hope that we could focus a little bit more on the preventative aspect and the early intervention, and beef that up. There are people who will need inpatient and chronic care. But I think what I'm seeing a lot of is that things that could have been managed early on end up in the hospital, longer term care because we did not take care of it earlier.

Now, there are some diagnosis that are much more challenging, as you know, than others. But I think we have unfortunately entered an era where a lot of people end up in the hospital that really don't need to be had they had the resources and the early intervention. I wanted to ask you a question though. When you talk about the different training programs, are you referring to our physicians? Are you referring to our nurses? Who are you referring to?

It's really across the board. So when we did the workforce analysis with UCSF, we looked at who is currently serving Medi-Cal beneficiaries as part of the county behavioral health safety net. Right. It's a very diverse array, depending on whether it's mental health or substance use disorders. And then we also looked at what available data we had on gender, race, ethnicity, language. So I can give you kind of like the very oversimplified version.

We have a disproportionate share of white women working in the safety net because that's the pool of licensed professionals that we're drawing from. We have, you know, and I can look it up. We have social workers, we have LMFTs. We have, on the sort of licensed side, psychiatrists, nurse practitioners, prescribers are a big deal.

For example, if we want to expand access to medication assisted treatment for people with substance use disorders, we really need to bring far many more prescribers into the county behavioral health safety net so that we can get people started on medication assisted treatment. And those are both nurse practitioners as well as physicians. Right. But we also rely pretty significantly in the safety net on paraprofessionals or non-licensed individuals. We need more data around that, for sure. We're building out the peer benefit in Medi-Cal. We're going to start to be able to have a community health worker benefit under the BH-CONNECT Waiver. And so it's sort of, I would say it's a both and. Right.

We need to both diversify the pool of individuals who are coming out of these schools as licensed or certified individuals, as well as expand the group of people who are unlicensed or maybe certified as community health workers, peers, etcetera. Because in specialty behavioral health, which I know this is slightly different from the medical model, a peer support specialist service can really be a make or break intervention for somebody's long term recovery trajectory. Right.

And that puts the peer on a very different, more even footing with some of the medical professionals who are in our sphere and gets to some of that biopsychosocial dynamic that is really unique. And my hope is that we bring some of that ethic, the nothing about us without us disability justice ethos, into the medical model as we're building out interventions that cut across populations.

Thank you. So I am surprised and concerned with this kind of, like, patchwork system that we have within our behavioral health system, which has been pointed out, we don't really see in other areas of medicine. with all of the things that the state is doing, all of the money, all of the focus, all of the initiatives that we're doing doing, go you see this improving with what we are proposing or currently doing?

From the standpoint of a clinician, I'd say we've had improvements over the last 10 years, but I feel like we've kind of plateaued in terms of what we have to offer. I think the other difficult part is that, if I were working in another county, my strategies would be different because they have different criteria, different availability of services within the county. And so that can be kind of a challenge, how quickly somebody can be seen, those types of things.

And so I do feel like we've kind of, we've definitely improved, but we've kind of reached a plateau of where we're going. And I think, I'm going to be honest, one of the big things is the lack of housing or the availability of, again, and supported environments to help people stay out of the hospital, to help them stay well. And across the lifespan, we have 18 year olds, or actually, I treat adults. But we have people who are kids, young adults to older adults. And so we need to make sure that we're supporting all of them.

If I may, in terms of the variation, I think that goes, goes to some of the grants based approaches that we have in our system. And so I just want to be really clear. The Medi-Cal criteria are mostly consistent. Where there are differences in the Medi-Cal criteria, it often does come down to the fiscal. Right. Because the state has a very unique way of paying for specialty behavioral health services.

They earmark certain tax revenues to county behavioral health, and it serves as sort of a global budget rather than a per member, per month actuarially sound rate. Right. And so within that global budget, counties have to manage the entitlement responsibility with the unfunded, acute, inpatient, and high level services, the underfunded crisis services. So you have sort of, the by design part is multifactorial, I will say. And so getting us to a more standardized system would require having more consistent benefits across commercial and safety net.

Right. Public and private. It would also require having fewer optional benefits in county behavioral health. And that's really a function of realignment, right, where the state said, here's your dedicated revenue stream, these are the things that counties agree to pay for. But after 2011, if the state wants to add new responsibilities, the state has to pay for the non-federal share of those Medi-Cal services.

So we see examples like mobile crisis, where the state went above and beyond and pays, picks up the non-federal share for mobile crisis, and so that's been structured as a statewide benefit. But things like Drug Medi-Cal Organized Delivery System, which provides that coverage for residential inpatient substance use disorder treatment services, is structured as an optional benefit. So only if the county can find the resources in their existing budget to make room for that new, expanded benefit, are they going to stand it up.

And that same dynamic keeps playing out, and it keeps reinforcing the patchwork within Medi-Cal, within the safety net. Right. So we've got a patchwork there, but there are other patchworks. And, I mean, it's a really fascinating tale, but it leads to people falling through the cracks, and it also leads to providers who could never, you know, hope to understand what all of the various origin stories are behind this, and then they just, you know, feel frustrated and confused. Understandably so.

I think the example that I had that kind of comes to mind is assisted outpatient treatment, which is Laura's Law. If we place a referral in Orange County, obviously, these are much different sized counties. They'll come usually within a few days to evaluate the person in the hospital. When we have an LA County resident, they'll be on a list. They said they'll probably try to get to the patient within months.

And so, again, that's an example of something that we obviously can understand why, it's probably a resources issue, but that can be a point of intervention. Again, I think we're all looking for what are the points of intervention that can cost less than what costs, you know, than what's going to happen five steps down. And so that's, that's an example which I think, again, goes toward, like, it's not that their criteria is different, it's just that the resources are different. Or resources are maybe in the county. Yeah.

If I may, I think left on its own, we will just reinforce the patchwork. But if the state says, you know, here's where we want to develop a strategic initiative to create that consistency with, you know, consistent understanding of kind of data reporting. Right. We don't have strong data report reporting systems in this state, as evidenced by your question of, we don't even know how many psychiatrists there are ,child psychiatrists versus not, you know, adult psychiatrists, who's serving whom. Right.

If we built fiscal incentives, which the state has done under CYBHI in some pretty phenomenal ways. They're using those dollars, DHCS, other departments are using those dollars to incentivize scaling, to reduce the patchwork nature, particularly in the school space, building out technical assistance. Because many of our community partners at the county level, but also community based organizations, and even on the commercial side, are interested and want to recognize sort of, you know, increased use of evidence-based practice.

There's a thirst to learn, to try to improve more community engagement around what expectations are. Frankly, I think, you know, if that was my family member in that hospital in Irvine, and Orange County said I'll be there in two days, and LA said four months. Right. And especially if I was paying the bill for four months in a hospital, I don't know who pays the bill for four months in a hospital when it should be four days. Right?

Again, I think there's an example of the lack of standards, the lack of attention, the lack of technical assistance, just that persistence around understanding what we're trying to get done, developing the strategy to scale, understanding why it's not happening on the national. Without those investments, we're very likely to just reinforce the patchwork that we have with those investments. California can move towards a more consistent approach to delivering care that is highly effective, that is available faster.

It will mean understanding the fiscal dynamics and other incentives that are getting in the way, which, and it isn't just finance. It can be licensing, it can be for individual staff or facilities. We're trying to scale an approach right now that puts sort of a crisis stabilization unit next to an emergency department. So in one community, someone comes in, law enforcement brings them there, come in on their own. They're identified as potentially a harm to self for others.

They're assessed by the hospital and by the emergency department, and they say they're not bleeding, they're not having a stroke or a heart attack, they're stable, but they need behavioral health care. One hospital, you'll sit there for four days to try to find a placement. We're working with half a dozen, eight or so hospitals to build a crisis stabilization unit 20ft away. You walk out of that emergency department within 4 hours and get stabilized, profoundly reduce costs, improve outcomes.

We don't have consistent licensing standards to scale that approach, even though it's emerging across the country as a highly effective practice to improve outcomes and reduce costs. So finance, licensing, staffing. If we're intentional, we can address the patchwork issue. If we're not intentional, it's likely to be replicated.

But again, to the point, I mean, a crisis stabilization unit will only be reimbursed up to 23 hours. And, you know, the safety net has to look comprehensively at what happens after that 23 hours of crisis stabilization unit service. Right. Where does a person go on to? And I think the sort of point from the safety net standpoint is we all have to hold it all. Right.

We all have to consider and care about what happens from the prevention side all the way through to the end of life for that individual. And it can't just be about sort of shifting from one system to another or from one service to another, but really seeing how we can pull together the full continuum.

And I know county behavioral health directors, when they have all of the pieces and the parts to make the flow work, they're really good at getting people into the right level of care that they need. The problem is we don't have enough of that. And I would argue that county behavioral health has a really good handle on what the gaps are for their unique system. And the gaps are different depending on who got what grant where.

Well, I want to thank our panel. This has been a very, very lively discussion, very informative, educational. It is extremely disheartening how patchy our current behavioral health system is. And these are conversations that we need to have, because if we, we don't, in five years, in 10 years, we'll look back and we'll say, we put all of this money, dedicated all of these resources, and we're still not in the place where we need to be.

And so when you talk about being very intentional about our next steps, I could not agree with you more. It's still very mind boggling how one county will do something or can offer one thing and the next county can't. And in the realm of healthcare, we don't do that. Things are standardized. And so we need to really work to improve what we do within our behavioral health space so that we're not continuously saying the same things over and over and over again. So we will definitely be continuing the conversation with you all, not only from a Committee, but also from a personal level. Thank you.

Okay. So we will now bring up Stephanie Welch from the California Health and Human Services Agency and Tyler Sadwith from the Department of Health Care Services.

Good afternoon. Thank you so much for having us, Dr. Weber, and inviting us to the Committee. I apologize, we were a little bit tardy. In fact, I really enjoyed getting to listen to the first panel first so that I can kind of change my remarks a little bit to make sure that I touch on some of the topics that they raised.

I think I was struck because the first time I ever was in this particular hearing room was to testify on AB-88, which was the original Mental HealthParity Bill in 1999, here in California. And I just graduated from UC Davis and was somebody who had to become a Medi-Cal participant in order to get access to the behavioral healthcare that I needed.

I'm more hopeful about the fact that in the last 25 years, we've made incredible progress, and we are on the cusp of making a much larger amount of progress with a catalyst of things that I think we're going to talk about today. In working in this field for the last 25 years, it's like almost a little bit like I can't catch my breath in the last four years. Being in this role as the Deputy Secretary of Behavioral Health under this Administration, it's an awesome responsibility.

In many of the points that you made about making sure that we are meeting certain expectations, meeting outcomes is really important. But I think, frankly, part of the patchwork discussion that I heard you discuss or the panel discussed before we got here is unfortunately the topic of behavioral health. People suffering from mental illness and substance use disorders continues to be really stigmatized.

And the fact that we had to go through a 20 year period to kind of achieve better mental health parity, to have behavioral health included in our essential health benefits under the ACA and the expansion of Medicaid, and that really only happened about a decade ago, less than a decade ago, that we have yet to realize, I think some of the major policy changes that we have. So I wanted to start with that.

I appreciated the work that the LAO put together with the particular brief. We worked on a similar brief last year, really trying to lift up many of the things that you heard the panel before me talk about, that there shouldn't be a choice between prevention and ongoing supportive care. In fact, when we make those choices, we end up with not having flow in our system.

People with behavioral health conditions, as you know, as a physician in different parts of their lives, have different levels of need, and people have to be able to move in and out of the system with care coordination in order to swiftly get their needs met and to have a tailorized or a tailored, individualized service plan. And that is something that we are really working towards. But frankly, to ask how we think the Continuum is doing is really a difficult question.

I do want to underscore the panel before, I believe, really talked about almost like, these three systems that we have that treat the behavioral health care needs of Californians. You have people like myself who may have commercial insurance. I have access to that commercial insurance because it's employer based insurance. And frankly, my behavioral health conditions can be managed in that system. If I need a higher level of care, I should be able to get it in that system under my commercial coverage.

And many people maybe are not able to get access to that in an accessible and adequate way. And unfortunately, the time between a really, really significant behavioral health crisis or the onset of a major behavioral health condition and when someone may no longer be able to go to work and being active and being employed is not necessarily that long of a timeframe. And I think we think that that could never happen to us or that could never happen to a loved one.

But I bet you everyone in this room has somebody that they care about, including potentially themselves, that has a pretty serious behavioral health condition that they're trying to work hard to support them in. So, there's that system, and then we have our Medicaid system, and I'm sitting here next to our state Medicaid Director.

I know we'll go into detail details around that, but people who have mild to moderate conditions should be able to get some supports to help address those needs so that they don't have chronic conditions or in the rare cases where that is the case, they can utilize and have access to the specialty system that manages those needs for Medicaid beneficiaries.

But what I'm trying to say is that along that entire continuum, you have three different systems that all have a role to play to keep people well. And I think what we're trying to do with the bulk of many of our initiatives under this Administration and support the Legislature has been a tremendous support in all of these efforts, is to support each system to be working at its best and to be able to have the capacity to fulfill its obligations and its responsibilities.

So I think some of the questions that were brought to us were to talk a little bit about ways in which we think the Continuum could also do more to address equity. I want to lift up that. I would agree that equity is most certainly a challenge. There are a number of reasons why I think something that I did not quite hear, maybe mentioned by the panel before us, is that the actual experience of behavioral healthcare can be very traumatizing.

And the reality is that because of that stigma or maybe that lack of knowledge of how to navigate the system, a lot of people do not get any help for their behavioral health issue until there is a crisis. And that crisis can be very traumatizing. And maybe the first experience that someone has engaging with the behavioral health system is not a positive one. And I think that's just a reality.

And so I think there's certain populations who historically have been marginalized, discriminated against, who may have an inherent distrust of a system, or have only experienced any kind of behavioral health treatment by interacting with law enforcement. And so I think part of what we really need to do is figure out how to go upstream and make sure that we're educating people about how to get early access to treatment and to be help seeking.

And I'm really pleased with some of the work that our children and youth behavioral health initiative is doing to encourage people to do that. I think also there was a lot of discussion today about workforce, and I think it's absolutely tied to issues around equity and access. As you heard the panel before, we do not have a workforce that represents what Californians look like.

And so I think what we've really tried to do with some of our initiatives, starting with the children and youth initiative, and very pleased to say that now that the voters have supported Prop One, that we will have a sustained source of workforce funding. I really wanted to pick up on what Miss Cabrera had mentioned around slots.

I'm a social worker by training, and I remember when we first passed the Children and Youth Behavioral Health Initiative, you know, it was one-time money at the time, this was a couple of years ago and the schools were, yeah, but how do we expand all these slots or bring in new professors if we don't have a sustained funding source for this work?

And we're going to be able to provide that sustained funding work so that the state, and I think it's an appropriate state responsibility, continues to invest in the workforce of tomorrow in terms of behavioral health. And one of those kind of success stories, I think, was really excited to have an opportunity to work initially on the wellness coaches. We have over 1000, I believe, I don't have the number right in front of me. Who have created accounts to seek certification.

These are people that we're hoping are coming from communities that they want to turn around and serve, that they have a pipeline if they want to get their certification. And they love doing this work, working with young people, helping them navigate and coach them through their behavioral health challenges. Maybe they want to get their BA in social work or go and become a psychiatrist like the woman who was sitting here next to me.

But it's a wonderful entree to not only create more opportunities for young people to have like a low barrier entry into our workforce, but also a pipeline of continuing to skill build if they want to stay in this workforce. So I do believe that between really doubling down on our investments and our workforce capacity, that we will start to make some progress around increasing more access.

But we do need to continue to make sure that things that are not the door getting in that's crisis are available to everybody in their community communities. And that includes raising awareness. But also did want to share some positive notes about the work that we're doing in the crisis care continuum with our first round of our behavioral health infrastructure program dollars. At this point, we've been able to support counties in either enhancing or developing completely new 300-plus mobile crisis teams.

These mobile crisis teams can bill Medi-Cal and they are non-law enforcement based. And I do think, when I think about pillars of what could be a catalyst for sustainable change in how people experience and access mental health care, this is definitely one of them. I think also we've been able to accomplish in the last year increasing our call volume to 988, which is our crisis line, by close to 20%. And so we have an in-state call answer rate of 90%.

And I think we're hopeful at some point, in partnership with our counties and our contractors and also our emergency personnel partners, to find ways in which hopefully, like you were mentioning, the whole goal in this is to prevent the crisis in the first place, to refer somebody to help and have that help be available. But if that crisis does occur, how can it be a less traumatic experience?

And so that the entree into receiving services is one in which people feel comfortable and positive and hopeful that they're going to get well. I think one of the last things I really want to lift up, and I believe that Mr. Sadwith will do this as well, is when I think about the crisis continuum and the patchwork, we've never had a source.

First of all, when we received the resources for BHCIP for the Behavioral Health Infrastructure Program, $2.2 billion. While we'd had things before, maybe like No Place Like Home, there just simply wasn't an ability to invest in the publicly funded mental health and substance use treatment system, at least in my recollection in the last 25 years, really in a substantial way.

And I know I've talked to Miss Krayer about this, but it's really hard when you're the public safety net to have enough resources to build a building that's very, very difficult to do. And so I do feel like it'll be a really critical game changer. And we've been able to so far in our Behavioral Health Continuum Infrastructure Program, expand outpatient capacity by over 280,000 slots.

And we've also been able to create over 2,600 inpatient and residential beds. Now, are they all built yet? No, because it takes a while to build those things and to build capacity. But I do think that it's substantially more than we've ever had collectively in the past.

Even though counties worked really hard in the past to use MHSA dollars to do things like MHSA Housing, this really is a double-down investment on making sure that there is what we refer to as flow in the system.

If I need to be hospitalized because I've had a suicide attempt or self injurious behavior, that there is a place where I can go after that that's available or I'm ready to get treatment for my substance use disorder, and there's a residential bed that's available in my community.

And so while it'll take us years, I mean, to be honest, to realize that in some cases, the money is there, and with the Proposition passing and giving us the ability to have another $4.4 billion, essentially more than doubling the investments that we've made so far, I think we have a chance at really building out a continuum that can meet people where they're at and support them to get to the least restrictive level of care.

The last point I want to make, and I do feel like it totally went off my script, but the last point I really want to make is that, you know, with all of our various initiatives, including things like everything from Behavioral Health Parity to the Care Act, I think the intent is to get at someone early before they are in those very restrictive settings. Care, for example, was designed to prevent people from having to be incarcerated or having to be conserved.

And one of the bright silver linings in care that we've seen so far with our early implementation counties is they're really looking at two things. How do you step somebody off of conservatorship through care, or how do you divert somebody from a longer conservatorship after a temporary conservatorship? And one of the things that we have to have in order to do that is provide residential support. And so it kind of came up a couple different times. We've discussed it a few different ways.

We might refer to it as enriched residential. This is that small group of individuals who have very chronic, serious behavioral health conditions, and they need more intensive supports. And so they may not be successful in independent permanent supportive housing. Or maybe they just need to step up into something that's a higher level of care and when they're doing well, step down.

That's the flow in the system that belongs in our housing continuum, so to speak, that blurred line sometimes between our housing continuum and our care continuum, because some people need residential care and they need it for a significant amount of time. I think I'll just close.

I have a mother who's in her eighties and she had to have double knee surgery, and I was not capable of taking care of her, but she was able to go to a rehabilitation hospital for, I think, 30 to 45 days, I can't remember the exact timing, and get really intensive therapy. And she was able to come home and walk up and down her stairs into her apartment. And I think that's for a smaller subset of our population.

If we're able to do that for them, then they do not need to be in these locked high levels of care. And so I'm really excited that hopefully with baby Prop One and some of the other exciting things I'm sure Tyler is going to talk about that are tools and resources that we are exploring and implementing with our Medicaid program that we're going to be able to help people like that.

And that kind of cycle of having to use really, really high-intensity services is broken because people are actually able to go and step down to kind of like a recovery or rehabilitation type of a service before they then seek to live fully independently in their own housing. So, I'm happy to take questions.

I think you might have had a couple of other specific questions I may not have touched on, but we can, I want to make sure I have plenty of time for Mr. Sadwith to make some comments and can take your questions.

Thank you.

All right, good afternoon. My name is Tyler Sadwith and I'm the State Medicaid Director at the Department of Health Care Services. Thank you for the opportunity to participate in this hearing. It's been a really invigorating and sort of candid conversation as to sort of how fragmented our behavioral health financing and service delivery system is and sort of how we got here. It feels like we're making several decades of sort of neglected funding investments and policy reforms within the span of a few years.

And so I think we're happy to sort of share some of those key policies and strategies that we're undertaking to strengthen the behavioral health continuum and highlight how we're tracking the impact of those across the state. So I'll share just a few key points about how we plan to do that with the Behavioral Health Infrastructure and Housing Programs that were touched upon, as well as the Children and Youth Behavioral Health Initiative and some of our reforms under CalAIM and BHCIP Connect.

Through the Behavioral Health Continuum Infrastructure Program or BHCIP, the department will award $2.2 billion to really expand brick-and-mortar infrastructure across the entire continuum of care. To date, we have awarded $1.7 billion in funding. This includes, as Stephanie mentioned, 48 cities, counties, and tribal entities that are now expanding 300 new or enhanced mobile crisis response teams across California so that individuals can be engaged when they're experiencing a crisis by the human services system and not the law enforcement system.

We've awarded over $1.4 billion in funding that will directly lead to over 2,600 inpatient and residential beds and 280,000 outpatient treatment slots, and a condition for receiving these funds is that every project must participate in Medi-Cal and operate for 30 years. The department also recognizes, as the panelists have touched upon, that housing is really a key part of the continuum. It's hard to get well and stay well and discharge from inpatient and residential settings if you don't have a supportive housing environment.

The department is distributing $1.5 billion in grant funding to county behavioral health agencies and tribal entities through the Behavioral Health Bridge Housing Program, which is designed to meet the immediate housing needs of Californians who are unsheltered and have significant behavioral health conditions. We've begun awarding $907 million to 53 counties and $30 million to nine tribal entities.

I think the last funding investment that I'll quickly touch on is the Children and Youth Behavioral Health Initiative, which is a multi-year, $4.7 billion initiative that really takes a whole child approach to address the contributing factors that can lead to the mental health and wellbeing of our children and youth.

To date, the department has awarded nearly $250 million in grant funding to organizations across all 58 counties to improve access to the evidence based services as well as community defined practices that are really important to sort of standardize and scale up across the state from sort of the pockets of where they exist today.

So in addition to tracking sort of the outcomes that these investments will achieve in terms of expanded capacity and infrastructure, the department is monitoring how these investments will impact and increase access to care for members. We have several different sort of tools or vehicles for monitoring access to care. One of them is Medi-Cal behavioral health network adequacy data and requirements. These are sort of federally-mandated and state-mandated standards that counties must meet.

There are specific requirements related to provider network capacity, such as provider-to-member ratios, like certain number of psychiatrists for every adult in the network and every child and youth in the network. There are time and distance standards so that services can be available near where members live and there are timely access standards to ensure Medi-Cal members are offered initial appointments and follow-up appointments in a timely manner.

We have a number of independent evaluation and independent review technical review reports that are conducted annually, and I'll touch on those in just a moment. I think one other sort of key platform for monitoring the impact on these investments in service capacity and service utilization will be through new sort, sort of of accountability components of Proposition one, which requires the department to collect behavioral health outcomes accountability and transparency reports from county behavioral health agencies every year and to develop new behavioral health performance measures.

The Committee asked questions about gaps, gaps that exist in the continuum, gaps that remain displayed despite these investments. So in addition to these access monitoring tools, the department issued a report in 2022, which really is a statewide needs assessment for the behavioral health continuum. The purpose of the report was to serve a sort of a data-informed foundation for some of these major initiatives that we're implementing.

So some of the gaps that were specifically identified in the needs assessment really centered around crisis services, which were touched on today. Two thirds of counties reported insufficient capacity for crisis stabilization units. Over half counties reported a lack of crisis residential treatment facilities, and over three-quarters of counties lacked sobering centers. And we also know from Medi-Cal network adequacy data that residential treatment for mental health and substance use disorder for youth in particular, is a key gap in care.

Under the investments in BHCIP, we've begun to close those gaps. We've increased crisis stabilization units across the state by 26%. We have launched or supported the launch of 11 new children's crisis residential programs. We've increased sobering center capacity by 72% and adolescent substance use disorder treatment capacity by 20%.

In addition to these sort of brick-and-mortar physical expansions, the department is taking key steps to really standardize and scale the availability of evidence-based service models in Medi-Cal that we know from research are proven to improve outcomes for patients, improve quality of life, reduce emergency department utilization, reduce hospitalization, and reduce involvement with law enforcement. So these are some of the services that the prior panel touched on, such as coordinated specialty care for first-episode psychosis.

Under our BH Connect waiver, we will provide a new dedicated reimbursement model to support counties with delivering net service and other services like assertive community treatment and supported employment and clubhouse services that we know are really needed to shore up that early intervention outpatient part of the continuum so that we reduce the need for inpatient services.

We're providing not only dedicated funding and service models for covering that in Medi-Cal, but also extensive technical assistance resources for counties and for providers to conduct fidelity assessments and receive coaching for clinical practice transformation so that the workforce can actually have the tools they need to deliver these services with fidelity.

In terms of workforce under BH Connect, we're also proposing to draw down significantly leveraged federal funding so that we have, over a five year period, $2.4 billion in new workforce development funding that would go towards expanding the types of training programs that the last panel talked about and ensuring that the workforce is culturally and linguistically commensurate with Californians receiving services and that the workforce looks like the patients showing up in the offices.

The Committee asked several questions about delays in funding and why it's so slow to spend money with under the BHCIP program. As Stephanie mentioned, it does take time to build new buildings, the type of construction that awardees are pursuing, whether it's a real estate acquisition or renovation of an existing building, or sort of purchasing new grounds and breaking grounds, it can really require various levels of local permitting and zoning and county approvals.

We've seen projects that even obtain all of those requisite approvals lose their site location due to local opposition, including NIMBY dynamics. We've also seen county projects be significantly delayed due to extended timelines that county Board of Supervisors have for approving projects, as well as workforce shortages in the construction industry that lead to significant delays in construction. We're providing technical assistance to counties to help them with navigate the complex real estate acquisition and housing development processes.

The Committee asked about how we are looking on the horizon at demography and changes in California's population and how we're planning for those trends. I think when I think about that question, I think right now and I think about equity, I think about how do we make sure that services at this moment in time and the next few years look at, are capable of meeting the needs and successfully engaging with Californians today, not just 30 years out.

So that is really a cornerstone of a number of efforts in CalAIM, as panelists have mentioned, we're adding coverage for new services like community health worker services. We have covered peer support specialists as part of CYBHI. We're partnering with HCAI to develop wellness coaches. And right now we're negotiating with our federal partners to secure approval for traditional healers. That would be a Medi-Cal benefit for our American Indian and Alaska Native populations.

These are really, really designed to ensure that these are trusted messengers, providing that engagement, establishing that therapeutic alliance, being in the community, seeing people in person, outside of the clinic, setting, outside of the four walls. This is where healthcare needs to be because this is where people are.

Looking ahead to the future though, we know that by 2030, over 10 million Californians will be an older adult making up one-quarter of the population. The department has partnered with the California Department of Aging to promote behavioral health resources. The department convened Medicare Advantage plans to discuss opportunities and strategies to improve access to behavioral healthcare services for Medicare members. And we've also partnered with CMS, our federal partners, to promote awareness of new Medicare benefits in the program.

We were asked to touch on sort of how we differentiate the state's role from the county's role in the behavioral health service delivery system. I think of it as sort of a dual role, one of oversight and regulation, and one of partnership and technical assistance. The Department is the state Medicaid agency. So we operate Medi-Cal, which is in itself a state-federal partnership. It's California's Medicaid program. We designed it within certain federal parameters.

And our behavioral health benefits, the specialty behavioral health benefits, really are delivered through county behavioral health agencies. We also purchase non-specialty mental health services from Medi-Cal managed care plans. And we've been taking steps to increase the ways members can be appropriately referred to and access non-specialty mental health services so that the safety net isn't entirely responsible for all behavioral health care in the state. The department also has other functions, facility licensure, and certification.

But counties are ultimately responsible for providing behavioral health care to residents. They have a patchwork of funding. 1991 Realignment, 2011 Realignment funds, formerly the Mental Health Services Act, which was recast as the Behavioral Health Services Act through Proposition One, through Medi-Cal and through federal grant programs that we administer to to our counties. Counties contract with providers. Sometimes counties operate services directly. Sometimes counties contract with community-based providers. So providers really are key actors and key partners in the healthcare delivery system.

I think in addition to our role as a payer and a regulator, we work hand in hand with counties to provide technical assistance to help scale innovation and to really ensure that these incredible and once-in-a-generation, funding opportunities are designed in a way that can be successful on the ground. So we listen and we learn from our counties to make sure that the programs we're administering are going to be effective for them.

The Committee requested a discussion on outcome and performance measures, so I'm happy to very briefly touch on how we measure access and quality and outcomes for behavioral health services. We have a comprehensive framework for measuring and monitoring quality of care and health outcomes for Medi-Cal members and consumers. The department published a comprehensive quality strategy which lays out health equity goals and supports a 10-year vision for the Medi-Cal program.

And within the quality strategy, there are a specific set of core quality metrics that counties report annually related to behavioral health. So these are sort of standard HEDIS or managed care plan metrics that CMS uses that look at things like the rates of follow-up for behavioral healthcare after an individual visits the emergency department, rates of follow-up mental health care after an inpatient hospitalization for psychiatric care, and the use of evidence-based practices like medications for addiction treatment, for schizophrenia, and for depression.

So these are measures that right now we are reporting on. And in the future, there will be certain expectations and targets that counties meet performance thresholds on the measures and may face penalties if they don't meet them. These are reported publicly. We also have a number of dashboards that we report that show other measures and service utilization.

We have independent quality reviews that we publish every year, and we have independent evaluations of our drug Medi-Cal organized delivery system, which provides substance use benefits for 97 percent of Medi-Cal. To wrap up, I think perhaps most importantly, we use annual member experience surveys for both mental health and substance use disorder. And the department, broadly speaking, is investing in creating new ways for us to meet with Medi-Cal members directly and hear from them.

Not just advocates, not just advocacy organization, but members who receive services. So, we are doing this, and behavioral health, it may not be surprising, is a top priority for our members. So I'll close just by looking, looking ahead, we've been asked to speak to a couple questions about the implementation of Proposition One, I would emphasize that we are now launching an extensive planning process to prepare us and to prepare counties and providers to implement the various provisions of the law.

The majority of the provisions go into effect in July 2026. So about a little over two years out, there will be a tremendous amount of consultation and stakeholder engagement and sort of roll-up-your-sleeve planning conversations that will occur on a regular basis to help us collectively prepare for a successful implementation. And there was one specific question related to bond funding that will be made available via the BHCIP program as authorized by Proposition One. The department has begun engaging stakeholders on the bonds.

We had a public listening session last Friday, on the 19th, on the portion of the bond funding, which represents $4.4 billion, that will be administered through the BHCIP program that we've touched on. The Administration is evaluating costs and analyzing program specifics, and we will share more during the May revision. So I know that was a lot of information. Appreciate your patience and happy to answer any questions.

Thank you both so much for being here. I also want to acknowledge that Nathaniel Williams is here from the Department of Finance if we need any questions answered. So thank you so much. Just a few questions.

So when you were referring earlier about the increase in inpatient beds and some of the things that we're doing when we're looking at implementing different things, even with Prop One, are we going to be implementing them equally across the state, or is each county going to have to essentially fight for these funds and these programs?

Yeah. So the BHCIP program, which is what the bond is based on, it's basically a continuation of that program with more resources, is a competitive program in which counties, cities, nonprofits, for-profits, and the tribal set aside are all eligible to apply for the funds for different projects. One of the things that happened in BHCIP that I hope we can remind people of is that several counties, and actually several tribes as well, in round two of BHCIP, did a community planning grant.

And really what we were hoping that those would reflect is what are the needs of your community? As I would really underscore what the previous panel said, counties look very, very different and have, you know, they have different populations that they're serving, but they also just have different infrastructure. And so I think it was at least over 30.

Miss Cabrera might know the exact number, but the majority of counties did do that planning process to really do their own assessment of where they felt the need was. I think there have been some other efforts by both RAND that was commissioned by the County Behavioral Health Directors Association to really try to assess as well where do they need to make these investments.

And then lastly, I would say that the guidance that we've put out is pretty robust for the BHCIP program. In 2022, as Tyler had mentioned, we did a very comprehensive behavioral health needs assessment, to really try to, on a statewide basis, identify priorities for the investments. I think I'm not going to remember all of them off the top of my head, but certainly, youth and young adults was one, across the board substance use disorder populations who were justice impacted.

And I'm sure I'm forgetting some other, Tyler that you might remember, but we did do a comprehensive assessment, working with manot, not to try to really, on a statewide basis, understand what some of the needs were. Any other thing to add?

In BHCIP, which will be the sort of the vehicle for dispensing the bond funds. We use the needs assessment as sort of a data-informed basis for identifying where are the needs, where are the gaps to avoid unnecessary investments and over-concentration. And every county, every applicant that was not a county applicant required a letter of support from the county, so had to fit into the local ecosystem.

Thank you for that. You know, I really hope that this does not perpetuate the patchwork that we see. So my hope is that at the state level, we have some basic guidelines and some basic standards based on national evidence.

And I'm coming from a health care perspective of how certain things should be managed, and then take that to see which counties are doing it and which counties aren't, and filling in those gaps, and not just necessarily allowing the counties to direct the funds, because then what we're going to continue to see is you can get one thing in San Diego County and another in Orange County and another in LA County, and that's not really helping our patients.

So I hope that we would learn the lessons from what we've been doing incorrectly for the last 20-plus years to better utilize these funds that our voters have graciously given us through Proposition One. My other question actually comes from a fellow Assemblymember who's not on this Committee, but very interested in this particular area. The question is, do our crisis intervention approach, including mobile crisis centers, have training and best practice interventions that involve individuals on the autism spectrum?

Yes, it's one of the questions that I forgot to answer. So I apologize. Yes. Let me start with the Medi-Cal mobile crisis benefit.

So mobile crisis teams, and there was guidance that we can certainly send you so that the member has that guidance and detail that was published earlier this year might have been late last year, where mobile crisis teams are to respond to a beneficiary with intellectual developmental disabilities to ensure that there are natural support, so working as best as they can, if appropriate, with family caregivers, personal attendants.

To the extent possible, mobile crisis teams are encouraged to include a team member with IDD expertise on their actual team, and then members of mobile crisis teams are also required to participate in training on how to respond appropriately in crisis situations with individuals who are living with intellectual and developmental disabilities. So that includes autism spectrum disorder, co-occurrence of IDD, and mental health conditions, which is pervasive and actually is a population who often experiences this kind of crisis.

And counties are also required to develop MOUs with Regional Centers to coordinate services generally, and this would be one area in which they could look into better coordination. And then I just also wanted to share that as part of our state 988, 5-year implementation planning process, we are working with the state Developmental Disabilities Council.

They are represented on that Advisory Committee, but also will have a portion of that five year implementation plan with specific recommendations in this space, not just for mobile crisis, but for improving crisis response overall with this population.

Thank you and if you can provide that information, I'm sure that the Assemblymember would be greatly appreciative of that. And with that, I'm going to thank our second panel and open it up for any comments from the public.

Thank you, Madam Chair, for this important hearing on this very important topic. Mark Farouk, California Hospital Association. Just want to make a few comments. First, related to the implementation of Proposition One. We urge the Legislature and DHCs to focus on county transparency with their communities as we move forward on implementation.

And that before making critical decisions about how to adapt current spending, local community members and stakeholders should be given clear and detailed information from their counties about current and projected revenues the counties received to provide mental health and substance use services, current spending on existing mental health and substance use disorder services, and up to date information about the quality and accessibility of care being provided.

We really think it's important that this be a open stakeholder process alongside local providers, families, and consumers so that this is not something, decisions are not being made behind closed doors, that it's an open process. And then finally, just wanted to mention, we've obviously heard in this hearing today about the severe lack of behavioral health and substance use substance abuse treatment capacity.

You know, there was a recent report from RAND Incorporation that found a shortfall of 8,000 behavioral health beds at the acute, subacute, and residential level here in California, and we have 24 counties. I think this was mentioned earlier, where residents have no in-county access to inpatient psychiatric hospital services at all.

Overall, on any given day, 550 psychiatric patients languish in hospitals when they no longer need to be there, and they stay, on average, close to one month in the hospital, even when they're ready for discharge. The primary reason for this is that counties and health plans lack adequate networks of step-down care options, places for people to go once their most acute symptoms are stable.

For many individuals, simply discharging back home is not an option because they may lack the supports to stay stable and healthy or their incomes are too low to live someplace permanent and safe. Discharge delays make it harder for patients to recover. It increase healthcare costs and strains hospital capacity. Today, services such as crisis stabilization, inpatient psychiatric hospital services, crisis residential and residential treatments aren't even counted in the state's network adequacy reviews for Medi-Cal mental health system capacity.

We contend that the state should bolster its Medi-Cal and commercial health plan monitoring to ensure that there are adequate networks of inpatient and post-hospital care options available to people living with serious mental illness. Thank you.

Good afternoon, Madam Chair. Bridgeton Davis with the California Council of Community Behavioral Health Agencies. Just wanted to say that we appreciate the conversation and wanted to highlight a couple of things that are related to our members, like the mobile crisis services, workforce stability in relation to Medi-Cal reimbursement rates, and also our providers. They serve a diverse spectrum within the behavioral health continuum. So we just want to support any standardization and the streamlining of supports of these services so they can provide to their communities. Thank you.

Good afternoon, Madam Chair. Jolie Onodera with the California State Association of Counties, representing all 58 counties, just wanted to thank you and the panel for today's discussion, and then just wanted to say I look forward to working with you, your Committee, and the Administration on all of these behavioral health initiatives, including Proposition One. Understand there's a lot of work ahead. Thank you.

Good afternoon. Jennifer Alley with the California Opioid Maintenance Providers, representing about 120 licensed non-narcotic treatment programs in California. Treating about 40,000 patients. We appreciate the thoughtful discussion today and just wanted to touch on one item in the agenda, which was the budget change proposal regarding our licensing fee transfer.

And we just want to acknowledge the hard work that DHCs does with our providers on a regular basis and how much we appreciate that, but also that we also appreciate the transfer rather than the increase in fees. As my members, you know, face a lot of, well, issues identifying hiring staff in such a competitive wage market time. So thank you very much.

Well, I want to once again thank everyone who participated in the panel, everyone who gave public comment. We are definitely at a crossroads with all of the resources that we have been granted.

So I'm hopeful that those of us in the Legislature, but also all of the Department and the counties, were listening in and really understand the challenges that we've had in our behavioral health space and the way in which it has been created as far as this patchwork, which at the end of the day has not really helped our residents.

And so from a Legislator standpoint, we definitely need to have more oversight, more accountability, and more transparency to actually ensure that the dollars that we have allotted is actually being spent in a way that is helping all Californians and that it shouldn't matter really what county you live in, but that we are using evidence based methods to treat some of our most vulnerable in this space, regardless of where they live, regardless of how much they make, regardless of their race, gender, gender, ethnicity.

That is our responsibility, and that is definitely something that we will be watching very closely. So, once again, thank you, and this hearing is adjourned.