BILL ANALYSIS Ó SB 1045 Page 1 Date of Hearing: June 10, 2014 ASSEMBLY COMMITTEE ON HEALTH Richard Pan, Chair SB 1045 (Beall) - As Amended: May 13, 2014 SENATE VOTE : 35-0 SUBJECT : Medi-Cal Drug Treatment Program: group outpatient drug free services. SUMMARY : Changes the number of individuals allowed in a group to a minimum of two and a maximum of 14 for outpatient drug free services for the purposes of Drug Medi-Cal (DMC) reimbursement and requires at least one individual in the group to be a Medi-Cal eligible beneficiary. EXISTING LAW : 1)Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which qualified low-income individuals receive health care services. 2)Establishes the DMC program, which provides substance use disorder services to Medi-Cal recipients. 3)Allows DHCS to enter into contracts with counties for the provision of DMC services. If a county declines to contract with DHCS, existing law requires DHCS to contract for services in the county to ensure beneficiary access. 4)Requires each county to fund the nonfederal share for DMC services through realignment funds, as specified. 5)Requires providers of DMC services to obtain certification from DHCS to provide those services. 6)Requires a group for outpatient drug free services and narcotic treatment programs to consist of a minimum of four and a maximum of 10 individuals, of which at least one must be a Medi-Cal-eligible beneficiary. FISCAL EFFECT : None COMMENTS : SB 1045 Page 2 1)PURPOSE OF THIS BILL . According to the author, even though DMC treatment services have been expanded, many counties find it difficult to offer these benefits due to state restrictions, such as the limitation on group size for outpatient treatment (counseling services). Current state law specifies that outpatient counseling groups must have between four and 10 participants in order for the program to bill for and receive Medi-Cal reimbursement. The author further states that this restriction poses a problem for both small and large population counties. Small-population rural counties, in which program participants may have to travel long distances to attend group counseling sessions, often have trouble getting four or more people together for a group, but if they have less than four participants, they cannot receive Medi-Cal reimbursement for that counseling session. Large-population counties have the opposite problem. According to the author, when more than 10 people show up for a group session, a common occurrence, some participants may have to be excluded, otherwise the county cannot bill Medi-Cal for any of the services provided to the Medi-Cal-eligible participants. Thus, the group size restriction presents a significant barrier to effective treatment. 2)BACKGROUND . Alcohol and other drug (AOD) use disorders are substantial public health problems, affecting approximately 10% of the population and resulting in economic costs to the Nation of around $360 billion annually, with roughly half of this amount attributable to alcohol use disorders (Office of National Drug Control Policy 2004). According to the National Institute on Drug Abuse, in 2011, 21.6 million people aged 12 years or older needed treatment for an illicit drug or alcohol use problem, but only 2.3 million received treatment at a specialty substance abuse facility. a) Drug Medi-Cal. The DMC program was established to provide outpatient substance use disorder treatment services to Medi-Cal beneficiaries. In 2011, funding for the program was transferred from the Department of Alcohol and Drug Programs to DHCS as part of the Public Safety Realignment initiated by AB 109 (Committee on Budget), Chapter 15, Statutes of 2011. Current regulations create requirements for oversight of DMC providers at both the SB 1045 Page 3 state and county levels. DHCS is tasked with administrative and fiscal oversight, monitoring, auditing and utilization review. Counties that elect to contract with DHCS to provide DMC services are required to maintain a system of fiscal disbursement and controls, monitor to ensure that billing is within established rates, and process claims for reimbursement. Most counties choose to contract with DHCS; however, 13 counties (Alpine, Amador, Calaveras, Colusa, Del Norte, Inyo, Modoc, Mono, Plumas, Sierra, Siskiyou, Trinity, and Tuolumne) do not participate in DMC. In addition, 15 providers statewide currently operate without a county contract, instead contracting directly with DHCS. b) Group Treatment. According to the 2011 publication, "Treatment Improvement Protocol (TIP) No. 41 'Quick Guide for Clinicians'" by the federal Substance Abuse and Mental Health Services Administration, group therapy can be a powerful therapeutic tool for treating substance abuse. In many cases, it is as effective as individual therapy because groups intrinsically have many rewarding traits, such as reducing isolation and enabling members to witness the recovery of others. These qualities can draw clients into a culture of recovery. TIP No. 41 also states that treatment groups should generally have no more than 15 members in order to maximize treatment effectiveness and, to the extent possible individuals be divided into groups best suited to their needs based on other factors such as gender, age, and stage of recovery. 3)SUPPORT . Mental Health America of California and the California Council of Community Mental Health Agencies, write that this bill creates more flexibility in group outpatient drug free services under the DMC program by decreasing the minimum size from four to two and increasing the maximum size from 10 to 14. They argue that given the shortage of facilities and low reimbursement rates that create a significant access problem, this bill helps address that problem. 4)RELATED LEGISLATION . a) AB 1644 (Medina) would have required DMC providers to be designated as a 'high' categorical risk and be subject to criminal background checks as a condition of DMC SB 1045 Page 4 certification. AB 1644 was held under submission in the Assembly Appropriations Committee. b) SB 1339 (Cannella) requires a county or DHCS, before contracting with a DMC provider, to obtain criminal background checks for the owner and key staff. SB 1339 is in the Assembly pending referral. c) AB 1967 (Pan) requires DHCS, when it commences or concludes an investigation of a DMC provider, to notify counties that contract with the provider. AB 1967 is in the Senate Health Committee. d) SB 570 (DeSaulnier) requires AOD counselors to submit criminal background checks for review by DHCS. SB 570 is in the Assembly pending referral. 5)PREVIOUS LEGISLATION . a) SB 1529 (Alquist), Chapter 797, Statutes of 2012, revises screening, enrollment, disenrollment, suspensions, and other sanctions for fee-for-service Medi-Cal providers and suppliers to conform to the federal Patient Protection and Affordable Care Act. b) SB 857 (Speier), Chapter 601, Statutes of 2003, makes numerous changes to the Medi-Cal program intended to address provider fraud, including establishing new Medi-Cal application requirements for new providers, existing providers at new locations, and providers applying for continued enrollment. 6)POLICY QUESTIONS . Lowering the minimum requirement of a group to consist of only two individuals raises questions regarding the effectiveness of group treatment versus individual treatment for just two individuals. It is not clear that group treatment for two individuals is more effective than a provider treating a single individual. Individual counseling requirements are significantly more restrictive than requirements for group counseling, and consequently it may be more difficult to make referrals for individual counseling than it is for group counseling. Current requirements for individual and group treatment as described in Section 51341.1of Title 22 of the California Code of Regulations are as follows: group counseling sessions shall focus on SB 1045 Page 5 short-term personal, family, job/school, and other problems and their relationship to substance abuse or a return to substance abuse. Individual counseling shall be limited to intake crisis intervention, collateral services, and treatment and discharge planning. It is possible that providers are referring individuals to group treatment when individual treatment might be more appropriate, but is restricted due to current limitations. In addition to concerns regarding the restrictions of individual counseling requirements, allowing for a group as small as two individuals may result in one Medi-Cal beneficiary being joined by another individual solely for the purposes of meeting the group requirement and the provider receiving Medi-Cal reimbursement. For this reason, the Committee may wish to amend this bill to ensure that in instances where just two individuals are being treated, both are receiving medically necessary services for a diagnosed substance abuse disorder. 7)RECOMMENDED AMENDMENT . On page 3, line 5 insert, "For groups consisting of two individuals, any individual that is not a Medi-Cal eligible beneficiary must be receiving outpatient drug free services for a substance abuse disorder diagnosis as determined by a physician." REGISTERED SUPPORT / OPPOSITION : Support County Alcohol and Drug Program Administrators Association of California (sponsor) California Council of Community Mental Health Agencies Mental Health America of California Opposition None on file. Analysis Prepared by : Paula Villescaz / HEALTH / (916) 319-2097 SB 1045 Page 6