BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                  SB 1045
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          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  :   








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           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  








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               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  








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               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  








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            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 











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