Prepared by Protection & Advocacy, Inc
In consultation with Beth Stoneking, Ph.D., University of Arizona, Health Sciences Center
January 13, 2000
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FINDINGS AND RECOMMENDATIONS |
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I. BACKGROUND |
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A. THE STATE’S MENTAL HEALTH MANAGED CARE WAIVER |
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B. PREPARATION OF THIS REPORT |
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A. TIMELINESS OF APPOINTMENTS AND WAITING TIMES |
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1. Accepted Waiting Time Standards |
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2. The Absence of Waiting Time Standards in California’s System… |
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3. San Diego’s Waiting List Problems |
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B. INCREASED RE-HOSPITALIZATION RATES AND LACK OF FOLLOW-UP CARE AND DISCHARGE PLANNING |
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C. INCREASED INVOLUTARY DETENTION RATES AND DENIAL OF VOLUNTARY SERVICES |
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D. CLIENTS ARE "SCREENED OUT" WITH NO NOTICE OR FOLLOW UP |
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III. PROVIDING THE FULL ARRAY OF COVERED MEDI-CAL MENTAL HEALTH SERVICES |
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A. PSYCHOSOCIAL REHABILITATION SERVICES |
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B. CASE MANAGEMENT ASSISTANCE WITH TRANSPORTATION AND OTHER BENEFITS |
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C. CRISIS SERVICES |
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D. PSYCHOTROPIC MEDICATION |
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E. SERVICES FOR CHILDREN |
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1. Poor Outreach and Identification of Children with Special Mental Health Needs and Lack of Coordination with the Special Education, Probation and Dependency Systems |
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2. EPSDT and the Problems of Inadequate Services |
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3. Special Problem of Foster Children |
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IV. THE IMPORTANCE OF CONSUMER CHOICE, INCLUDING INFORMATION ABOUT GRIEVANCE AND APPEAL RIGHTS |
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A. CLIENT-DIRECTED SERVICES |
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B. ADVANCE DIRECTIVES |
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C. INFORMED CLIENT CHOICE |
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D. AWARENESS OF GRIEVANCE AND APPEAL RIGHTS |
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V. THE STATE MUST EXERCISE BETTER OVERSIGHT IF THE MANAGED CARE WAIVER IS TO CONTINUE |
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A. THE STATE HAS FAILED TO SET ACCESS STANDARDS |
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B. THE STATE HAS FAILED TO COLLECT THE DATA IT NEEDS FOR OVERSIGHT ENFORCEMENT |
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C. THE IMPORTANCE OF ENFORCEMENT AND SANCTIONS FOR NON-COMPLIANCE |
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D. INADEQUATE AND UNEQUAL COUNTY FUNDING |
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VI. RECOMMENDATIONS |
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ACCESS TO SERVICES |
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PROVIDING THE FULL ARRAY OF OUTPATIENT SERVICES |
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CLIENT-DIRECTED SERVICES |
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STATE OVERSIGHT |
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ENFORCEMENT AND FUNDING |
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TABLE 1: Inpatient And Re-Hospitalization Rates All Patients, 1993-1998 |
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TABLE 2: Inpatient And Re-Hospitalization Rates Children and Youth, 1993-1998 |
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TABLE 4: Mental Health Clients With Only One Outpatient Contact, 1997-98 |
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TABLE 8: Data DMH Could Require Counties to Collect Starting Now from their UR/QI Data |
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Prepared by Protection and Advocacy, Inc.
In consultation with
Beth C. Stoneking, Ph. D.
University of Arizona, Health Sciences Center
Sponsored by and on behalf of:
California Network of Mental Health Clients
California Association of Mental Health Patients’ Rights Advocates
Western Center on Law and Poverty
National Health Law Program
Bazelon Center for Mental Health Law
In January, 1995, California began implementing a managed mental health care demonstration program involving more than 300,000 recipients of Medicaid, known in California as Medi-Cal. All Medi-Cal eligible mental health consumers in the state are included in this program, which operates under a special waiver from the federal Medicaid agency. The managed care waiver program began with inpatient mental health services and was extended to outpatient services in 1997 and 1998. In November 1999, California submitted a request to the federal government for permission to continue its program for another two years. Federal rules allow the public 90 days to comment on the state’s proposal. This report was prepared as part of the public response to the state’s request to renew the managed care waiver program.
The waiver has had some positive results, including greater client and family member involvement in state-level planning. There is no question that in some counties, mental health services have improved under managed care. Since these successes are already described in the state’s own request for a waiver renewal, this report targets what needs to be improved and corrected. The report identifies policies, procedures and services that have been useful and important in other managed mental health care systems, and that appear to be missing from California’s system. It is a critique of the state’s managed care waiver program from the perspective of mental health clients and their advocates, including the organizations that have sponsored this report.
This report recommends that California’s mental health managed care waiver program continue for another two years, but with changes and conditions which address the following areas:
California’s Medi-Cal managed care waiver program should be approved for another two years but only with new conditions which will address problems with access barriers, inadequate services, limited client information and choice, and weak state oversight.
While some counties have used managed care to expand access and services, other counties have not. In many counties, the access barriers include long waiting lists for appointments, no follow-up care after discharge from an inpatient setting and limited availability of voluntary services as an alternative to emergency hospitalization. As a result of the new, more restrictive eligibility standards, many clients are "screened out" by the telephone access lines with no record and no follow-up.
The consultants hired by California to evaluate its managed mental health care program reported an increase in spending on outpatient services and a drop in inpatient hospital spending. Unfortunately, this does not necessarily mean that access to mental health services has improved. The consultants’ report also shows that in the last 5 years, there has been a sharp increase in the percentage of people requiring re-hospitalization within 6 months of discharge. At the same time, state reports show that there has also been a dramatic increase in the number and rate of involuntary hospital commitments, especially for children. This points to a breakdown in access to the voluntary outpatient services that enable clients to remain stable and successful in the community.
RECOMMENDATION: The state should set standards and require data reporting on waiting times and timely appointments, require counties to provide outpatient follow-up appointments within 7 days of discharge, clarify the right to voluntary hospitalization, restore the former eligibility and medical necessity standards and track clients who are screened out under managed care.
California has given county mental health plans almost unfettered discretion to provide any mix of mental health services they choose. Some counties have expanded services, especially crisis services and the rehabilitative, recovery-based services that many clients want. Other counties provide only a limited range of service options, which denies clients services they need. Coordination of medication and access to support services and case management are also problems. In many counties, services for children and youth are especially fragmented.
RECOMMENDATION: California should require that every county offer an adequate array of psychosocial rehabilitative services and assure access to crisis stabilization, in-person crisis intervention after hours and on weekends, transportation to services where needed and coordination of medication. Counties must be required to fully implement EPSDT services for children and coordinate these with special education, probation, social services, foster care, etc.
Although there is general consensus that services should be client directed, client leadership is sometimes stifled. While clients and family members have been included in planning and oversight at the state level, involvement in county planning has been erratic. County mental health plans have failed to implement advance directives, have not consistently developed and distributed notices and brochures about the available services and providers and about client appeal and grievance rights. Denials are difficult to document or appeal because there are no forms for clients to request the services they want and DMH regulations require written notices of action in only a very few situations.
RECOMMENDATION: California should require that counties provide clients with lists of services and providers, forms and information about advance directives and training and outreach regarding appeal and grievance rights. The state should monitor the extent to which clients have a meaningful role in state and county-level planning and advisory groups and direct staff and management positions.
RECOMMENDATION: California should adopt minimum performance standards in its managed care regulations and enforce timely compliance from plans which fail to meet them. The state should immediately begin the data reporting recommended by the Mental Health Planning Council and raise and equalize Medicaid funding across counties.
For a number of years, the California Department of Mental Health (DMH) has been moving the mental health system for Medi-Cal clients towards a managed care model.[1] Prior to 1995, Medi-Cal mental health services were provided through two parallel systems: the normal Medi-Cal "Fee-For-Service" system which allowed clients a free choice of providers, and the Short-Doyle Medi-Cal system administered through the county mental health departments. Beginning in January, 1995, DMH and the California Department of Health Services began implementation of a plan to consolidate inpatient Medi-Cal mental health services under the control of county operated mental health plans (MHPs) using a managed care model.(1) Because the new system restricted Medi-Cal beneficiaries to the MHP in their county with its network of contract providers, the state required a waiver of provisions of the federal Medicaid Act which otherwise guarantee beneficiaries their choice of provider. The Health Care Financing Administration (HCFA), the federal Medicaid agency, granted California’s request for a freedom of choice waiver for inpatient services under Section 1915(b) of the Social Security Act, which governs managed care waiver requests.
In 1997, HCFA approved California’s request to extend Medi-Cal mental health managed care to outpatient services. A new waiver was granted for two years, from September 1997 to September 1999. DMH involved clients, family members and the mental health community in planning for the expansion of managed care to outpatient services through the creation of a Client/Family Member Taskforce, a Managed care Steering Committee and most recently, a statewide Quality Improvement Committee. All three groups have included many leaders in the client and family member community. In addition, DMH has included clients and family members in the annual on-site oversight reviews of each MHP.
As a condition of the waiver, HCFA required the state to contract for an independent assessment of its program. The Independent Assessment was completed in September 1999 by Nancy Callahan and Alan Yamamoto of I.D.E.A. Consulting. Their 2000 page report, California’s Medi-Cal Mental Heath Delivery System - Independent Assessment of HCFA 1915b Waiver, provides extensive statistical data about California’s Medi-Cal mental health system which had not previously been available. The assessment also includes more detailed studies with on-site interviews, focus groups and client outcome surveys in 10 selected counties: Alameda, Contra Costa, Fresno, Humbolt, Kern, Los Angeles, San Diego, San Joaquin, Siskiyou and Sutter/Yuba. For the state as a whole and for the 10 counties studied in depth, the report analyzes comparative expenditures and numbers of clients served for inpatient, outpatient, crisis and day treatment services, rates of re-hospitalization, utilization patterns for different ethnic groups and population groups such as foster children, families, etc.
In August 1999, the state requested a renewal of its Medi-Cal managed care waiver for another two years. The state released the Independent Assessment to the public in October 1999 and submitted it to HCFA on November 4, 1999, at which time California’s request for a waiver renewal was complete. HCFA has 90 days from this date to accept public comments regarding the state’s request for a renewal of its Section 1915(a) waiver.
Protection and Advocacy, Inc. (PAI) convened a series of meetings between July and November 1999 to discuss with clients, family members and the advocacy community their experiences with the new mental health managed care system. Representatives attended the meetings from a wide variety of groups and individuals, including representatives from the sponsoring organizations. This report represents the findings and recommendations from these meetings. It was prepared with consultation by Dr. Beth C. Stoneking from the Health Sciences Center of the University of Arizona, a recognized expert in public managed behavioral health care programs. Additionally, this report is based on review of the following documents:
The sponsoring organizations and their descriptions are:
Access to outpatient services must be the first area addressed when developing, implementing, or monitoring any managed care system. The state’s Independent Assessment concluded that access had improved because Medi-Cal spending on inpatient mental health services has decreased under managed care, while statewide spending on outpatient services has increased. Independent Assessment, page I-7. The state provided assurances to HCFA that access to outpatient services is adequate and at least as good as before the implementation of managed care. Waiver Request, page 17. The state’s Annual Oversight Reviews of each county mental health plan ("MHP") also consistently found that access to services met the standards the state had adopted.
In addition, clients and family members report that in some counties, mental health services improved significantly under the waiver. Of the ten counties surveyed in the Independent Assessment, a number had used the additional waiver funds to make significant improvements, including adding crisis alternatives, consumer-run services and recovery based programs. Independent Assessment, Chapter III (Contra Costa); Chapter IV (Fresno); Chapter VI (Kern); and Chapter IX (San Joaquin).
Nonetheless, clients, family members and mental health advocates in many other counties report serious difficulties accessing services. During the meetings in preparation for this report, participants described long waits for services and other access barriers. As described below, these observations echo those expressed in the many focus groups of mental health clients and family members convened as part of the annual oversight reviews. In these focus groups, many participants stated that access was poor and services very limited under managed care.[2]
The State’s own Independent Assessment also identified serious problems with access in its in-depth survey of 10 selected counties. The Assessment reported instances in which:
The following sections discuss how these and other problems can be addressed so that access to basic mental health services can be improved.
Waiting times to access outpatient services and timeliness of appointments are serious issues for California mental health consumers. Long delays in getting appointments were reported in many DMH focus groups.[3] At meetings with client leaders, many identified a frequent problem with consumers being discharged from a hospital following a psychiatric crisis with only a few days worth of psychotropic medication. Typically, neither the hospital nor the mental health plan which authorized the hospital stay would arrange a follow-up visit with an outpatient clinic prior to the discharge. Once back in the community, the consumer was often unable to obtain an appointment for medication review before the medication he or she had obtained from the hospital ran out. Being abruptly cut of medication with no medical supervision left the consumer in a very difficult and dangerous situation. The Independent Assessment describes how patients are given a three day supply of medication at the hospital but cannot get an outpatient medication appointment within that time. Page IV-127. See also, Independent Assessment, page V-12 (County failed to resolve grievance from a client who was turned away from walk-in medication clinic for two weeks in a row); DMH Oversight Focus group, San Diego, 2/99 (client was discharged with two days of medication, could not get a medication appointment before her medications ran out).
A 1997 summit of the American College of Mental Health Administration (ACMHA) in Santa Fe, New Mexico reviewed a series of performance standards from different mental health managed care bodies. Attendees included many mental health officials from California, from both the state and counties. The group reached consensus on a set of key "process indicators," which are designed to "reflect a system’s performance in serving the needs of the individuals it serves." Final Report of the 1997 Santa Fe Summit on Behavioral Health, Preserving Quality and Value in the Managed Care Equation, American College of Mental Health Administration ("ACMHA Report") at page 15.[4] One universally accepted indicator was that "consumers who receive inpatient services receive face-to-face follow up care within seven days of discharge." Indicator P-I-2, page 15. Another indicator is that "children and their families receive the appropriate services that they need, when they need them." Indicator A-1-5, page 16.
The data used to measure these indicators relates to timeliness of appointments. Mental health plans should measure the number of inpatient discharges followed by an outpatient appointment within 7 days. ACMHA Report at 39. Plans should also measure the length of time from initial contact to first and second face-to-face appointment, and the percentage of clients who show for a face-to-face interview within 30 days of contact. ACMHA Report, page 39, 41. The plan is then evaluated based on the percentage of clients – typically 80% or more – who receive care within these timelines.
A good example of standards for access to outpatient appointments comes from Arizona’s most recent contract protocol for its own Medicaid mental health managed care waiver program.[5] Arizona has established measurable indicators which address many aspects of patient access to outpatient care, including timeliness of routine and urgent appointments, waiting time to be seen and transportation to an appointment.
…The contractor shall ensure, and require all subcontracted providers to ensure, that eligible and enrolled persons received covered services in accordance with the following requirements:
The Contractor shall establish procedures to monitor the availability of appointments and disseminate appointment standards to enrolled persons and providers.
Despite the recommendations of the ACMHA Santa Fe Summit and in contrast to other states such as Arizona, access standards for waiting times for outpatient services are lacking in California’s managed care system. The California Mental Health Planning Council has recommended that the state at least begin maintaining data about waiting times for appointments.[6] But the Planning Council stopped short of calling for actual waiting time standards.[7] The state has taken no action on the Planning Council’s recommendation for more data collection and has no process in place to begin setting standards for timely appointments.
The state’s annual oversight review of the county mental health plans focuses on structural standards, such as whether there is a quality improvement plan, whether providers are credentialed and enrolled, etc. However, the oversight review protocol does not mention appointment waiting times as an area of review under the section on access. Appendix IV-C-1-a, IV-C-1-d to Waiver Renewal request. Neither the managed care regulations nor the boilerplate mental health plan contract establish or even mention appointment scheduling standards. Exhibit 8 to Waiver Renewal request (contract); Waiver Request, Exhibit 4 (Cal. Code of Regs., tit. 9, §1810.405—regulation on access.)
However, the county MHP is required to set goals for timelines for routine outpatient visits and timeliness of urgent care services as part of its annual Quality Improvement (QI) work plan. Attachment A to Boilerplate Mental Health Plan Contract, Exhibit 8 to Waiver Renewal Request. In addition, the county was required to establish a mechanism to monitor these goals for timely appointments. If implemented and enforced, this requirement would have produced some of the needed indicators of plan performance, an important step towards setting consistent standards for timely appointments. However, in the first two years of the waiver, state oversight has not reviewed the QI work plan goals, the effectiveness of the monitoring mechanisms, if any, or the data they produced. The oversight protocol only required that the county have a QI committee; there was no review of the contents of the plan or whether the QI committee even met.
The new Oversight Review protocol for 1999-2000 does for the first time address whether the county has an annual Quality Management work plan. However, the new protocol still does not evaluate whether the work plan complies with the requirements in the contract attachment, nor does it specifically reference the required waiting time issues. Moreover, since the new protocol is only a yes/no format, it will offer no insight into these or any other substantive access issues facing the county. DMH should strengthen the annual Oversight protocol by addressing whether the county’s Quality Management activities actually comply with state requirements, and including an expanded narrative about substantive access issues.
The state’s Independent Assessment failed to collect data on waiting times for services, even in the ten counties that were intensively studied. The San Diego assessment mentions waiting lists only in passing, to note that there may be a "waiting period" to see a psychiatrist. Page VIII-15. In discussing areas for future development, the assessment notes simply that the county has provided additional funds "to assist in reducing waiting times and improving access to services." Independent Assessment, page VIII-129. In fact, a local news article in late 1998 uncovered increases in waiting times for outpatient services under managed care. The newspaper reported that waits at some clinics exceeded 8 weeks. See, San Diego Union-Tribune, November 29, 1998. As a result, waiting lists for mental health services have been a high-profile issue in San Diego and even attracted the attention of HCFA staff in the San Francisco regional office.
Following publication of the news article, the mental health plan began tracking waiting times at each clinic site and the issue was addressed in the mental health director’s monthly reports to the county mental health board. While waiting times were eventually reduced at most sites, the problem remains a persistent one in San Diego and in other counties. Despite this press attention and response from the mental health plan, the Independent Assessment did not mention the existence of the waiting time reports or the waiting time problems in the county.
Similarly, waiting times were not directly addressed in the state oversight review report on the San Diego MHP following a site visit on February 22-25, 1999, which was after the release of the Union Tribune article. In the county’s initial implementation plan, a study of waiting lists for services was one of many topics that the Quality Improvement committee planned to address in the 1998-99 year. San Diego Implementation Plan, Attachment F1-page 5, received by DMH, March 5, 1998. The Oversight Review team is supposed to evaluate the county’s Quality Improvement committee and its annual work plan, based on questions in the Review Protocol under Provider Satisfaction. Phase II Oversight Review Protocol, Section E, page 11, Appendix IV-C-I-a, Waiver Renewal Request. However, San Diego’s oversight report did not discuss the Quality Improvement work plan in the discussion under Provider Satisfaction, so there is no record whether the county followed through on a waiting list study as it had promised.
Significantly, the San Diego focus group convened as part of the Oversight Review did identify waiting lists as a problem. One family member described the long delays in obtaining mental health services for children from the county: ". . . after being assessed you are placed on a waiting list. The time period for the waiting list can vary for each clinic, but it can take up to five or six months before the person is seen." DMH Oversight Review of San Diego County, May 14, 1999 draft, page 11. The facilitator recommended follow-up with the MHP to determine: "Are the waiting lists really as long as reported by focus group participants?" Oversight Review, page 12.
Under the access section of the oversight report, the team noted also that the number of providers had decreased. Member of the review team were forced to accept the county’s assurance that the number of clients had increased and that access had not diminished although they complained that they "were unable to verify this information because we were not given any statistics with which to compare before and after consolidation." Oversight Review Report, page 2. Several months later, the Independent Assessment did obtain actual data and found that the number of clients served had decreased. Despite all these clues, the Oversight Review team made no negative findings regarding access, concluding that the county was in full compliance with the state managed care regulations and its implementation plan.
Here, state-level reviews failed to identify an access problem with county mental health managed care implementation which was so well-publicized that it made the front pages of the local paper and was mentioned in both client focus groups. This is a striking example of how the state’s failure to set standards for timely appointments has led it to overlook a serious barrier to access.
The Independent Assessment noted that as inpatient costs had declined, the rates of re-hospitalization had climbed from 33% to 46% of total admissions statewide, an increase of more than a third. Page I-40. In some of the counties studied in the Independent Assessment and for children especially, the increases in rates of re-hospitalization were even greater than the statewide average. Table 1, page 46 (all inpatients), Table 2, page 47 (children and youth).
This increase could be due to "churning," a process of repeatedly hospitalizing clients with severe and chronic mental illness without linking them to stable services in the community. The increase in re-hospitalization correlates with reduced inpatient reimbursement rates and the shortened length of hospital stay reported in the Independent Assessment. County mental health plans have reduced inpatient hospital reimbursement rates by 27%. Page I-34. They have stepped up their scrutiny of medical necessity and fiscal disallowances so that length of stay has also dropped. More than a third of all inpatients stays are for only 72 hours, as compared to 25% five years ago. Page I-39. The Independent Assessment heralds this as a great success, but it does not necessarily translate into better client outcomes or greater services in the community. Faced with a financial squeeze, the hospitals’ response seems to have been to limit admissions so that they will accept only patients who are on involuntary holds, and to discharge patients after 72 hours before their first commitment hearing. This short emergency hospitalization makes fiscal (if not therapeutic) sense because it virtually guarantees a finding of medical necessity and financial coverage by the MHP.
A shortened inpatient hospital stay is often positive for the client as long as he or she has access to follow-up services after discharge. But this critical linkage is missing on a basic structural level. California’s shift to managed care did not include a requirement that county mental health plans ensure that patients have access to outpatient services following discharge. Some county plans wisely DO provide follow-up after discharge and ensure that patients are connected back to community services. Independent Assessment, page IV-6 (Kern County crisis unit follows clients for 3 weeks after discharge or until linked to outpatient services). But as with many other good practices, this is not required and many plans fail to connect patients back to outpatient services. Independent Assessment, page 11-128; page III-127; pages IV-126, 127, 129; page V-15; page VII-16.
The result is a "disconnect" between inpatient and outpatient care. The DMH oversight focus group for Mendocino described a typical example, in which the shortage of community placements and services led to one client cycling repeatedly back into the hospital without appropriate medications or discharge planning. A participant in another DMH Oversight focus group complained about the lack of discharge planning for clients who leave crisis residential services: "They assume when you are released that you can make all the linkages yourself, which is not true." San Diego, 2/99.[8]
The normal standard in managed mental health care programs is to require the plan to arrange an outpatient visit within seven days of a normal psychiatric discharge and within three days of discharge after an emergency hospitalization. At the 1997 ACMHA summit meeting in Santa Fe, the single most common standard and the one on which there appeared to be complete consensus was that a mental health plan must arrange an outpatient visit within 7 days of discharge from an inpatient setting. ACMHA Report, page 15. Yet California has failed to adopt it. In fact, most plans do not keep the most basic data about the percentage of patients who are linked back to outpatient care, let alone assure that this occurs.
The dramatic increase in re-hospitalization rates across every county suggests that the disconnect between inpatient and outpatient care has gotten much worse under managed care. Overall, barriers to access to outpatient care and California’s failure to set waiting time and discharge standards have combined with the shortened length of stay to create a destructive increase in re-hospitalization rates. DMH must address these by developing data reports for each county on timeliness of follow-up care after hospital discharge and by requiring MHPs to arrange an appointment within seven days for all discharged patients. ensure continuing access to medication during this first week and facilitate other linkages to needed community services including housing, benefits, etc.
The importance of access to voluntary treatment was a point of consensus at the 1997 ACMHA Santa Fe Summit, which adopted the principle that "Consumers receive mental health inpatient services in a voluntary, non-coercive manner." Indicator P-I-5, ACMHA Report, page 15. The ACMHA report explains that "a well functioning service delivery system should be able to minimize unplanned, coercive hospital admissions through care management and effective alternative treatment resources. High rates of involuntary hospitalization may indicate inadequacies in ambulatory care services that are less intrusive/restrictive."
Measured by this standard, California’s system is sorely lacking. There is evidence from clients and family members that it is increasingly difficult for clients to access inpatient services on a voluntary basis. Testimony of Sally Zinman before the California Little Hoover Commission, September 23, 1999; DMH Oversight Focus groups from Monterey, 6/98, Napa, 12/98.[9] When people request hospitalization on a voluntary basis early in a crisis, hospitals turn them away and will only admit them later when they have deteriorated and meet the criteria for an involuntary hold.
The Independent Assessment provides an example of this problem. The Sutter/Yuba MHP operates an inpatient psychiatric health facility ("PHF"). The assessment explains: "There are no voluntary or planned admissions to the PHF . Clients believe the ability to admit themselves voluntarily would help them resolve a crisis earlier in the cycle. Clients could receive intervention without the discomfort of requiring a full-blown emergency to take place." Independent Assessment, page XI-12. Access to voluntary outpatient services is also difficult, with waiting lists of up to 4 weeks for medication appointments and 6 to 8 weeks for therapy. Independent Assessment, page XI-11 to12. The MHP spends comparatively little on outpatient services (page XI-30) and has little drop-in or crisis capacity because the on-call psychiatrist is fully booked with appointments. Page XI-9, 12. Case management is also weak, especially for adults. Page XI-9, 124. The Independent Assessment suggested that there was an over-reliance on inpatient placements at the PHF which was not reflected in the inpatient data because the facility is ineligible for Medi-Cal funding. Page XI-1, 125. In these counties and in many others, clients literally have no alternative to involuntary inpatient commitment.
This finding is consistent with other data from DMH on increases in involuntary hospitalization rates. The California DMH is required by state statute to publish an annual report on involuntary psychiatric holds and conservatorships under the state mental health statute, the Lanterman-Petris-Short (LPS) Act. California Welfare and Institutions Code § 5402. Unfortunately, the state has neglected this obligation, so that the last available report was released in 1998 and covers only 1990 to 1995.[10] Although outdated, this report is revealing. It demonstrates that over this five year period from fiscal year 1990-91 to 1994-95, the number of involuntary 72 hour holds increased by 22% among adults and 57.8% for children, with some counties experiencing an even higher increase. Table 3 page 48, Comparative rates of Involuntary Hospitalization, Adults and Children.[11]
The data report on involuntary hospital detentions also uncovers a problem with state oversight. DMH refuses even to look at involuntary detention statistics when evaluating a county’s managed mental health system, claiming that this is mixing "apples and oranges."[12] Consequently, DMH has never examined the dramatic variations in county practice, with counties such as Humbolt, Alameda and San Francisco showing a rate twice that of the state average and counties such as Sonoma, Shasta and Ventura with rates far less than the state average. Table 3, page 48. While not all persons detained on an involuntary hold are Medi-Cal eligible, the majority of them are.
When involuntary admissions increase and people are denied services until they meet the involuntary criteria of danger to self, grave disability, or danger to others, consumers suffer and mental health plans lose control over authorizations and utilization. DMH must treat high rates of involuntary inpatient holds as a measure of system failure for a county MHP, track this data as a compliance issue and require better data and reporting.
The Waiver Request and the Independent Assessment fail to answer an important question regarding this managed care demonstration. What happened to the Medi-Cal beneficiaries who were previously served under fee-for-service and who no longer meet the strict eligibility and medical necessity guidelines of the new program? As critical as this question is, the state cannot identify the number of clients in this category or what happened to them.[13]
Part of the problem is the narrow eligibility and medical necessity definitions in the 1997 mental health managed care regulations adopted by DMH. These are inconsistent with other definitions of medical necessity for rehabilitative services in federal and state law and unnecessarily limit access to mental health services under the waiver. DMH has failed to respond to comments regarding these regulations or to promulgate final regulations which remedy any of the problems.[14]
Until DMH adopts more appropriate eligibility standards, it is even more critical for the counties to maintain accurate and complete data on the clients who are denied and screened out under the current criteria, as narrow as they are. Unfortunately, data is sketchy or non-existent. While the state promised HCFA that the counties would track the clients they denied or referred out, the Independent Assessment found instances among even the 10 counties surveyed where the MHPs failed to even log, let alone follow, denials and referrals out when the county would not provide services. Page V-15 (MHP’s access/intake process difficult to track or understand, request to some sites not logged); X-8 (MHP’s intake logs were incomplete).[15] When initial requests for service are denied and clients referred elsewhere, denial notices are virtually non-existent.[16]
The data in the Independent Assessment offers a hint of the potential magnitude of this issue. For outpatient services, the Independent Assessment compared number and percentages of clients who were seen for one month out of the year, two months out of the year, three months, etc. and how many units of service (or contacts) were received by clients in each category.[17] The number of clients per year who had only a single contact was very high – as much as 10% or more in most counties and more than 30,000 people statewide in 1997-98. See Table 4, page 49, Mental Health Clients With Only One Outpatient Contact, 1997-98. These could well be the clients who are turned away with no follow-up after a single call or intake. These numbers could easily be higher, since many callers are rejected by the telephone access lines without a record of the request. The large numbers of clients potentially involved makes accurate data even more critical.
The problem of these "lost" clients is compounded by the lack of standards for screening and evaluation for eligibility. The state managed care regulations do not clearly specify that eligibility assessments must be face-to-face. When clients first call the MHP access telephone line, it has not been clear to the counties whether the staff can screen a client for eligibility over the telephone and if so, whether they must send a notice of action denying eligibility.[18] Although DMH staff have taken the position that eligibility cannot be determined over the telephone, an unknown number of counties continue to do so in the absence of a definitive regulation. This has led to situations where people have called the counties’ toll-free access lines for help and information and were evaluated over the telephone for eligibility for services without knowing it. This result is both inaccurate and unfair, since clients are unlikely to confide painful details about their emotional life to a stranger over the telephone when they are unaware that their ability to access any help at all may depend on what they say.
DMH could resolve many of these problems by broadening the eligibility and medical necessity standards so they conform with federal law, instructing counties to make all eligibility determinations only after a face-to-face interview, and requiring counties to track turn-aways and the many clients who receive only a single contact with no follow-up.
California’s Medicaid plan offers a rich menu of mental health services. Under state and federal law, the full range of these services should be available in every county. An access indicator adopted by the 1997 ACMHA Santa Fe Summit was that "[a]ccess to a full range of services is demonstrable." Indicator A-I-4, ACMHA Report at page 16. The ACMHA report explains: "Easy access to a narrow range of services is not genuine access. (As the folk adage puts it: ‘If all you have is a hammer, everything looks like a nail.’)" Page 16.
In seeking the new federal waiver, California promised that managed care would increase the array of services available to clients. As noted above, in some counties this promise has been realized. But in other counties, the range of services has not increased. Because clients are now confined to the service providers with which their county plan has contracted, in many cases the range of services is far less than before managed care. In addition, the availability of services is based on arbitrary, historical funding formulas, not need as it would be in a truly capitated system where each plan’s funding is based on the number of eligible clients. See Table 6, page 51, Medi-Cal Mental Health Spending per Capita.
Moreover, California’s mental health regulations give the counties almost unfettered discretion to decide the array and mix of the outpatient services a mental health plan will provide. Cal. Code of Regs., tit. 9, Sec. 1810.345(a) ("the MHP shall not be required to provide or arrange for any specific specialty mental health service, but shall assure that the specialty mental health services available are adequate to meet the needs of the beneficiary.") The Boilerplate contract with the mental health plans does not specify any specific services. Attachment 8 to Waiver Renewal, Section V.B., page 11 (only requirement is that the mental health plan must provide services which are "medically necessary"). DMH staff members confirm that they do not require every mental health plan to provide for every type of covered Medi-Cal mental health service.[19]
In contrast, other states have explicitly required local mental health managed care plans to cover a specific range of services, including psychosocial rehabilitation services. GAO Report at 14 –16.[20] DMH will never be able to ensure that all clients have access to the services they need unless it adds similar language to its plan contracts and requires counties to offer all the services covered in the state Medicaid plan. As an interim step, DMH should at least provide comparative data about what types and categories of services each county plan provides and omits, since this information is available from claims data but not readily available to clients, family members, advocates or other members of the public.
Some county mental health plans in California have chosen to emphasize and fund the psychosocial, recovery-based services that many consumers want.[21] Other counties have not provided significant funding for psychosocial rehabilitative services. Some offer rehabilitative services only on a pilot basis for small numbers of consumers, if at all.[22]
Psychosocial rehabilitation services need to be present in the continuum of care. The medical model for treatment is not enough to support the outcomes of recovery and self-sufficiency. People can work, live in the community, and lead productive, meaningful lives while experiencing positive symptoms of mental illness. Psychosocial rehabilitation ultimately attempts to improve role performance or status in consumers’ living, learning, working or social environments. Research literature indicates that mental health consumers want recovery and self-sufficiency, not simply stabilization of symptoms and reduced use of acute care.[23] Outcomes research strongly supports use of psychosocial rehabilitation and cost-effectiveness studies of psychosocial rehabilitation show an average reduction of more than 50 percent in cost of care due to reduced hospitalizations when psychosocial rehabilitation services are available (Barton, 1999). Current evidence supports a policy of funding the psychosocial rehabilitation components of community support systems and balancing allocations for these systems among various levels of service intensity (Psychiatric Services 50:525-534, 1999).
Important programs that fall under the broader term of psychosocial rehabilitation services and which are Medicaid fundable in whole or in part include supported employment, supportive housing, supported education; a focus on skills training and family psycho-education; crisis residential services, mobile crisis teams, pre-crisis warmlines and in-home crisis stabilization; support in creating, identifying, and enhancing natural supports, and programs which employ consumers as providers of service.[24]
The Independent Assessment corroborates that there is a problem with inadequate access to psychosocial rehabilitative services. Even among clients who had successfully accessed mental health care, as many as 40% reported no improvement in their functioning at work, school or home. Independent Assessment, page I-150, III-124, V-119, VI-127, IX-124. The Independent Assessment repeatedly advised that the county plans need to increase rehabilitative services to assist members in developing the skills necessary to become more self-sufficient in school, work, at home, and in the community.[25] The state will have little ability to implement this recommendation unless it assumes more control over the service mix and availability than it presently exercises.
One positive step will be to simply compile consistent data from each MHP about the rehabilitative and recovery based services it provides. Many of the data measures in the MHSIP Consumer-Oriented Report Card relate to the percent of resources of the managed care plan devoted to consumer-led programs, recovery-based services, etc. See Tables 7 and 8, summarizing data measures that DMH could adopt immediately.
Under its Medi-Cal plan, California covers both medical case management and targeted case management. These can include brokerage services such as assisting clients in obtaining non-Medi-Cal services, SSI benefits, housing and vocational support, as well as rehabilitative support to assist clients in living independently in the community. Support through case management can be critically important for mental health clients. In some counties, however, case management is available only on a token basis. For example, Los Angeles has 792 targeted case management slots for 94,000 mental health clients. Independent Assessment, page VII-11. In other counties, case management is provided only to clients who have been repeatedly hospitalized or whose cost of care exceeds a certain threshold, criteria which are inconsistent with a focus on preventive care. Such policies exclude people with comparable needs for case management services and force clients needlessly into crisis in order to qualify for assistance.
Case management and support can be especially important in assisting mental health clients with transportation to clinic and therapy visits and in reaching crisis services. Transportation is always a problem for low-income clients, particularly in rural areas. Clients with psychiatric disabilities in a mental health crisis may find it impossible to negotiate public transportation, maintain a working car or make alternative transportation arrangements. Medical transportation is a covered Medi-Cal service and arranging for medical transportation can be an important case management service for a client. Some county MHPs recognize this and provide transportation assistance to clients who would otherwise be unable to access care. See, for example, Independent Assessment, page IV-130 (case managers assist with transportation); X-9 (same). In most counties, clients report that they receive no assistance in securing transportation to mental health services, and that this is one of the primary barriers to access which they face.[26]
Improved case management would also address the problem of missed appointments. Instead of closing the client’s case, as many MHPs do, a missed appointment may signal that the adult or child has more difficult problems and requires home-based intervention or additional support. Independent Assessment, page III-126 (MHP needs to respond to "huge no-show problem"); IV-128 (clients need case management assistance)
Under DMH’s managed care regulations, MHPs do not have clear standards for case management. The regulations provide that MHPs are not responsible for medical transportation, but fail to address how mental health clients should access Medi-Cal covered transportation and the role of case management in this process. See, Cal. Code of Regs, tit.9, § 1810.355(a)(1)(B). DMH needs to establish clear guidance for county case management and clarify that eligibility for case management services is based on individual need and not on a client’s cost history.
The state Medicaid plan covers three different kinds of crisis services: crisis intervention, crisis stabilization and crisis residential. Some counties have effective crisis programs, with mobile crisis teams and an investment in high quality services at a greater cost per unit that pays off in lower inpatient hospitalization rates. Table 5, page 50, Medi-Cal Mental Health Crisis Services, 1997-98.[27] Despite the obvious effectiveness of this approach, the Independent Assessment found there was an unmet need for crisis alternatives in the service continuum of mental health plans. Independent Assessment, pages II-5, 129 (Alameda – needs crisis team evenings or weekends); X-5 (Siskiyou – in crisis, police bring clients into the emergency room); XI- 9, 124 (Sutter/Yuba – on call psychiatrist too busy to handle crisis/walk-ins, need to add crisis case management with adults).[28]
Even out of the 10 counties surveyed, only 5 offer any form of mobile crisis intervention and only six provide access to a crisis stabilization unit. These figures include Los Angeles county which provides crisis stabilization and mobile crisis intervention but on such a limited basis that it is not available as a practical matter to most clients. Independent Assessment, page VII-33 (percent of clients served by crisis programs dropped over 5 years).
For the remainder of the state, there is no easy way to determine which counties provide crisis stabilization or mobile crisis intervention until DMH produces more public data on the services each county provides. The initial implementation plans did not require this information. It is safe to assume that many, and perhaps most, of the other 47 county mental health plans do not offer these services to their Medi-Cal clients, especially in view of the overall small percentage (4-5%) of the total mental health funding for crisis services/alternatives. DMH should prepare public, statewide data on the availability of the different types of crisis services and require each county MHP to provide adequate crisis alternatives.
The Independent Assessment noted that clients faced problems obtaining medications prescribed by MHP providers, since these are "carved out" of the mental health managed care program and are not the responsibility of the mental health plan.[29] Although the county MHP should provide case management assistance to resolve any problems with authorizations, this often does not occur. The county patient rights office in San Diego recently assisted a client when Medi-Cal refused to fill a prescription from her county MHP psychiatrist. Her doctor had prescribed a non-standard medication because more traditional psychotropic medications had been unsuccessful. The mental health plan and United Behavioral Health, its administrative services organizations well as DMH and its Ombudsman office were unable to resolve the impasse and she went for more than a week without medication until Medi-Cal finally relented.
Given the importance of consistent access to medication for many clients, some counties have taken the initiative to resolve these problems by directly paying for psychotropic medication prescribed by county doctors whenever there is a problem.[30] DMH approved the San Mateo mental health plan’s request for authority and funding to provide the medications its doctors prescribe; this pilot is already demonstrating increased cost effectiveness and better outcomes. DMH regulations require county mental health plans to have a memorandum of agreement with physical health care plans in their county regarding disputes about medication coverage. Although slow to be completed, these agreements have helped when the problem involves another managed care plan. However, the agreements do not apply when there is no physical health managed care plan and Medi-Cal itself is denying coverage. DMH has refused to adopt regulations to require MHPs to advance the funding for psychotropic medications when coverage is disputed, subject to reimbursement from Medi-Cal as well as a physical health care plan, and has opposed legislation to accomplish the same goal. See, California Senate Bill 745 (Escutia).
Family members, family advocates and members of many focus groups reported especially significant problems accessing services for children with mental health needs (often called seriously emotionally disturbed or "SED"). They reported lack of providers, long delays in accessing services such as therapy, residential placements, etc., poor coordination with special education, probation, dependency, substance abuse programs and few linkages for transition age youth. See Testimony of Karen Hart, UACC, before the California Little Hoover Commission, September 23, 1999 (describing inadequate services for children). As noted elsewhere in this report, children fared poorly on several key measures of mental health status.[31]
As noted in earlier sections of this report, Medi-Cal clients, including children and youth, are entitled to coordination and "brokerage" services as a covered Medi-Cal service. The state DMH has provided many counties with new mental health funds to develop "Childrens’ Systems of Care" programs intended to offer coordinated services to children with serious emotional disorders. Federal Medicaid law also requires that EPSDT services to children be coordinated with special education services. Similarly, state law requires that county mental health departments provide assessment and services for children with SED who are identified through the special education system; this is known as the AB 3632 process, after the enabling state legislation.
Despite these requirements, DMH has not set standards in regulation or plan contracts requiring county plans to engage in outreach and identification of Medi-Cal eligible children in need of mental health services. MHP’s are not required to coordinate with other agencies such as school districts, probation departments, etc. Even in the absence of clear direction from DMH, some plans conduct outreach and proactive identification.[32] However, many others do not.
Many parents in focus groups described how they had tried for years to get services for their SED children through the school system, without ever knowing that the mental health system was available to them. Many commented that services were adequate once they "got in" but that finding out about services was very difficult. Many parents noted that their child was identified as needing mental health services only when he or she ended up in the probation system or after an acute psychiatric admission, despite years of begging for mental health assistance. The Independent Assessment also noted problems coordinating mental health services with the special education system.[33]
Without major reforms in this area, California cannot comply with HCFA’s new guidelines for managed care plans serving children with special needs. On June 4, 1999, HCFA announced new "Review criteria for Children with Special Needs" who are mandatorily enrolled in Medicaid managed care programs. HCFA has explained that these criteria will apply to California’s request for a renewal of its mental health managed care waiver.[34] These criteria are that:
To satisfy these criteria for renewal of its managed care waiver, California must establish standards in regulation and in plan contracts for county mental health plans to conduct outreach and proactive identification of children in the special education, juvenile justice and dependency systems, ensure that all counties provide case management and coordination for these children, and add these areas to its monitoring protocol.
In many counties, parents reported serious shortages of services and providers and long waiting lists. These kinds of problems are predictable with adult services because of the unequal and inadequate state funding formulas described in a later section of this report. But with children, there should be no excuse because the county mental health plans have access to open-ended funding through Medicaid’s Early, Periodic Screening, Diagnosis and Treatment ("EPSDT) program. The Medicaid EPSDT program requires states to provide children under age 21 with expanded services, including mental health services. California implemented the EPSDT program only after being sued in federal court in 1995. As a result of this lawsuit, the state DHS transferred additional Medicaid funds to DMH to distribute to the counties. Once a county has spent an amount equal to its baseline expenditures for 1994/95, county MHPs are reimbursed fully without the need for county matching funds. From the counties’ perspective, additional EPSDT expenditures are "free," subject to uncapped funding reimbursement from state and federal funds.
That services are still so inadequate in many counties is the result of uneven state oversight. Apart from offering the incentive of new EPSDT funds, DMH has left the degree of service expansion entirely to the discretion of individual counties. Without uniform state standards for minimum EPSDT penetration rates or service capacity, utilization of EPSDT funds has been extremely uneven from county to county. Some counties have expanded children’s mental health services ten-fold while others such as San Diego have refused since 1997 to draw down any EPSDT funds above their baseline. In fact, DMH oversight has focused exclusively on counties which were high utilizers of EPSDT funds. The state extended no scrutiny or sanctions for counties that ignored the EPSDT mandate. San Diego – one of the larger counties in the state - decided only this winter to begin drawing down EPSDT funds, years after other counties had elected to do so. As a result, EPSDT mental health penetration rates in some counties remain very low. DMH has done little to ensure that all counties fully implemented EPSDT mental health services for children as federal law requires.
The state managed care regulations are another example of the lack of state oversight and direction for this critically important program. The regulations do not define what supplemental EPSDT services county MHPs must provide, do not explain the procedure for requesting these services or in any way inform counties or families of the additional responsibilities the county mental health plans have to provide EPSDT services. For example, federal EPSDT law requires the state to assure that there are providers; when there are shortages of providers, the state must provide a needed service directly, unless it can assure that there are other able and willing providers. This duty is transferred down to the county mental health plans. Overall, DMH has done little to ensure that children in all counties have equal access to EPSDT mental health services.
The lack of adequate mental health services for children in many counties also violates HCFA’s new criteria for managed care waivers requiring the mandatory enrollment of children with special needs. The new HCFA criteria announced June 4, 1999, require that the state:
DMH has done none of these. DMH has no capacity or performance standards for children’s mental health services, and, as with the rest of the Medi-Cal mental health system, leaves it to the counties’ discretion to determine whether providers and services are adequate. Under HCFA’s new criteria, DMH must become more active in overseeing at least these children’s services by setting standards and then monitoring closely the range of contracted providers and their capacity, waiting times for services, scope of services, etc.
The Independent assessment was able to track penetration rates and service utilization specifically for the foster children population. In some counties, the data indicates that access to mental health services for foster children declined under managed care. In Alameda County, the MHP changed its procedures so that foster children could not access services directly, although other children could. Page II-12. The result was that the number of foster children served by the mental health system dropped and the penetration rate for the foster child population declined, while the rate of hospitalization for foster children increased. Independent Assessment, pages II-113, 115, 116. Because this is such a vulnerable population, DMH needs to investigate anomalous results such as this and compile and publish similar comparative data on utilization by foster children in all counties.
DMH has been aware of the special problems its county-based managed care design poses for children placed in out-of-county foster care. Participants in a DMH oversight focus group in Napa County in December, 1998, complained that children placed in Napa had to go back to San Francisco – the placing county – for counseling, a process which they described as "impractical." In other cases, the placing county would demand that providers in the county where the child was placed must enroll and contract with the placing county, a burdensome process which the providers rejected. In an effort to solve these problems, DMH and the counties developed a complex contract arrangement with a commercial managed care plan, ValueOptions, to credential and authorize providers for children placed out-of-county. The plan is financed with state and federal Medicaid dollars funneled through a non-public group - the California Mental Health Directors Association.
Two years after outpatient managed care began, implementation of the ValueOptions plan is just beginning. Start-up has been slow, since it requires each of the 58 counties to pass a special resolution and enter into a new contract, a process that is not yet complete. In addition, the scope of the contract with ValueOptions has been radically scaled back to cover only routine mental health services for foster children in out-of-county placement.[35] Case management and more intensive services such as day treatment, partial hospitalization, inpatient treatment or supplemental EPSDT services must still be authorized directly by the home county which placed the child. This division may be confusing to foster parents and even to county staff, since it multiplies the complexity by spreading responsibility among not just two but now three entities – the home county, the county where the child is placed and ValueOptions. In addition, adding ValueOptions for some services will not solve authorization problems with the remaining services a child may need.[36] In the past two years of managed care, families and advocates have observed situations where the county which placed the child fails or refuses to authorize inpatient treatment and insists that the child must be returned hundreds of miles to the home county for hospitalization.
A consistent theme in the focus groups convened as part of the state oversight process and the Independent Assessment was that consumers wanted more information and choice than they had been provided. This section covers client-directed services including system planning, choice of treatment and advance directives, and information about beneficiary rights, including appeal and grievance rights. An indicator adopted by the 1997 ACMHA Santa Fe Summit is that the plan’s structure has "effective consumer and professional representation in policy making" and that "consumers and families are educated about their rights, the array of services available to them and likely outcomes of treatment interventions." Indicators S-I-1, S-I-8, ACMHA Report at page 17, 18.
Consumer involvement in planning, implementation and evaluation of the administration of the mental health plans varies widely. The state DMH has provided an exemplary role model by including consumers and family members on numerous committees involved in planning, implementation, evaluation, and decision-making about the statewide mental health system. See, testimony of Karen Hart, UACC to the Little Hoover Commission, September 23, 1999 (describing client/family member involvement). Each DMH annual oversight review includes a client or family member as a member of the review team.
There are limits to this process, however. Despite the fact that clients and family members sit on various boards and committees and lend their names to the group’s final product, they report that their recommendations are often ignored or deleted. The clients and family members report that administrative staff say that their proposals are too costly and unrealistic to be adopted or funded, given the county’s budget. This experience is disempowering and discouraging.
County involvement of clients in decisionmaking is spotty. Of the 10 counties reviewed by the Independent Assessment, Contra Costa County had a consumer and a family member as a part of the administrative management team, and Fresno County had one consumer as a full-time member of their administrative management team, with high consumer and family involvement. Other counties ranged from only unpaid or volunteer consumer and family involvement in the mental health plan's decision-making processes, to no involvement at all.[37] It is a very positive development that the new DMH oversight protocol includes questions about client and family member participation in the county Quality Management process. See, e.g., Santa Barbara Oversight Report, 10/99 (plan of correction required because MHP did not include clients and family members).
Although the scope of this report does not permit an in-depth analysis, in the ten counties studied, the Independent Assessment appeared to draw a positive correlation between the existence of consumer and family "voice" or involvement and the existence of psychosocial rehabilitation services such as self-help drop-in centers, skills training services and peer supports. The California Mental Health Planning Council and the California Association of Local Mental Health Boards and Commission have completed a joint report on consumer and family member participation in local mental health boards. DMH should direct the county mental health plans to begin reporting comparative data on the degree of client and family member involvement in planning and oversight. See Tables 7 and 8. This data can be correlated with the Planning Council’s survey of consumer /family participation for a more systematic view of the effectiveness of client voice.
Advance directives are another means of insuring client-directed services. Many states have implemented trainings for clients on how to develop advance directives, ensure that copies of advance directives are available when accessing information about a member of the mental health system, and have developed policies and procedures and standards that direct providers in the utilization on advance directives. This was one of the recommendations of the Independent Assessment. Page IV-127.
On June 7, 1999, HCFA sent a letter to all state Medicaid directors, instructing them to "develop and provide current information about state laws that deal with advance directives." HCFA urged "all State Medicaid programs to work with their State mental health authorities to ensure appropriate attention to mental health issues in their advance directives policies, and to consider how these policies are operationalized in Medicaid program services."
California has taken no steps to implement this guidance regarding advance directives. Without initiative and guidance from DMH, there is no organized means to ensure that all mental health clients are informed of their right to prepare an advance directive and to be assisted in this process. County MHPs have taken no steps to monitor whether their contract hospitals comply with the requirements regarding advance directives in the new HCFA regulations on patient rights, which is a condition of participation for all Medicaid certified acute care hospitals. Moreover, county MHPs have no procedure to assist their contract hospitals and providers in locating advance directives so that they can be honored.
Since advance directives are such an important tool for clients in directing their own treatment, DMH should use its leadership position in the state to prepare standard, written information and model forms for clients about advance directives and the services these can cover and ensure that counties provide these materials to clients at every opportunity. State oversight should consider whether counties have procedures in place to implement and enforce advance directives and to monitor compliance by their contract facilities.
In almost every county, clients report that they are not provided with basic information about the services and providers available to them. This is because the MHP brochures are not specific enough and not widely available. Participants at a DMH Oversight Focus in Alameda County in March 1998 asked for a "catalogue of the names and contents of services," and "written information on what you can do, where you can go."[38] Unlike the information materials provided to enrollees in physical health care managed care programs, the information brochures provided by the county MHPs do not list providers or specific services and locations. Although the state provided assurances to HCFA that provider lists would be available to clients on request, clients are seldom told that they have the right to make this request. Even advocates report difficulties obtaining current service and provider lists from counties. DMH should amend the state regulations to require that information brochures be more detailed and include specific lists of services, all available providers and where these are located. DMH should also require that this information be provided annually and when clients are hospitalized, rather than only at first contact and upon request.
The counties also differ on client choice for culturally competent services. San Joaquin has providers with a range of staff who are bi-lingual in many languages; clients may select the provider based on these factors. Independent Assessment, page IX-13. In contrast, San Diego assigns clients to contract providers without choice of cultural compatibility. Page VIII-15. See also, page XI-125 (chart review showed that family members interpreted for mental health clients); DMH Oversight report, Monterey, 11/99 (corrective action plan required because in 2 test calls, MHP access line did not respond to Spanish caller, saying no assistance was available); DMH oversight focus groups: Glenn (not enough Spanish speaking therapists), San Bernadino, 10/99 (long waits because so few Spanish speaking staff). Data from the Independent Assessment shows that Latino and Asian clients are under-represented among mental health clients, as compared to their representation in the general Medi-cal population. Lack of language access and poor cultural competence could explain part of this discrepancy
The result is that in some counties, clients are poorly informed about their options, experience little choice and are forced to accept whatever services or providers the county offers.[39] In the DMH focus groups, although many clients stated that they wanted to see their therapist or psychiatrist more often, or for longer time periods, or that they wanted to see different providers, they were not aware that they could act on these choices and wishes.[40]
In 1997, a similar situation developed in Los Angeles County involving Medi-Cal managed care for physical health care. On the eve of mandatory enrollment of Medi-Cal recipients in the county’s "Two-Plan Model" managed care program, it became apparent that clients were not adequately informed of their options. As a result, HCFA delayed implementation of mandatory enrollment until there was evidence that a strong program of client and community education and outreach was in place. Since mental health managed care also involves mandatory enrollment, the need for client education and choice deserves equal attention. DMH and HCFA should mandate that MHPs provide more detailed information about specific services and lists of available providers, that this information be provided to clients more frequently, and that MHPs conduct more extensive outreach, publicity and training about the programs and services.
The most consistent response from every client focus group was that the members were not aware of their appeal and grievance rights. Especially troubling was the fear in many groups of retaliation if they did try to complain, a concern that was echoed in the discussion groups leading to this report. Without a full explanation of their rights and how to protect themselves, clients were concerned that they would be labeled as troublemakers and denied the services they has struggled to obtain; some had already experienced retaliation. See, DMH Oversight focus group notes from Alameda, Butte, Glenn, Humbolt, Kings, Monterey, and San Diego counties. The low numbers of appeals and grievances filed by clients in the two years of outpatient managed care may also reflect this fear.[41]
This fear and lack of information has several causes. One is the inability of many MHPs to produce effective education materials on their own. The most common compliance violation in the DMH annual oversight reviews was failure to develop and distribute accurate brochures about client rights. Waiver Renewal Request, Appendix IV-C-1-b, Summary of Review Findings (of the 11 counties listed, 9 had compliance violations regarding beneficiary rights).[
42] While somewhat expected during start-up, these problems persist even in recent oversight reviews.[43] A second problem is that many MHPs have weak grievance systems and little follow-up or feedback to their quality improvement systems.[44]To resolve these problems, DMH needs to show leadership and step in with standard, statewide materials that are effective and understandable by clients. Leaving the job entirely up to each county has proved to be a disaster, especially in small counties where there is not enough staff or experience to develop and translate appropriate client materials. Given that the existing outreach and education efforts are clearly unsuccessful after two years, DMH should also increase the required distribution points so that clients are assured of getting updated materials at the time of first contact, annually thereafter and at the time of admission to and discharge from an inpatient facility.[45] The addition of the Ombudsman Office is a very positive step that should also help in the future.[46]
Other steps should be taken to address fears of retaliation and to promote client education. MHPs should ensure that clients are offered an oral explanation of the grievance and appeal process by their provider or county worker and that there is written documentation in every client’s file that this explanation has been provided. DMH should also require MHPs to provide training to clients about their rights as well as the services that are available to them.
The virtual absence of any notices of action also contributes to clients’ lack of information about their appeal and grievance rights. Both the Independent Assessment and the oversight reports noted that some counties had never issued a notice of action. Normally, clients learn about how to appeal and file a grievance from the notice they receive when their request for services is denied. Under the managed care regulations, denial notices are only issued when a provider’s request is denied by the MHP. The county MHP is not required to provide a written notice when it denies a request made by a client directly, often because he or she cannot get access to a provider. As a result, the appeal and grievance system is a Catch 22: the most common kind of denial will never trigger a denial notice that would inform the client about his appeal and grievance rights.[47] Denials are also difficult to document or appeal because there are no forms for clients to request services when they are unable to see a provider who can submit the request for them.
DMH must amend its regulations to require a written notice of action when a client’s request for services is denied, deferred or modified, even when the request is not submitted by a provider or when the provider has already been paid. DMH needs to provide clients with forms to request services when they can even be seen by a provider, which is a common problem and complaint.
Defining minimum access standards is inherent in a state’s oversight and monitoring responsibilities. In a Medicaid managed care system, access standards can be set out in regulations and/or in the state’s contract with the managed care plan. Unfortunately, although California requires the county mental health plans to ensure that there is access to services and includes access as part of the annual oversight review protocol, it has never set standards which specify what access actually means. The Independent Assessment provides important insight into the state’s problems:
Counties have much autonomy in implementing [the state managed care] regulations. At this time, there is no systematic method for assuring standards are implemented; reviews are based on the verbal report of county staff and review of documented policies and procedures. .
Independent Assessment, page I-13 (emphasis added)
The California DMH serves as the single state authority to provide coordination, planning, administration, regulation, and monitoring of the state public mental health system. Setting, implementing, and monitoring standards and operationally defining what is expected in relation to program requirements, contract funding and uniform and special terms and conditions are common core responsibilities. The only way to ensure that persons across over 50 different mental health plans in California are provided with a minimum standard of care is for the DMH to accept the responsibility for setting standards and to take that next step in implementing a quality managed mental health care carve-out. The fact that individuals relying on public mental health services only have one choice makes standardization even more critical.[48]
The California DMH has made significant progress in implementing managed mental healthcare across 56 mental health plans. Consumer and family involvement at the State level is but one example of DMH’s attempt to create a collaborative and cooperative process. The relationship between the DMH and the California Association of Mental Health Directors’ Association is another example of a collaborative partnership. However, the strong bonds that exist between the county mental health directors and the DMH are a double-edged sword when it comes to setting enforceable standards. The county mental health plans are understandably reluctant to subject themselves to standards that they may not be able to meet. As a result, it may not be possible to set standards through a consensual process involving the county plans. Not all mental health plans need the DMH to set standards and model the use of data to manage systems of care, but some do. There have always been county mental health directors, now mental health plan directors, who set standards for care, use data to manage and correct systems, and are on the cutting edge of best practice provision. Unfortunately that is not true across all mental health plans and it is the state DMH’s job to see that people receive a minimum standard of care.
Setting minimum standards of care for all mental health plans and enforcing them, developing standard protocols and performance outcome measures to be used by all mental health plans, and collecting, analyzing, and reporting data in the form of trends to be used in decision-making are the next steps to be taken by the California DMH. It is through having access to such information that the State Quality Improvement Committee, the Planning Council and other advocacy groups can do the work they have been asked to do.
In addition to lack of standards, the state suffers from lack of data. The 1997 Santa Fe ACMHA Summit agreed that "accountability must be based on reliable comparable data . . . . Data must assist delivery systems to improve and provide a meaningful yardstick for comparing costs and outcomes to people outside those systems." ACMHA Report at page 11. The Independent Assessment found a far different situation in California:
DMH staff interviewed stated that they do not currently use data to assess access, penetration rates, or analyze cost-effectiveness. However, they noted that they are beginning to look at data from the beginning of Phase I [January 1997]. . . .
The leadership of DMH in setting standards for the counties to produce accurate monthly data is critical. Many counties rely on the state to analyze and generate data, because they lack the staff, expertise and time to develop the decision tools. Data that shows client utilization and cost-effectiveness must not be three years old. It must be current, accurate and timely to be useful."
Page I-13 to15. In fact, the state’s existing data on mental health services is woefully outdated. The consultants who prepared the Independent Assessment conceded that because there is so little data from the current waiver period, their report does not evaluate the effectiveness of the current waiver program and Phase II consolidation of outpatient services into managed care, although this was the charge from HCFA. Independent Evaluation, page I-152. The most recent data available to the consultants was from fiscal year 1997-98, before most counties implemented outpatient managed care.
Sadly, the state’s own data collection is so weak that the Independent Assessment itself provides the only useful statistics on MHP performance, as limited as these are. Even among the counties surveyed, the Independent Assessment identified serious problems with five – Alameda, Humbolt, San Diego, Los Angeles and Sutter/Yuba – that represent the majority of the population in the ten counties. Without specific data about the remainder of the state’s 46 mental health plans, it is likely that there are additional problem counties which remain unidentified.[49] DMH has recently developed a plan to prepare annual data reports on each county, a positive step which is sorely needed. Its reports should incorporate the data recommended in the ACMHA report and by the California Mental health Planning Council, summarized in Tables 7 and 8, pages 52 and 53 of this report.
The GAO has noted that HCFA has proposed new managed care regulations which will require separate external quality reviews by an independent peer review organization for each managed care plan. GAO Report at 24. The state has requested an exemption from this requirement. Waiver Request at 11. In fact, separate external reviews of every county plan are desperately needed, given the limited nature of existing oversight.
In addition to the other examples noted in the text, the need for external review is illustrated by the difference between the Independent Assessment of Humbolt County and the DMH annual oversight review. Both noted that Humbolt had added a walk-in clinic several days a week. The Independent Assessment revealed that clients were turned away with no logs of their requests, that some clients returned multiple times without receiving any care, and that there was an underlying problem with excessive waiting times for scheduled visits. Yet the DMH oversight report noted no problems with the walk-in clinic and attributed an increase in penetration rates to its inception. (See also examples from San Diego earlier in his report.) Clearly, DMH oversight alone is inadequate.
The state’s oversight and monitoring responsibilities must keep as its first priority the consumers seeking services, whose positive progress and satisfaction takes precedence over that of providers or mental health plans. Providers exist only because of, and in the service of, the Medi-Cal beneficiaries who have a right to those services that support their recovery from serious mental illness. The literature is replete with research and testimonies from consumers that indicate that rehabilitation services must accompany clinical services if persons are to gain higher levels of self-sufficiency and community integration. This point is important to make. Those county MHPs which do not have the funds and/or the infrastructure to provide the full array of quality services required may not be able to meet the demands and pressures of providing managed mental health care in today’s market.[50]
If a mental health plan's performance is found to be below minimum standards by the designated DMH review team, action by the DMH is necessary. Procedures for the DMH to offer technical assistance to the mental health plan in the development and approval of plans of correction already exist. If the mental health plan does not develop and implement an approved correction plan within standard timelines, it is the responsibility of the DMH to develop and apply standard consequences. These consequences should range from sanctions to terminating the plan’s managed care contract, with the state stepping in to actually provide services until another plan is named through a request for proposal process.
California’s managed care oversight system has thus far operated without clear standards, sanctions or other consequences when non-compliance is identified in the annual oversight reviews. Nonetheless, most counties have been extremely cooperative, with prompt implementation of corrective action plans. But a few counties will not or may not be able to solve the problems. For example, the first annual oversight review for Lake County in 1998 found that the mental health plan did not have accurate beneficiary rights notices. The problem was still present a year later during the second annual oversight review in August, 1999, with no sanctions or consequences from the state. This same pattern was repeated in Yolo, Lassen, Los Angeles and other counties.
The DMH has the regulatory authority to impose sanctions, Cal. Code of Regs., tit. 9, Sec. 1810.380, 1810.385. The agency has been reluctant to use this power. In its recent report on Medicaid managed mental health care, the GAO noted that state oversight was hobbled by concern that imposing sanctions on a mental health plan could have harmful effects on clients. In California, one option for DMH would be to combine sanctions with a strategy that addresses inadequate mental health funding. Under state law, counties are able to transfer their state mental health Realignment funds (which they would otherwise use to match federal Medicaid dollars) to other uses. Many counties do so, even when they are out of compliance with state managed care requirements and/or provide inadequate services. For example, despite its compliance problems, noted above, Lake County transferred $93,000, or 8% of its state mental health Realignment funds to other uses. Oversight Review of Lake County. See, Independent Assessment, Appendix I (list of Realignment transfers); Page XI-18 (Sutter/Yuba transferred out funds in 1996/97).
DMH’s enforcement strategy should (1) ensure that sanctions will be paid from county general funds and will not reduce the mental health budget, (2) bar any further transfers of mental health Realignment funds to other purposes and (3) compel the transfer back of any funds which were moved to other accounts in the previous fiscal year. These sanctions may require an amendment to DMH’s contract with the counties, which DMH should implement in the next fiscal year. If these steps require additional statutory authority, DMH should request this from the Legislature.
Another barrier to mandating an adequate mix and supply of services in every county is the lack of equity in funding between counties due to the arbitrary, historical formula used for distribution of Realignment funds. The issue was missing from the Independent Assessment, although it was on the original work plan for the consultant. There is no discussion in the report of the extreme discrepancies in per capita funding by county. Of the 10 counties surveyed, mental health expenditures per county Medi-Cal beneficiary range from a low of $41 per capita in Sutter/Yuba to a high of $153 per capita in Contra Costa; the state average is $87 per Medi-Cal beneficiary. See Table 6, page 51, Medi-Cal Mental Health Spending, Per Capita. The only data from DMH dates from 1993/94 and also reveals a huge discrepancy in per capita funding among counties, as well as great unmet need overall. DMH has provided some equalization funding but not enough to remove the inequity, as the current figures demonstrate.
Unequal county funding is tied to the overall inadequacy of California’s Medi-Cal mental health funding. The Independent Assessment agrees that the California’s Medi-Cal per capita expenditures are a "dismal picture - in lowest 10 %" of all 50 states. Independent Assessment, page I-13. DMH prefers to point to the fact that California is mid-range among the states on per capita spending on mental health, when funding sources in addition to Medi-Cal are included. Independent Assessment, page I-12. But this raises many more questions, such as the state’s heavy emphasis on placements in facilities that are not Medi-Cal eligible and thus, excluded from the Assessment.
Because fiscal information on non-Medi-Cal mental health placements is missing altogether from the Independent Assessment, it paints an incomplete picture of county spending and the state’s movement towards community based services. The Assessment excluded all data on the state’s increasing expenditures on locked psychiatric nursing homes, known as IMDs, or "Institutes for Mental Disease." ("Psychiatric Health Facilities," or PHFs, are also considered IMDs if they have more than 16 beds.) Because these institutional placements are denied federal Medicaid reimbursement, the Independent Assessment did not include any data or information about IMD placement rates per county or about the funds that California spends on these placements.[51] Other data establishes that there are as many as 5000 residents of these IMDs, with an annual placement cost of approximately $20,000 to $30,000 or more per person per year. The fact that the state and counties are spending hundreds of millions of dollars more on institutional mental health placements should also be considered before concluding that the system has successfully become community based.
The Independent Assessment makes several sound recommendations for the state. These include:
In addition to the recommendations in the Independent Assessment, the following additional recommendations are proposed as a condition of renewing the managed care waiver:
Waiting Times\Standard Timelines for Service Response: In many counties, waiting times for outpatient appointments and to access other types of services are excessive. Most counties do not keep data on waiting times.
Follow-up Care After Inpatient Hospitalization: Many county MHPs do not provide effective discharge and aftercare planning and coordination by the MHPs with outpatient services, which contributes to rising re-hospitalization rates.
Voluntary treatment: Clients report that hospitals will not admit them unless they meet the criteria for involuntary detention under California Welf. And Inst. Code Sec. 5150.
Limited Definition of Medical Necessity and Plan Eligibility: Many clients who were formerly served through fee-for-service providers and still need mental health care are now denied eligibility because they do not meet the severity and impairment criteria in the new managed care regulations. County MHPs do not track these clients, who could represent as much as 10% to 20% of mental health clients.
Limited County Services: Because DMH does not require county MHPs to provide the range of services covered under the state Medicaid plan, many counties fail to offer critical services that clients need. Some counties provide little more than brief therapy, medication management, day treatment and hospitalization.
Psychosocial Rehabilitation and Recovery-based Services: DMH must ensure that the full range of rehabilitative services is available in every county.
Crisis Services: Many counties do not provide access to a crisis stabilization unit, to mobile crisis intervention teams or to crisis intervention staff during the evenings and weekends.
Transportation and other case management services: Many clients and providers
report problems getting to mental health appointments, so that clients are labeled "no shows" and their cases are closed. Clients also need help accessing SSI benefits, locating housing, finding work, etc. Medi-Cal covers "targeted case management" or brokerage assistance accessing non-mental health services, as well as medical transportation.
Medication: Clients have problems obtaining medications prescribed by MHP providers, since these are "carved out" of managed care and are not the MHP’s responsibility.
Children’s Services: Many counties offer only limited children’s services and have failed to utilize expanded EPSDT funding. Mental health services are often fragmented with little coordination between the county MHP, school districts, probation department and foster care agencies.
Informed Choice of Services and Providers: Clients are rarely informed of the full array of outpatient services and providers available to them and are not given a free choice of services or providers.
Advance Directives: Clients are not informed of their right to prepare an advance directive or assisted in this process. County MHPs have no procedure to ensure that contract hospitals and providers honor advance directives.
Effective Notice of Appeal and Grievance Rights: There is an extremely low level of understanding among mental health clients about their appeal and grievance rights. This is because MHPs have failed to develop and distribute adequate notices and brochures. Denials are impossible to document or appeal because there are no forms for clients to request the services they want and DMH regulations require written notices of action in very few situations.