Medi-Cal overhaul proves difficult for psychological well being care

A 12 months has handed since an enormous statewide effort referred to as CalAIM started rolling out. Amongst a number of important adjustments CalAIM promised: An overhaul of the supply of psychological well being look after younger individuals insured by Medi-Cal, the general public insurance coverage program for low-income Californians. 

Advocates for youth psychological well being say they continue to be smitten by CalAIM’s potential, utilizing phrases like “game-changing” and “transformational.”

However additionally they say the brand new framework is being born at a difficult time. Three years into the pandemic, supplier burnout and escalating affected person want have mixed to create a extreme psychological well being workforce scarcity. In the meantime, community-based organizations that present lots of the psychological well being companies outlined beneath CalAIM say they really feel not noted of the loop in essential conversations about coming fee reforms.

Gov. Gavin Newsom’s finances proposal — which might  delay sure behavioral well being investments to fight a projected $22 billion deficit — additionally dangers hampering progress for CalAIM.

“Our members are actually panicked proper now,” mentioned Adrienne Shilton, director of public coverage for the nonprofit California Alliance of Baby and Household Companies. In September 2022, hers was one among a dozen organizations that signed a letter to the state Division of Well being Care Companies expressing issues a couple of lack of transparency across the new charge construction. “Suppliers should have the power to plan and put together alongside their county companions,” it mentioned. 

Shilton’s group additionally co-authored a letter Wednesday to legislators, decrying the proposed finances delays.

Shilton instructed CalMatters earlier that different points CalAIM is supposed to handle, together with assuaging burdensome documentation necessities, have but to vary the on-the-ground actuality for a lot of suppliers.

CalAIM is about rather more than psychological well being. The initiative, brief for California Advancing and Innovating Medi-Cal, is a five-year plan that started rolling out a 12 months in the past. It goals to supply kids and adults insured by Medi-Cal with higher entry to a spread of well being and psychological well being companies. It additionally strives to make use of a “complete particular person care” method to handle social points that impression well being, together with housing and meals insecurity.

It additionally redesigns the fee system to extra seamlessly combine the county psychological well being plans and managed care organizations that pay for these companies. 

The relevance and urgency of addressing kids’s psychological well being is very clear: Racism. Faculty closures. On-line bullying. Local weather catastrophe. A pandemic pocked with grief, loss and concern.  

All of those elements have aggravated a youth psychological well being disaster that’s been raging for greater than a decade. Incidence of self-harm for younger individuals, which elevated dramatically even earlier than the pandemic, has spiked additional previously few years.

CalAIM has not but considerably shifted the on-the-ground actuality for a lot of of those younger individuals, consultants say, however quite a few essential coverage adjustments are formally underway: 

• About 40% of the state’s kids and youth are insured by Medi-Cal. They now not want a proper analysis to entry specialty psychological well being companies. 
• The state has simplified behavioral well being documentation necessities.
• A “No Incorrect Door Coverage” ought to make it simpler for youngsters and adults to obtain behavioral well being care regardless of the place they enter the system, changing what can really feel like a bureaucratic maze that varies by county.
• An “enhanced care administration” profit gives companies and case administration to members of precedence populations, together with those that are homeless, experiencing early psychosis or concerned with the kid welfare or legal justice programs.

Different efforts, together with altering the best way psychological well being companies are paid for, are additionally rolling out this 12 months.

 Newsom’s administration, which early on made behavioral well being a signature situation, is concurrently unveiling a number of different bold initiatives, all of which require further staffing and funding: a statewide program to arrange new courtroom programs to handle the wants of individuals with extreme psychological sickness, referred to as CARE Courtroom; expanded disaster response companies by state funding for a 988 hotline; and a significant initiative to enhance psychological well being care for youngsters and youth, elements of which can be affected by the proposed finances delays.

Regardless of belt-tightening in different areas of the governor’s proposed January finances, CalAIM continues to be funded. Newsom’s proposal would dedicate greater than $10 billion to CalAIM implementation, together with $6.1 billion over 5 years to enhance native therapy companies and pay for short-term stays in therapy services for individuals with severe psychological and behavioral well being sicknesses.

“We’re dedicated. We’re not touching that,” he mentioned in a press convention earlier this month.

The finances proposal does, nonetheless, delay greater than $1.1 billion in different behavioral well being investments over the following two years, together with cash supposed to extend therapy capability for adults and youngsters in disaster, and cash for workforce growth. These investments have been supposed partly to shore up CalAIM’s targets, in keeping with state paperwork.

“We’re involved in regards to the delays,” Shilton mentioned. “That is funding outdoors of CalAIM however … the system is so careworn. Having this extra funding from the state was actually helpful.”

The governor’s workplace didn’t reply to questions in regards to the proposed funding delays. He’ll revise his finances proposal in Might, based mostly on precise state income, and hammer out a remaining funding take care of legislators in June.

Whereas CalAIM is a crucial step towards assembly the psychological well being wants of weak younger individuals, consultants say staffing shortages, particularly, are complicating the image. Consequently, some say, it’s not but clear how and when official coverage adjustments will translate into higher psychological well being therapy for people. The proposed finances would delay practically $400 million for well being care workforce coaching, together with some social work and behavioral well being pipeline applications.

“The place are the people who find themselves going to be delivering these companies?” Shilton mentioned.

Michelle Cabrera, govt director of the County Behavioral Well being Administrators Affiliation, calls CalAIM “an uber-ambitious reform agenda that’s sitting on prime of a system that’s actually been by the storm.” 

Counties are being requested to implement “bold, sweeping new reforms on prime of the worst workforce disaster we’ve ever seen,” she mentioned.

In an emailed response to CalMatters, the Division of Well being Care Companies mentioned the Newsom administration is dedicated to “collaborating intently” with counties, well being plans and others to plan, implement, and monitor the assorted “unprecedented and intersecting initiatives.” 

Nonetheless, community-based organizations that contract with counties and managed care organizations to supply psychological well being companies say they’re nervous in regards to the fee they’ll obtain for his or her companies and the way that would have an effect on their capability to recruit and retain vital employees. 

Jodi Kurata, chief govt officer of the Affiliation of Group Human Service Companies, which represents nonprofit organizations in Los Angeles, mentioned the teams she works with are too overwhelmed coping with workforce shortages to give attention to the executive transformation underway. 

“The system proper now’s simply so depleted,” she mentioned.

She mentioned she worries that insufficient charges might result in an extra exodus of nonprofit psychological well being suppliers from the Medi-Cal system, a priority others have echoed.

The state says a preliminary draft of revised fee charges has been shared with counties. The Division of Well being Care Companies mentioned it has dedicated to publishing a payment schedule within the first few months of this 12 months.

Cabrera, of the County Behavioral Well being Administrators Affiliation, mentioned CalAIM’s new fee construction marks an essential shift in that the state will now enable counties to pay suppliers with out being capped, and can take away many burdensome documentation necessities. She mentioned counties are simply now seeing the brand new charges, and that the administration’s “aggressive” timeline will seemingly result in a “bumpy trip this 12 months” earlier than finally leading to a optimistic change. 

When care relies on your county

Different longstanding funding issues stay unaddressed. This previous fall, Younger Minds Advocacy, a kids’s psychological well being advocacy group, printed a report exhibiting that longstanding variability in the best way the state funds county specialty psychological well being companies has translated into disparities within the sorts of intensive care provided to younger Medi-Cal enrollees.

For many years, mentioned Patrick Gardner, an legal professional who based the advocacy group, the state has underfunded sure counties “and their efficiency has suffered accordingly, typically fairly dramatically.”

In his report, Gardner discovered that counties with considerably lower-than-average state funding typically offered younger individuals with much less intensive companies than counties with considerably higher-than-average state funding. In line with his report, in 2019-20, poorly funded San Joaquin and Madera counties offered simply 16% and 17% of the estimated want for care, whereas the better-funded Santa Clara and Butte counties offered 86%.

Whereas CalAIM is shifting “in the precise course,” Gardner  mentioned, it fails to handle this basic situation. (Cabrera contends that the evaluation fails to seize the companies that counties present with out billing Medi-Cal.)

Regardless of these issues, many psychological well being advocates say they’re already witnessing essential adjustments to the best way care is delivered beneath CalAIM. 

“We’re seeing shifts taking place already,” mentioned Leticia Galyean, CEO and president of Seneca Household of Companies. She mentioned her group — which serves youth and households in 14 counties — is very seeing “a direct profit” when it comes to quicker entry to specialty psychological well being look after foster youth, homeless youth and people concerned within the juvenile justice system.

Brian Blalock, a senior employees legal professional on the Youth Legislation Heart, which advocates for youth within the little one welfare and juvenile justice programs, referred to as CalAIM “an important factor California has accomplished in a very long time.”

“​​There’s simply great alternative there,” he mentioned. 

Now, he added, “we as a state can go in both course — both we understand that promise, or we let this move us by.”