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IMPACT OF HEALTH CARE REFORM

Los Angeles County

Annual Drug Court Conference

May 16, 2013

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Patient Protection and Affordable Care Act of 2010 (PPACA)

• Passage of PPACA was possibly the biggest change in U.S. health care since Medicare in 1965!

Triple Aims of Health Care Reform

• Improving the experience of care.

• Improving the health of populations.

• Reducing per capita costs of health care.

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Provisions of PPACA

• Establishment of state health insurance exchanges to streamline enrollment and price transparency; conduct consumer education, and implement a structured appeals process.

• Establishment of ten essential health benefits covered by all individual and small group market plans and health insurance exchanges.

• Requirement for coverage of preventive services with no cost sharing.

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Provisions of PPACA (cont.)

• Increased access to employer-sponsored health insurance.

• Medicaid expansion to cover persons with incomes up to 133% of Federal Poverty Level.

• Increase transparency about health insurance premiums and control premium increases.

• Individual mandate for enrollment in health insurance.

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PPACA Provisions Affecting SUD Services

• Substance use disorders (and mental health) services included in essential health benefits.

• Medicaid expansion includes low-income single adults without children. Enrollment begins on October 1, 2013, coverage starts January 1, 2014.

• (Federal Substance Abuse Prevention and Treatment Block Grant program extended – to be used for prevention services and for treatment services not covered by Medicaid.)

PPACA In California

California adopted all provisions of PPACA listed in previous slides including:

•Will operate a State health insurance exchange, known as Covered California.

•Will participate in Medicaid/Medi-Cal expansion.

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California Provisions for SUD Services

• Substance use disorders services to be included in benefit package for the Medi-Cal expansion population.

• SUD benefit package not yet decided.

(Drug Medi-Cal services?)

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Health Care Reform in Los Angeles County

The County health system is preparing for life with ACA:

•Public health system (Healthy Way LA and DPH-SAPC’s SUD programs) must successfully compete with private health plans for their share of members.

•Moving towards coordinated and integrated care between primary health care, acute and specialty health care, and behavioral health (mental health and substance use) care.

•Initial steps included the Low Income Health Program and the Dual Eligibles Demonstration Project (Cal Medi-Connect).

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Direction of SUD Services in LA County

Substance use disorders services are included as integral components of the County health care system:•Emphasis on patient-centered model with coordinated /integrated care.•Presently, behavioral health (SUD and MH) remains carved-out from general Medi-Cal services.•BH will likely move towards managed care models (service criteria, care authorization, utilization review, provider credentialing).

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Abel C.’s Drug Court to Recovery

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Abel C.’s Drug Court Journey to Recovery

1. Abel C. (AC) appears in court for eligible drug offense.

2. AC agrees to program participation (and other conditions imposed by Court/Probation) and contacts health plan to request services.

3. AC is assessed by health plan network SUD provider for SUD severity and receives recommendation for treatment plan.

4. SUD provider requests authorization for treatment admission based on medical necessity criteria.

5. AC is admitted to treatment program for authorized level of care for specific number of days/sessions.

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Abel C.’s Drug Court Journey to Recovery

5. AC participates in treatment program, may transition through various levels of care with health plan authorization, and information on treatment progress is transmitted to Court/Probation as needed.

6. AC’s progress in SUD treatment will determine type and length of service authorized by health plan based on SUD program reports (with Court/Probation input).

7. AC completes SUD program, complies with other conditions imposed by Court/Probation, and graduates.

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Issues for Consideration

• “Court mandated participation” versus “medical necessity” as driver of length and type of program participation.

• Mandatory health insurance coverage includes SUD services (State Medi-Cal SUD benefit package not yet decided).

• Uninsured population and “safety net” SUD services (services not covered by Medi-Cal or health plans).

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Issues for Consideration (cont.)

• Capacity building and skills building needs - training for SUD treatment programs, Probation personnel, bench officers and Court personnel, attorneys.

• Care coordination of program participants between Court/Probation and health plans.

• Impact of State-County realignment of drug court program funding as a component of SUD account.

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Questions and Discussion

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For more information contact:

Wayne Sugita, Deputy Director

Substance Abuse Prevention and Control

Department of Public Health

wsugita@ph.lacounty.gov

(626) 299-4571

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