Call to Order and Roll Call
The 4th meeting of the SB 192 Implementation Oversight Committee was held on Monday, September 14, 2015, at 10:00 AM, in Room 131 of the Capitol Annex. Senator Christian McDaniel, Chair, called the meeting to order, and the secretary called the roll.
Present were:
Members: Senator Christian McDaniel, Co-Chair; Representative Denver Butler, Co-Chair; Representatives David Floyd, and Joni L. Jenkins.
Guests: Connie Freking, Children’s Home of Northern Kentucky; Jim Thaxton, HIRT; Daniel Shubert, DPA; Joan Arlinghaus, PAR/HIRT; Lolita R. Curtis, SAMHSA; Pam Dimmerman, Transitions, Inc.; John Launius, VOA-MID; Karen Davis, Assistant Jefferson County Attorney.
LRC Staff: Jon Grate, Jonathan Scott, Sarah Kidder, Alice Lyon, and Cindy Smith.
The minutes of the August 10, 2015 meeting were approved without objection.
SB 192 Implementation Update and Substance Use Treatment in Medicaid
Lisa Lee, Commissioner, Department for Medicaid Services, Cabinet for Health and Family Services presented an update on substance use treatment in Medicaid. In January 2014 in response to the Affordable Care Act (ACA), the Cabinet submitted a State Plan amendment to the Centers for Medicare and Medicaid Services (CMS) to expand Medicaid to cover individuals at or below 138 percent of the federal poverty level. In addition, the provider network was expanded so there would be a broader base of individuals to deliver services to the new folks coming in, as well as those currently on Medicaid. Expansion demographics indicate that the average recipient is 38 years old, and there is an even distribution of males and females. Expansion members receive the same benefit package as traditional Medicaid members. The ACA required coverage for the expansion population of 10 essential health benefits including behavioral health and substance use disorder services. Prior to the ACA, substance use treatment was limited to pregnant women and women 60 day postpartum. Post ACA, substance use treatment benefits are available to the entire Medicaid population. Now, options after 60 day postpartum include traditional Medicaid, Medicaid expansion, or coverage through kynect. Approximately 79 percent of pregnant women re-enter Medicaid after delivery.
Commissioner Lee discussed additional behavioral health and substance use services provided through Medicaid. There is now an array of rehabilitation services covered. Targeted case management is now included in the service package for adolescents and adults with substance use disorders; and adults and children with co-occurring mental health or substance use disorders and chronic or complete physical health issues.
Commissioner Lee discussed new provider types for mental health and substance use services. Knowing that Medicaid would be expanded, the provider types that could deliver behavioral health services to Medicaid recipients were expanded to include licensed practitioners, licensed organizations, and provider groups. Prior to January 1, 2014, the service delivery was limited to Community Mental Health Centers (CMHCs). The Cabinet worked with the Office of Inspector General to develop a new licensure category for Behavioral Health Services Organizations (BHSOs) to provide clinical behavioral health and substance use disorder services in community-based and residential programs.
Residential Crisis Stabilization Units are another new separate licensure category being developed to augment existing CMHCs and residential psychiatric crisis stabilization services. There are also some non-licensed service professionals, including targeted case managers, community support associates, or peer support specialists who must meet training and supervision requirements as approved by the Department for Behavioral Health.
SB 192 required the Department to process applications for providers within 45 days. Since the Department does not distinguish what services an enrolling provider delivers, all behavioral health applications are already expedited. Current average processing time for behavioral health provider applications is 11 days.
In response to a question by Representative Butler, Commissioner Lee said prior to the ACA there was some limited targeted case management. Dr. Brenzel added that case management has been a service that has been available in the State Plan for persons with serious and persistent mental illness. A case manager is an integrator of all of the components of treatment. The case manager’s responsibility is to ensure that all the players have information and that there is a shared treatment plan. It is a low-cost role that results in better outcomes when the services are coordinated by an individual.
In response to a question by Representative Butler, Dr. Brenzel said he is not sure how many case managers Kentucky has. There are several different levels of case managers. There are case managers in all community mental health centers and private providers can now provide case managers within the confines of their offices.
In response to a question by Representative Floyd, Commissioner Lee said before the ACA if you were a disabled individual coming into the Medicaid program, income eligibility would have been approximately 100 percent of the federal poverty level, but that individual would have had to meet the criteria to qualify for Medicaid.
In response to a question by Senator McDaniel, Dr. Brenzel said he will address providers of medically assisted treatment in his upcoming presentation.
Substance Use Treatment Capacity and Licensure
Maryellen Mynear, Inspector General, Office of Inspector General, Cabinet for Health and Family Services presented an overview of licensure and different provider types that are licensed. She said the Division of Health Care within the Office of Inspector General is responsible for inspecting, monitoring, and licensing health facilities, including programs which offer alcohol abuse, drug abuse, and mental health services. The Office of Inspector General tends to license entities, as opposed to individuals. Individuals when required to be licensed are generally licensed through their professional licensing boards. The licensure categories include: Alcohol and other Drug Abuse Treatment Entities (AODE), Behavioral Health Services Organizations (BHSO), Community Mental Health Centers (CMHC), Chemical Dependency Treatment Centers (CDTC), and hospitals. The AODEs are the more well known. They operate a variety of programs within their licensure. The total number of non-residential AODEs is 206. The total number of residential AODE facilities is 27 with 1134 beds statewide. On July 15, 2014, the Office of Inspector General filed an emergency regulation to establish requirements for the operation of BHSOs, a new category of licensure for entities that provide community-based services to individuals with substance use disorder, mental health disorder, or a co-occurring disorder. Because BHSOs are eligible to enroll in the Kentucky Medicaid Program, this new licensure category enhances patient access to needed behavioral health services, including substance abuse treatment, and helps prevent unnecessary admissions to facility-based care. The total number of dually licensed BHSO/AODE outpatient programs with substance abuse treatment is 43 parent facilities and 92 extension locations. The total number of dually licensed BHSO/AODE residential programs with substance abuse treatment is 24 with 714 beds statewide. The next licensed category are CMHCs. They provide a comprehensive range of accessible and coordinated mental health and substance abuse services. Fourteen CMHCs provide services statewide. The residential bed count for substance abuse treatment is included in the AODE numbers. The next category is CDTC. There are a total of four freestanding CDTCs in Kentucky: Louisville, Ashland, Georgetown, and Falmouth. These centers must have at least 8 beds and inpatient services must last less than 30 days. Inpatient CDTCs are not eligible for enrollment in Medicaid, but they may elect to provide and bill Medicaid for outpatient substance abuse treatment services. The last licensure category is hospitals. There are six hospitals in Kentucky with chemical dependency beds, with a total of 146 beds statewide.
In response to a question by Representative Floyd, Dr. Brenzel said part of individual variations in geography in terms of who the best provider of outpatient services is makes a difference. In areas where there may be a strong community mental health center outpatient service, there may be less need. But it is best when each provider can treat the patient across the continuum.
In response to a question by Senator McDaniel, Inspector General Mynear said the St. Elizabeth number does not account for the new beds that were announced on Friday.
Substance Use Treatment Continuum of Care
Mary Begley, Commissioner, Department for Behavioral Health, Developmental and Intellectual Disabilities, and Allen J. Brenzel, M.D., M.B.A., Medical Director, Department for Behavioral Health, Developmental and Intellectual Disabilities presented information on the continuum of care for substance use treatment. Commissioner Begley said there was an addition of Medicaid substance use disorder treatment benefit in 2014. The expansion of Medicaid eligibility included low income adults and opened the provider network in Medicaid beyond CMHCs. Also, there was an addition of the Licensed Drug and Alcohol Counselors to the provider network within the Medicaid program. Commissioner Begley said all the stakeholders have to be involved. She also noted that there are many tools to be used, and noted that quality evidence-based practice is very important. It is important to get quality services, not just services.
Dr. Brenzel discussed addiction. According to the American Society for Addiction Medicine the definition of addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. One size does not fit all. All individuals with substance use disorder are unique and treatment must be specifically tailored to that individual at that moment in time. There has to be access to a multi-dimensional assessment, and individuals need to be plugged into a continuum of services where they need to be. Without addressing the social determinants as a society, it will be a struggle to be successful. Building a high-quality assessment capacity that can justify the appropriate level of care is critical in developing access to services. Effective treatment is individualized. The one thing that is universal is the history of trauma. Building a trauma-informed approach enhances the ability to provide effective services and keep people engaged and lead them into recovery.
Dr. Brenzel discussed levels of care. When someone presents intoxicated, that is often a medical emergency. This is mainly treated in hospitals and emergency rooms, but it is also treated in jails and outpatient settings. These settings are often the initial contact with treatment. On way to build on this treatment is “SBIRT”, which is an offer of screening, brief intervention and referral to treatment. This is also a Medicaid-covered benefit which needs to be fully implemented in Kentucky. The next level is withdrawal. Some drugs create life-threatening withdrawal symptoms and require immediate medical attention. An assessment needs to be provided and then the individual needs to be plugged in an appropriate continuum. Very often a break from their environment is the next step. Entry into care can occur in a variety of settings. The number of individuals in treatment in 2014 for heroin and other opiates was almost 9,000. That number is just the surface for those that need treatment from those substances.
Dr. Brenzel noted that medication assisted treatment (MAT) is an evidence-based approach that involves prescribing medications to a person who is opiate dependent with benefits. MAT allows the individual to be stabilized and engaged in therapeutic services. Medications used in MAT include: Methadone, Buprenorphine, and Naltrexone. MAT requires close follow-up and engagement with the individual, and adjustment to the lowest dose that will control symptoms with periodic attempts to lower doses when clinically appropriate. A percentage of individuals may require chronic treatment. In 2014, 4500 individuals were treated in the 20 narcotic treatment programs in Kentucky. There is also office based opiate therapy (OBOTS). There are currently 517 physicians that have certification to prescribe Buprenorphine. The limit is 30 patients for the first year and then 100 per year. Eighty percent of the prescriptions for Buprenorphine are written by 20 percent of the doctors with the certification.
Dr. Brenzel discussed some special populations where the service access may look different. These include pregnant women and children. Pregnant women are a very complicated population to manage when opiate dependent. Fortunately in Kentucky there are some very specialized programs for these women. The other population, children, are usually at a different place with their patterns of abuse. They are usually not in need of residential because they have family that can monitor them. Attorney General settlement dollars were awarded to 19 programs across the state and some school-based screening programs were used to identify at-risk and early patterns of substance use disorder.
Dr. Brenzel concluded by noting that a challenge ahead is developing, funding and sustaining a comprehensive substance use disorder treatment continuum. Improving access to treatment has an impact. If access to treatment is improved, the number of deaths will decrease. Kentucky is still seeing about 1,000 deaths per year from substance use disorder.
Commissioner Begley discussed prevention. She said BHDID has been awarded $3.5 million SAMSHA grant targeting prescription drug use among 12-14 year olds. The Prevention branch is collaborating with the Treatment branch to reduce opioid use among pregnant women (Kids Now Plus). In 2014, new opioid-specific questions were added into the Kentucky Incentives for Prevention (KIP) school survey.
In response to a question by Representative Butler, Dr. Brenzel said those being treated for addiction to opiates other than heroin include primarily prescription drug abuse.
In response to a question by Senator McDaniel, Dr. Brenzel said two suggestions for parts of the continuum that need further development are the SBIRT intervention, a low-cost, low-yield service, and also mobile crisis services to come to ER’s.
In response to a question by Representative Butler, Commissioner Begley said one gap is that traditionally hospitals and community mental health centers did not work together. Unless someone needed state services, the two did not meet. The cabinet is encouraging the CMHCs to get into the ERs and let those ERs know what services they provide at the local level.
In response to a question by Representative Jenkins, Dr. Brenzel said the issue with Medicaid paying for Naloxone is because the preferred form, the nasal administration, is not approved by the FDA, therefore it is not on the Medicaid formulary. The FDA is currently trying to expedite approval of this drug.
In response to a question by Representative Jenkins, Dr. Brenzel said the old-school thought is before you can treat mental illness you have to treat the substance use disorder. There is now increasing recognition that they need to be treated in parallel. There is definite need for programs that recognize co-morbidity.
In response to a question by Representative Jenkins, Commissioner Begley said her department is working with the Department of Education on more prevention efforts in schools. Schools are locally managed, so it is up to the local districts. Unfortunately there is only so much that can be done by the state.
In response to a question by Senator McDaniel, Dr. Brenzel said there is Medicaid reimbursement for the Buprenorphine drug itself if Medicaid pre-authorization is obtained. In the future, the pre-authorization process could potentially be streamlined for providers identified as giving high-quality service, but at this time diversion of the drug is a big concern. Reimbursement for the office visit is a separate issue, and those rates are not set by the Cabinet. Commissioner Begley added that prior to Medicaid coverage, $400 cash payments once per month were made by individuals to physicians for a Buprenorphine prescription. Now those individuals are covered by Medicaid, so those $400 cash payments can no longer be made, and any price rate less than that may not be enough to incentivize physicians.
The meeting was adjourned at 11:28 a.m.