To: The Honorable Christina Henderson, Chair, DC Council Committee on Health

Members of the Committee on Health

From: Ruth Pollard, President and Chief Executive Officer, DC Primary Care Association

Re: Oversight Hearing for DC Department of Behavioral Health

Date: January 29, 2024

The DC Primary Care Association (DCPCA) works to build a healthier DC by sustaining community health centers, transforming DC care delivery, and advancing racial and health equity. Our collaborators in this work include community health centers—serving almost 1 in 4 District residents in every ward of the city, District government agencies, and other providers in the DC health ecosystem. Thank you for the opportunity to provide testimony regarding the work of the District of Columbia Department of Behavioral Health (DBH.)

The following issues under the purview of DBH either in whole or in part are of particular importance to DCPCA:

Transition of Behavioral Health Services from DBH to Medicaid Managed Care Orgs (MCOs)

DCPCA is closely tracking the carve-in of DBH services into the MCO contracts beginning April 1, 2024. An issue of great concern is that of MCO readiness to pay for new services accurately and timely. DCPCA hosts a weekly meeting of FQHC Finance and Billing staff because of difficulties receiving accurate and timely payment for services in the existing MCO contract. We know from experience that MCOs need considerable time and maximum testing ahead of any changes. Additionally, errors and delays in credentialing on the MCO side can severely impact cash flow for providers, most of whom have limited reserves to support them when inevitable systems problems emerge.

Administrative burden impacts provider willingness to engage with insurers, especially Medicaid. Timelines for credentialing, no fewer than four different Medicaid MCO systems each with its own unique administrative requirements, claims denials, and payment delays are solvable problems that are likely contributing to workforce shortages. Standardization of administrative processes across all Medicaid MCOs should be the goal before the District fully carves in all behavioral health services in the MCO contracts. Community health centers are concerned that with less than 3 months to go before the transition, some operational details have yet to be fully addressed.

Related issues include a lack of clarity regarding level-of-care assessments, concern about payment for services provided to non-Medicaid patients, and credentialing of non-licensed staff currently authorized to provide certain services. Providers need technical assistance and support for implementation to ensure the transition is as smooth as possible.

Requirements for National Accreditation

DCPCA supports DBH’s efforts to improve quality among District providers by requiring national accreditations from the Joint Commission, the Council on Accreditation, or the Commission on Accreditation of Rehabilitation Facilities. However, DCPCA urges that national accreditation should replace existing duplicative DBH certification requirements.

FQHCs are asked to maximize efficiency and health outcomes from limited revenue. Establishing consistent standards across DBH and the accreditation bodies will minimize the administrative burden on FQHC compliance staff, allowing them to focus resources on patient outcomes. DBH should replace its current duplicative certification requirements with those standards set forth by the national accreditation agencies in order to align both sets of evaluative standards and minimize undue burden on providers. National accreditation should supplant the need for local compliance review except for items that fall outside of the national standards.

Health Information Technology

DCPCA has worked closely with DBH to support Mental Health Rehabilitation Services (MHRS) and Adult Substance Abuse Rehabilitative Services (ASARS) providers connect to CRISP, the District’s Health Information Exchange (HIE). Forty-four MHRS organizations and 12 ASARS agencies have upgraded to a federally approved electronic health record (EHR), thereby qualifying for financial incentives totaling almost $2.7 million. DCPCA recognizes a need for ongoing technical assistance for DBH providers to support quality data collection and effective use of available reports.

Opioid Abatement Advisory Commission (OAAC)

DCPCA appreciates the opportunity to work with Council, government partners, addiction experts, and other health advocates to develop recommendations for use of Opioid Settlement funds. The OAAC has an appropriate sense of urgency to put the funds to best use to save lives and support recovery. Still, DCPCA seeks to ensure that the Commission makes decisions with a full understanding of gaps in current resources and with knowledge of strategies most likely to be successful for our population.

The OAAC has strong consensus regarding the value of peer support to bring people into care and to increase and sustain engagement in recovery. As we explore the many roles peers could play in improving outcomes for those struggling with substance use disorders (SUD), we will need to consider existing barriers for recruiting and retaining a robust peer workforce. In some cases, health system providers need a better understanding of the possibilities for peer staff, and technical assistance regarding how to best partner with and deploy peer support.

Rightly, DCPCA has focused on how to increase capacity to address SUD within primary care. Addiction medicine consults for primary care physicians could help PCPs do more to identify needs and provide support. We must make it easier to access the most effective treatments across all settings than it is to put drugs on the street. And we must follow the evidence of approaches like contingency management to invest in what works.

Addiction services need to aggressively integrate strategies that research shows work to help people into remission, support them through relapse, and relentlessly assist them in managing the chronic condition that is substance use disorder. With the right array of resources and supports, community health centers are well-suited to provide this kind of empathetic, compassionate, life-long care.

Workforce

Between 2019 and 2021, nearly every DC health center saw a significant decline in the number of Mental Health visits which FQHC CEOs attribute to the challenges in recruiting and retaining behavioral health clinicians. The 2022 data shows improvement, but health centers still delivered almost 22% fewer mental health visits compared to 2019. Given what we know about rates of anxiety and depression, this decline is especially concerning. Health centers continue to report acute behavioral health workforce shortages—at present, they report over thirty behavioral health openings across eight community health centers.

DBH and its sister health agencies should consider options that extend the workforce such as:

• reimbursing for new provider types,

• adding provider types that can bill without a supervising practitioner, or

• reimbursing for care delivered by trainees or the license-eligible workforce.

It is unlikely that we will remedy current shortages with clinical care alone. We also hope DBH will explore emerging models of community-based behavioral health that can broaden the base of behavioral health supports available in priority communities. Approaches to care need to build on social capital, individual and community agency, and support connections for a meaningful life.

Thank you for the opportunity to provide our perspective on the work of the Department of Behavioral Health. We appreciate our ongoing partnership with DBH and the Council to ensure that every DC resident has a fair shot at a full, healthy life.