In 2015 the Legislature authorized the Department of Social and Health Services (DSHS) to create Behavioral Health Organizations (BHOs) to purchase and administer publicly-funded mental health and substance use treatment services under managed care. BHOs are single, local entities that assume responsibility for providing these services, previously managed by counties and Regional Support Networks (RSNs). These include inpatient and outpatient treatment, involuntary treatment and crisis services, jail proviso services, and services funded by the federal block grants. DSHS began the process of developing contacts with BHOs in 2015, with services starting in April 2016.
Since the passage of SB 6312, Washington state has been working to transition Medicaid based behavioral health services contracts away from BHOs and replacing them with anywhere from 1 to 5 contracted Managed Care Organizations (MCOs) that will be procured for each region through an RFP process managed by the Health Care Authority (HCA). This transition is scheduled to be completed across the state by 2020. Two regions, known as early adopters, have transitioned already, which include the Southwest and North Central regions. In these regions, the counties no longer oversee the Medicaid system or non-Medicaid crisis system.
WSAC, in collaboration with ACHS and the BHOs, met several times by phone to establish a baseline of how a process could be put in place to develop a set of legislative priorities that could be recommended to LSC and address the main county concerns regarding behavioral health integration as it currently stands. These phone meetings culminated a day long, in person meeting in Spokane with all parties attending with the discussion resulting in agreement on the priority recommendations listed below. It was further agreed that ACHS and the BHOs/ASOs would maintain a high level of coordination during the legislative session and jointly provide reports, updates and action requests to the LSC as necessary or desired.
Four additional regions are transitioning in 2019. Known as mid-adopters, these regions include King County, Pierce County, North Sound, Greater Columbia and Spokane. These regions, with the exception of Pierce County, have made the decision to continue operating the crisis and diversion systems and will be transforming their BHOs into Administrative Service Organizations (ASOs). These regions encompass 23 of Washington’s 39 counties and a significant percentage of the State’s population.
In order to ensure a smooth transition to integrated managed care in these regions and to maintain the existing level of regional behavioral health crisis and diversion programs, and other required Behavioral Health ASO services, WSAC is requesting the Governor’s Office and the Legislature to support the following county behavioral health priorities during the 2019 Legislative Session:
1. Codify Language Regarding ASOs
ASOs are regional entities charged with managing the crisis system continuum, which is funded through State General Fund dollars and some federal block grants. Ensuring that the crisis system continuum can continue to function at current levels is of great importance as it is inextricably woven with the local criminal justice system. Counties need policy support with regard to defining the ASO structure in statute and preserving their right of first refusal to operate and manage the local crisis systems.
2. Non-Medicaid State Funding Sufficient to Support the Crisis Continuum, System Oversight and ASO Operations
As all Medicaid, and an additional 30% of non-Medicaid State General Fund dollars, for behavioral health has been shifted away from counties to the MCOs, it is necessary for the State to make significant investments in non-Medicaid funding to support the crisis system continuum in order to simply preserve services at their current levels. In this new integrated behavioral health system, it imperative that the State have strong regional ASOs to not only provide adequate crisis and diversion services, but also to serve as oversight bodies so as to identify areas of weakness and then work with the State, MCOs and other system partners to address them.
3. Supportive Housing Continuum
Rural and urban communities across Washington lack an adequate supply of affordable homes. In fact, there are only 29 affordable and available homes for every 100 extremely low-income renters in the state. Homelessness is the natural consequence of this lack of access to affordable homes. Robust investment in affordable housing is the best way to reduce homelessness. To reach the scale of housing investments that are needed, the Legislature should make use of all tools available to create affordable homes, including, for example: (1) increased investment in the Housing Trust Fund with no population set-asides and local flexibility to determine housing needs; and (2) the ability for local communities to retain a portion of the state’s sales tax to invest directly into affordable homes. If we cannot provide individuals with housing, it is difficult, if not impossible, to address their other basic health needs.
4. Community Based Behavioral Health Facilities
The closure of ITA wings at the state hospitals means that individuals will now need to be placed elsewhere in the community. It is clear that there is currently not enough space in the community to house these individuals. In response to this housing need, the Governor has expressed his desire to potentially construct six mini hospitals within the community. It will be important to ensure that there is not only funding provided to construct the necessary facilities, but to run and maintain these facilities as well. We have expressed our concern to the Governor’s office regarding the potential costs associated with community-based behavioral health facilities, and the importance of not burdening counties with those costs without providing state dollars.
Staff Recommendation: It is the recommendation of staff that WSAC call upon the Governor’s office and the Legislature to support the priorities listed above. In addition, staff recommends that WSAC support a strong collaboration between the BHOs, ASOs, ACHS and LSC to ensure a strong and consistent county voice on behavioral health issues.
This was an attachment to the Salish BHO Executive Board Meeting Agenda of 1/11. The full agenda can be found here.