Agencies/Organizations Contacted
  • Texas Health and Human Services Commission (HHSC), Medicaid/CHIP Policy and Programs
  • Texas Health and Human Services Commission (HHSC), Medicaid/CHIP Healthcare Transformation Waiver Operations


During the past decade, Texas has undertaken a redesign of its entire health and human services system with important ramifications for behavioral health delivery. For example, behavioral health programs previously managed and regulated by multiple state agencies were moved under a single regulatory entity, to streamline funding and administrative functions. In 2011, Texas received approval for a 5year Section 1115 transformation waiver demonstration to expand its existing regional Medicaid managed care (MMC) services to the entire state, to reform its uncompensated care payment system, and to develop a Delivery System Reform Incentive Payment (DSRIP) pool to fund innovative strategies for improving health care delivery. The latest phase of the demonstration was recently approved to continue through September 2022.[44]

Through the DSRIP program, provider organizations can apply for funding for a broad range of innovative projects aimed at improving access to and the quality of health care while controlling costs. To participate in the DSRIP program, providers must be members of their local Regional Healthcare Partnership (RHP). There are 20 geographically distinct RHPs throughout the state through which the program is implemented. Of the approximately 1,500 DSRIP projects funded during the initial waiver period (2011-2017), more than a quarter (461) had a behavioral health focus and 56 specifically addressed SUD. The areas of focus for the funded SUD projects include:

  • Integrated physical and behavioral health treatment.

  • SUD workforce development.

  • Increased capacity to treat SUDs with co-occurring mental health disorders or intellectual disabilities.

  • Improved interventions to justice-involved individuals who also need substance use services.

  • Coordinated care among health systems.

The SUD-focused projects collectively received over $432 million in DSRIP funds over the first 6 years of the waiver demonstration.

Alongside the innovative strategies facilitated by this large-scale waiver demonstration, the Texas Health and Human Services Commission (HHSC) implemented several projects and initiatives to strengthen the state's behavioral health system, such as the RSS Program to incorporate recovery supports into the system of care and to develop the recovery and peer support workforce. This case study summarizes the impact of these recent system transformation efforts on the SUD workforce.

Impact of System Reforms on Substance Use Disorder Services and Workforce

Training and Technical Support during System Transition

The shift from a FFS model to a managed care reimbursement model typically brings with it workforce challenges (such as uncertainty in requirements) as well as the need for new administrative processes, infrastructure changes, and practice transformation measures. The 1115 waiver demonstration has also introduced changes in the practice and reimbursement environment, adding to providers' need for support in adapting to ongoing changes.

The HHSC proactively responded to these needs by creating shared learning structures. The 20 RHPs participating in the DSRIP program all have a lead organization (anchor) responsible for keeping its members informed of regulatory changes and offering training and technical assistance to the collaborating providers. Anchors are required to establish a regionwide learning collaborative and develop a training plan. The HHSC conducts bi-weekly calls with the anchors to provide information and receive provider feedback. The HHSC also conducts webinars and distributes reporting templates and guideline documents to providers, and it conducts an annual Learning Collaborative Summit to bring together the members of all participating RHPs.

Many of the topics addressed in regional learning collaborative meetings support SUD providers. Some examples are:

  • DSRIP project implementation, strategic planning, and/or reporting.

  • Patient and community engagement.

  • Behavioral health integration.

  • Selecting the right care in the right setting.

  • Care navigation.

  • Specialty care access.

  • Medical homes.

  • Measurement strategies.

  • Telehealth.

Providers interviewed by the demonstration evaluation team expressed overall satisfaction with these shared learning efforts.[45] Additionally, Texas has a rigorous training program for behavioral health peer recovery specialists (discussed in the next section).

Recovery and Peer Support Specialists

During the past decade, there were multiple efforts to regulate and develop the peer workforce within Texas's behavioral health system. A statewide peer specialist certification program was established in 2012. By 2015, there were 180 training vendors for SUD peer specialists and 460 certified peer providers.[46] In 2014, HHSC launched the RSS Program following a 3-year planning and stakeholder engagement period. The program funded 22 SUD provider organizations to embed peer-based recovery supports into their existing service mix. The program also included a rigorous training and technical assistance program for peer recovery specialists. Through webinars, technical assistance calls, and site visits, the training program addressed topics[47] such as:

  • Hiring and training recovery coaches.

  • Engaging and enrolling persons in recovery.

  • Collaboration of clinical and recovery support teams.

  • Defining target populations.

  • Promoting person-centered planning.

  • Conducting strength-based global assessments.

  • Determining appropriate level of engagement and intensity of services.

  • Developing Peer Advisory Leadership Councils.

  • Conducting assertive outreach and early reintervention.

  • Promoting employee role clarity.

  • Encouraging self-care for recovery coaches.

  • Aligning traditional policies and procedures with a recovery-orientation.

  • Promoting community integration.

  • The role of Medication Assisted Recovery.[48]

  • Changing the locus of services from the agency to the community.

Between 2014 and 2018, 255 new recovery coaches were hired by the provider organizations participating in the RSS program.

A recent article reviewing best practices in peer support practices3 selected Texas as one of the four states that lead the nation in peer provider workforce development efforts (along with Arizona, Georgia, and Pennsylvania). The authors report that, at $15.69, the average hourly wage for peer recovery support specialist in Texas was the highest among the four "model" states they studied.

Until recently, peer support services in Texas were funded through grants. In 2017, the 85th Legislature passed House Bill 1486, directing the HHSC to create a Medicaid benefit for peer support services. In line with this mandate, HHSC assembled a stakeholder workgroup--composed of peer specialists, peer supervisors, and trainers of peer specialists--to provide input on Medicaid policies regulating the training, certification, scope of services, and supervision of Certified Peer Specialists and Recovery Coaches.[49] The draft rules were presented for public comment during the summer of 2018. The 2018-19 General Appropriations Act provides $79,500 each fiscal year (FY) for training and technical assistance to peer specialists and appropriated $834,600 (all funds) in FY18 and $2,375,100 (all funds) in FY19 to provide peer support services in the Medicaid program. These developments will substantially strengthen the status of peer specialists as health care professionals and increase the availability of funding for their services. However, the proposal to allow certified peer specialists to directly bill Medicaid for their services failed in the prior legislative session due to opposition from a variety of stakeholder groups. A senior policymaker interviewed for this study pointed out that, in general, adding a new provider category to a state's Medicaid program is a time-consuming and expensive process and suggested that this may have been one of the barriers encountered in this legislative effort.

Loan Repayment

Student loan repayment is an effective strategy for attracting new professionals into a specialty field and is widely used across the nation to address workforce shortages. Until 2017, Licensed Chemical Dependency Counselors (LCDCs) in Texas did not qualify for the state's Loan Repayment Program for Mental Health Professionals. A 2017 house and senate bill (HB 3083/SB 1509) added LCDCs to the program, making them eligible for loan repayment up to $7,000 (up to $10,000 if they hold an associate degree). The goal of the legislation was to incentivize them to serve Medicaid or CHIP patients and incarcerated individuals and to practice in medically underserved areas.[50]

Expansion of Telehealth

As of May 2017, there were 81 DSRIP projects specifically related to telehealth; 49 of those specifically addressed expanding behavioral health services through improved telehealth infrastructure.[51] These projects will increase the need for behavioral health practitioners, including SUD counselors, thus opening new employment opportunities for this workforce. Additionally, employment in facilities with telehealth capacity will help professionals participating in the newly available loan repayment program fulfil the requirement to bring services to underserved areas without having to relocate.

Remaining Challenges and Future Directions

Disparity in Reimbursement Rates and Administrative Burden

Recent health care delivery reforms have helped support and further develop Texas's SUD workforce, especially by creating new employment and reimbursement opportunities. However, some barriers to reimbursement remain to be addressed. For example, as one of our key informants mentioned, the Medicaid reimbursement rates for SUD services are in critical need of updating, a process the state has begun for block grant-funded services and plans to begin for Medicaid-funded services next year. To illustrate the urgency of the need for this update, our informant cited the example of the SUD-specific billing category "15-minute alcohol and/or drug services," which is reimbursed by Medicaid at $14.50 whereas the rate for a similar mental health billing category, "30 minutes psychotherapy," is $44.66. The informant also expressed concern about the complexity and administrative burden of insurance reimbursement for providers, especially for dual eligible (Medicaid and Medicare) patients.

Disparity in Skill Requirements and Educational Incentives

The inclusion of LCDCs in the student loan repayment program is an important factor for incentivizing professionals to join the SUD field. However, as a statement by the Texas Hospital Association pointed out in their statement supporting the measure,[52] the loan ceilings are much lower for LCDCs than for other behavioral health professionals eligible for the program. For example, LCSWs, LPCs, and licensed MFTs without doctoral degrees are eligible for loan repayments up to $40,000 and can receive up to $80,000 if they hold a doctorate.[53] The repayment scale for LCDCs stops at an associate's degree as the highest degree eligible for repayment consideration; the implied assumption underlying the program's structure is that LCDCs will not seek a higher degree. In contrast, the program provides incentives for other behavioral health professionals to continue their education through a doctoral degree.

Remaining DSRIP Challenges Cited by Stakeholders

The 2017 evaluation of the waiver demonstration included semi-structured interviews with stakeholders, including providers. The key themes from a qualitative analysis of stakeholder concerns included the following recommendations:

  • Streamline the DSRIP and MMC processes.

  • Simplify DSRIP and timelines and payment schedules.

  • Eliminate frequent changes in DSRIP rules and regulations.

  • Recognize and address the unique implementation challenges of different types of providers in meeting DSRIP requirements.

  • Include more provider types in DSRIP and MMC that were previously excluded from participating.

Need for Sustainability Planning

Finally, sustainability of the positive changes brought about by DSRIP is an important concern expressed by stakeholders. The newly approved waiver extension includes mechanisms for annual decreases in federal matching funds; these funds will be completely eliminated by the end of the demonstration in 2021. Maintaining the expanded employment and reimbursement opportunities for the SUD workforce beyond the demonstration period will require careful sustainability planning.