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The Affordable Care Act and You: Integration of Behavioral Health
Services into Primary Care Settings
Richard Rawson, Ph.D.
Beth A. Rutkowski, M.P.H.UCLA Integrated Substance Abuse Programs
Pacific Southwest Addiction Technology Transfer Center
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Credits and Acknowledgements
• During the 18 months we have attempted to learn as much as possible about potential impact of HCR on the delivery of SUD treatment. We have borrowed (and credited, hopefully) all those individuals whose materials we have adapted for use in this presentation. However, if we have failed to credit we apologize. Special thanks to Mady Chalk, Tom Kirk, Ron Manderscheid, Tom McLellan, Rob Morrison, and Pam Waters.
• At UCLA, thanks to Valerie Pearce, Allison Ober, Darren Urada, Desiree Crevecoer, Lillian Gelbert, Beth Rutkowski, Sherry
Larkins, Stella Lee, Sarah Cousins, Alex Olson, & Grant Hovik
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“In times of change, the learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists.”
-- Eric Hoffer
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Healthcare Reform Goals
President’s Principles:
– More stability & security for those who have insurance
– Affordable coverage options for those who do not
– Lower costs for families, businesses, and governments
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Affordable Care Act
A consolidation of: The Patient Protection and Affordable Care Act (PPACA)
and The Health Care and Education Reconciliation Act of 2010
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Changes in Place
• Pre-existing Conditions (2010-14): Eliminate exclusions, starting with children/adolescents .
• Adult Child Inclusion (2010): Permit adult dependent children to age 26 to remain on parents’ policy.
• Tax Credit (2010): Small businesses (25 employees or less & average salaries of $40K or less) can receive a 35% tax credit for insurance premiums.
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2014 Changes New insurance for about 32 million adults. Up to 133% of poverty level (133% is $14,484 in 2011 for an
individual): Medicaid (Medi-Cal) Up to 400% of poverty level (400% is $43,560 in 2011 for an
individual), sliding subsidies to buy private insurance. State Health Insurance Exchanges (2014): Individual
and Small Group Plans. All plans must include Substance Use Disorder
treatment.
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2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Coverage of preventive services with no co-pays
Ends lifetime and certain annual limits
Dependent coverage <26
Improves stu-dent loan access and repayment
Expanded Medicaid eligibility
Health Insurance Exchanges
Requires individuals to get insurance
Requires business with <50 employees to provide insurance
Ongoing refinement and implementation
Planning and implementation
of integrated careTax on high-cost insurance plans
Ongoing implementation
Health Care Reform Implementation Timeline
Stop smoking program for pregnant women
expands Home and Community Based services
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Wellstone-Domenici Mental Health Parity and Addiction Equity Act of
2008(MHPAEA) and the Interim Final Rule (IFR)
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Mental Health Parity and Addiction Equity: Overview of the Law
• Passed October 3, 2008
• Effective January 1, 2010. Implementing regulations issued February 2, 2010, requiring compliance of all new plans after July 2010
• Expected to affect more than 150 million people
• Adds SUD to MHP
• Impacts self insured (ERISA) plans for the first time
• Stronger State Laws Protected
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Overview of the Law
• If employer plans includes MH/SUD benefits, Mental health and addiction treatment benefits must have the same financial terms, conditions, requirements, and treatment limitations as they do for medical and surgical conditions
• Single Plan = Single Deductible – Cost-sharing, deductibles, co-pays, other forms
of co-insurance, and annual limits and lifetime limits must be equal to “predominant” coverage for “substantially all” of the covered medical and surgical conditions
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Wellstone-Domenici Mental Health Parity and Addictions Equity Act of 2008
• Does Address:– MH and SUD Tx– Employer health plans
that cover 50 or more persons
– Day and visit limits care management factors
– MBHCOs combine data with MCOs for single deductible.
• Does Not Address: Small group (<50) or
individual plans Medicare The uninsured A common definition
of medical necessity Scope of services Quality or outcome.
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How will Health Care Reform and Parity effect the
treatment of substance use disorders?
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Substance Use Disorders (SUD)
The language we use matters
Addiction
Abuse
Addict
Substance Misuse
Chemical DependenceDependence
Abuser
Drug Addict Alcoholic
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What happens when benefits for SUD are expanded?
Hints from…
Massachusetts Vermont Maine
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Background 2006-2008 - 39 States enacted laws to expand
access to health insurance
Maine, Massachusetts and Vermont – the states that sought to achieve universal health coverage
Need empirical studies of HCR effects on access to, as well as quality and outcomes of, substance abuse treatment (SAT) services
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Vermont (↑ in admissions by 100% from 1998 to 2007)
Blueprint For Health designed, first mobile methadone clinic
Buprenorphine initiative, first methadone clinic
Catamount Health, 1115a waiver, Green Mountain Care premiums decreased, funding for Blueprint
Parity mandate, 1115 waiver (first was in 1996)
4388
59886531
72357609
8116 8147 83899084 9146
0
2000
4000
6000
8000
10000
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Nu
mb
er o
f Peo
ple
State Fiscal Year
People Receiving Alcohol or Drug Treatment in Vermont 1998-2007
Blueprint For Health designed, first mobile methadone clinic
Catamount Health created, 1115a Medicaidwaiver (more flexibility in Medicaid), Green Mountain Care (Medicaid) premiums decreased, funding for Blueprint
Parity legislation, 1115 Medicaid waiver (first was in 1996) – non-categoricals
Buprenorphine initiative, first methadone clinic opened
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1435615595
17096 1766618151 17744 17054 17849
1881118951
10187 1095311743 12419 13043 13697 13796 14385 15104 14622
0
5000
10000
15000
20000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
# o
f Adm
issions
Year
Admissions to Substance Abuse Treatment in Maine, 1999-2008
Admissions Clients
Maine (↑ in admissions by 50% 1999-2008)
1115 waiver – non-categoricals enrolled in MaineCare (Medicaid)
Non-categorical enrollment frozen, MaineCare enrollment expanded, DirigoChoice enrollment began
Non-categorical enrollment re-opened (limited), NIATx
MCO for MaineCare SAT, DirigoChoice enrollment capped
DirigoChoice created, parity legislation
Pay-for-performance
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Massachusetts
MA residents required to purchase health insurance, CHCs hire nurse care managers,NIATx 200 begins, Connector waives co-pay for methadone
1115 waiver (first was in 1997), Chapter 58 enacted, Commonwealth Care created
Mandate & Parity enacted
Medicaid cuts (Level IIIB residential detox)
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Under HCRME, MA and VT:
– Saw the percent of uninsured drop
• ME - 13% in 2002 to 10.3% in 2007
• MA - 11.7% in 2004 to 2.6% in 2009
• VT - 9.8% in 2006 to 7.6% in 2009
– SUD admissions rose; public funding increased
• Medicaid expansions appear more significant than subsidized/private health plans (need to analyze claims)
– Opiate epidemic – big impact on type of care needed: Medication-Assisted Treatment (MAT)
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• Uninsured rate dropped, admissions rose, but many individuals with SUD clients still without health insurance– MA 2009 – 22% (down from 61% in 2005)– ME 2008 – 31% (steady since 2005)– VT 2007 – 30% (steady since 2005)
• Services paid for by safety net/SAPT funds– Without insurance or safety net funds, clients turned
away/put on waitlist
Still Many Uninsured Seeking SUD Services
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The Coverage GapThough the uninsured rate in Massachusetts was only 2.6 percent of the population in 2009, 22% of SUD clients were NOT enrolled insured (similar in VT, ME).
Causes: non-completion of Medicaid re-enrollment forms, non-payment of premiums. Associated w/substance use?
During incarceration, can lose coverage as parent of a dependent child then must re-enroll as a non-categorical (takes time, can disrupt transition from prison to community SUD treatment)
Important for CA, with other CJ treatment funding reduced.
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NASADAD Study:
The Effects of Health Care Reform on Access to and Funding of Substance Abuse Services in Maine, Massachusetts and Vermont
http://www.nasadad.org
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There will still be a large number of people who do not have
healthcare coverage.
Estimates are that 10-25% of individuals with SUD will not have coverage
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Role of the SAPT Block GrantRole of the SAPT Block Grant
• “These changes also present opportunities to establish the role of the block grants as critical underpinnings of the public substance abuse and mental health service systems, drivers of quality and innovation, and essential resources for transforming health care in America, especially in difficult economic times.”
Pamela S. Hyde,. J. D.
SAMHSA Administrator
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Role of the SAPT Block GrantRole of the SAPT Block Grant
The Block Grant funds will be directed to four purposes:•Fund priority treatment and support services for individuals without insurance or for whom coverage is terminated for short periods of time.•Fund those priority treatment/ support services not covered by Medicaid, Medicare or private insurance for low income individuals and that demonstrate success in improving outcomes and/or supporting recovery.•Fund primary prevention – universal, selective and indicated prevention activities and services.•Collect performance and outcome data to determine the ongoing effectiveness of behavioral health promotion, treatment and recovery support services and plan the implementation of new services on a nationwide basis.
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Role of the SAPT Block GrantRole of the SAPT Block Grant
SAMHSA helping states/territories with plans to include:•Reaching historically underserved populations.•Conducting a needs assessment and developing a plan to identify the strengths, needs and priorities of the behavioral health system •Designing and developing collaborative plans for health information systems—grants and other funding.•Forming strategic partnerships to provide individuals better access to good and modern behavioral health services.•Increasing focus on recovery for person with COD.•Redesigning systems and services to be more accountable for improving the caliber and performance of services funded.•Describing tribal consultation activities.
SAMHSA Press Release 4/11/2011, 12:05 am
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How will the universe of SUD care change today through
2014?
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Specialized Treatment
BriefIntervention
Prevention
Distribution of Alcohol (or Drug) Problems
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2M people (0.8%) receiving treatment*
21M people (7%) have problems needing treatment, but not receiving it*
≈ 60-80M people (≈20-25%) using at risky levels
US Population:307,006,550
US Census Bureau, Population DivisionJuly 2009 estimate
*NSUDH, 2008
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In treatment (2 Million)
• Diagnosable problem with substance use• Referred to treatment by:*
*Los Angeles County Data
Self/Family 37%
Criminal Justice 25%
Other SUD Program 8%
County Assessment Center 19%
Healthcare 3%
Other 8%
Healthcare 3%
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In need of treatment (21 Million)
• Reported problems associated with use• Not in treatment currently
• 1.1% Made an effort to get treatment• 3.7% Felt they needed treatment, but
made no effort to get it.• 95.2% Did not feel that they needed
treatment
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Using at risky levels (60-80 Million)
• Do not meet diagnostic criteria• Level of use indicates risk of developing
a problems.• Some examples…
Drinks 3-4 glasses of wine a few times per weekPregnant woman occasionally has a shot of vodka to relieve stressAdolescent smokes marijuana with his friends on weekendsOccasionally takes one or two extra vicodin to help with pain
These people need services,
but will never enter
the treatment system
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Implications
As long as the specialty care programs (AOD treatment programs) are the only places which address SUD:– most people with severe problems will not
receive treatment.– virtually all with risky use will not receive
professional attention.
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“If Mohamed will not go to the mountain, the mountain
must come to Mohamed”
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The Healthcare System
Mental Health
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What healthcare settings are good/important locations to
identify individuals with SUD?
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Healthcare Settings for locating individuals with SUD
• Primary care settings • Emergency rooms/
Trauma centers• Prenatal clinics/OB/Gyn offices• Medical specialty settings for
diabetes, liver and kidney disease, transplant programs
• Pediatrician offices• College health centers• Mental health settings
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A key partner…
The Federally Qualified Health Centers (FQHCs)
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What are FQHCs?
• Federally Qualified Health Centers (FQHCs), designation provided to BPHC grantees (HRSA) under Section 330 Public Health Service Act
• Private non-profit or public free-standing clinics serving designated MUAs or MUPs.
• One of few Federal programs for primary care to the non-institutionalized population
• Must meet additional requirements in order to participate in BPHC Health Center program
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Types of “Health Centers”• Terminology used interchangeably but confusing: “federally
qualified health centers (FQHCs)”, “health centers”, “community-based health clinics”, “community health centers (CHCs)
• Several types of FQHCs in the health center program:– Community Health Centers– Migrant Health Centers– Healthcare for the Homeless Program– Public Housing Program
• FQHC look-alikes• Others- clinics operated by IHS or tribal authorities, school-
based health clinics, nurse-led clinics
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FQHCs 1,080 grantees nationwide with 8,176 sites
FQHCs in California• 113 clinic corporations with 1,049 sites• 3.7 million patients served• 53% of state’s population below 100% of
Federal Poverty Level (FPL) and 26% below 200%
• 15% of state’s uninsured residents served• 46% of total revenues from Medi-Cal
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Federally Qualified Health Centers near Merced California
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Vista Family Health Center3569 Round Barn CirSanta Rosa, CA 95403-1757707-303-3600
Santa Rosa Street Clinic456 A St, Santa Rosa, CA 95401-5220707-565-4820http://www.swhealthcenter.org
Southwest Adult Day Health Care684 Benicia DrSanta Rosa, CA 95409-3058707-573-4565http://www.swhealthcenter.org
Southwest Community Health Center751 Lombardi Ct Suite BSanta Rosa, CA 95407-5454707-547-2222http://www.swhealthcenter.org/
Turning Point Satellite440 Arrowood DrSanta Rosa, CA 95407-7503707-284-2950http://www.swhealthcenter.org
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How will SUD services and MH services be integrated into primary care and other
healthcare settings?
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Interactive Table Discussions• Visualize yourself working in the post ACA
service system in 2014. What will it be like?• At your tables, discuss the following issues:
– What will be different about working in this new system?
– What new skills will you need to develop in order to be successful?
– What new systems (data, documentation, etc), will need to be developed in order to be successful?
– What will the benefit be for your clients?
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Coordination
Co-Location
Behavioral Health
Consultant
Integration
Medical HomeHealth Home
SBIRT
Bi-Directional Care
Behavioral Health Specialist
Four Quadrant Model
Integrated EHRs
Care Team
FQHC Integration
Primary Care Integration: A Growing Web of Confusion
Behavioral Health
Integration
Disease Management
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We’re planning on filling in the
details later
???
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What is “Primary Care Integration”?• Primary care integration is the collaboration
between SUD service providers and primary care providers (e.g., FQHC’s, CHC’s)
• Collaboration can take many forms along a continuum*
*Source: Collins C, Hewson D, Munger R, Wade T. Evolving Models of Behavioral Health Integration in Primary Care. New York: Millbank Memorial Fund; 2010.
MINIMAL BASIC
At a Distance
BASIC
On-Site
CLOSE
Partly Integrt
CLOSE
Fully Integrt
Coordinated Co-located Integrated
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The Primary Care System
SUD Care
System
Minimal Coordination
• BH and PC providers – work in separate facilities,
– have separate systems, and
– communicate sporadically.
MH Care
System
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The Primary Care System
• BH And PC providers – Engage in regular communication
about shared patients leading to improved coordination
Basic AT A DISTANCE
SUD Care
System
MH Care
System
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The Primary Care System
• BHand PC providers – Still have separate systems
– Some services are co-located (e.g., screening, groups, etc).
Basic On Site (co-location of services)
Referral
MH Care
System
Referral
SBI
Counseling
SUD Care
System
MH Services
Counseling
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• BH and PC providers – Still have separate systems
– Primary care services are integrated into BH Settings
Basic On Site (reverse co-location)
SUD Care
System
Medical Services
The Primary Care System
Referral
MH Care
System
Medical Services Referral
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• PC providers – Develop and provide their won
services
Integrated Care System
Integrated
The Primary Care System
SUD Care
System
MH Care
System
MAT
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• BH and PC providers – share the same facility
– have systems in common (e.g., financing, documentation
– regular face-to-face communication
Integrated Care System
Integrated
The Primary Care System
SUD Care
System
MH Care
System
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CA ADP Program Certification• ADP certifies residential and outpatient programs to
provide services at a specific location • Outpatient programs may be co-located in a medical
services building or FQHC. • If an SUD certified provider intends to offer services in
more than one location, each alternate site must be certified.
• An outpatient provider change address or to certify each independent outpatient site co-located with an FQHC, or medical services provider.
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CA ADP Program Certification• Licensed residential facilities may not provide
medical services to residents receiving drug and alcohol counseling and treatment services as part of their SUD services.
• Pursuant to Title 9, Section 10508(b), multiple-facility programs shall secure independent licenses for each separate facility.
Millicent GomesActing Deputy Director
CA Department of Alcohol and Drug Programs
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Specific services that are likely to be employed in integration activities
• MAT in primary care
• Brief Treatments (what are they?)
• Behavioral enhancement techniques (MET, MI, NIATX)
• “Warm hand off” techniques (cold referrals don’t work)
• SBI
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Screening, Brief Intervention and Referral to Treatment (SBIRT)
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What is SBIRT?SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services•For persons with substance use disorders•Those who are at risk of developing these disorders
Primary care centers, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users
Before more severe consequences occur
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SBIRT: Core Clinical Components
• Screening: Very brief screening that identifies substance related problems
• Brief Intervention: Raises awareness of risks and motivates client toward acknowledgement of problem
• Brief Treatment: Cognitive behavioral work with clients who acknowledge risks and are seeking help
• Referral: Referral of those with more serious addictions
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SBIRT Goals
• Increase access to care for persons with substance use disorders and those at risk of substance use disorders
• Foster a continuum of care by integrating prevention, intervention, and treatment services
• Improve linkages between health care services and alcohol/drug treatment services
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Rationale for screening and brief intervention
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Benefits of Screening and Brief Interventions
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Benefits of Screening and Brief Interventions
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Benefits of Screening and Brief Interventions
$1 Spent
Saves
$2-4
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Benefits of Screening and Brief Interventions
Work PerformanceNeonatal Outcomes
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Screening, Brief Interventions for Alcohol: Major Impact of SBI on Morbidity and Mortality
Study Results - conclusions Reference
Trauma patients 48% fewer re-injury (18 months)
50% less likely to re-hospitalize
Gentilello et al, 1999
Hospital ER screening
Reduced DUI arrests
1 DUI arrest prevented for 9 screens
Schermer et al, 2006
Physician offices 20% fewer motor vehicle crashes over 48 month follow-up
Fleming et al, 2002
Meta-analysis Interventions reduced mortality Cuijpers et al, 2004
Meta-analysis Treatment reduced alcohol, drug use
Positive social outcomes: substance-related work or academic impairment, physical symptoms (e.g., memory loss, injuries) or legal problems (e.g., driving under the influence)
Burke et al, 2003
Meta-analysis Interventions can provide effective public health approach to reducing risky use.
Whitlock et al, 2004
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Screening, Brief Interventions for Alcohol:Saves Healthcare Costs
Study Cost Savings Authors
Randomized trial of brief treatment in the UK
Reductions in one-year healthcare costs $2.30 cost savings for each $1.00 spent in intervention
(UKATT, 2005)
Project TREAT (Trial for Early Alcohol Treatment) randomized clinical trial:
Screening, brief counseling in 64 primary care clinics of nondependent alcohol misuse
Reductions in future healthcare costs
$4.30 cost savings for each $1.00 spent in intervention (48-month follow-up)
(Fleming et al, 2003)
Randomized control trial of SBI in a Level I trauma center
Alcohol screening and counseling for trauma patients (>700 patients).
Reductions in medical costs
$3.81 cost savings for each $1.00 spent in intervention.
Gentilello et al, 2005)
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How will the money change?
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New People, New Settings
• Specialty treatment system will need to be able to bill for individual services
• Specialty treatment system will need to respond to patient choice
• A whole new group of patients will enter the system through the health care system
• The healthcare (primary care, mental health, specialty docs) system will be able to provide some of our services
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Medical System
SUD services
Residential
Outpatient
Detox
OTP
Block Grant
MediCal
Insurance
Self pay
Current Funding Sources
Current Tx System
Block Grant
MediCal
Insurance
Self pay
HCR Funding Sources
Recovery Support
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We have lots to do and only a little time to prepare
2014
2010
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Behavioral Enhancement Skills for
Attracting New Patients/Clients under Health Care Reform
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Behavioral Enhancement Skills for Attracting New Patients/Clients under Health Care
Reform
Using more carrots to change behavior
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#1It is important in addiction treatment to:
Increase motivation
1. Strongly Agree
2. Agree
3. Neutral
4. Disagree
5. Strongly Disagree
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#2It is important in addiction treatment to:
Confront negative behaviors
1. Strongly Agree
2. Agree
3. Neutral
4. Disagree
5. Strongly Disagree
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#3It is important in addiction treatment to:
Give advice
1. Strongly Agree
2. Agree
3. Neutral
4. Disagree
5. Strongly Disagree
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What are the implications of HCR for the SUD Workforce?
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As the treatment of substance use disorders (SUDs) moves to the world of healthcare services………………………
A wide range of SUDs will be addressed, not just the most severe.
Patients will be viewed as respected healthcare consumers.
Treatments will need evidence of effectiveness
Treatment will be accountable.
Patients will have choice about treatment types and goals.
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• Regulatory issues including credentialing and licensing
– State laws/rules regarding licensure of mental health and substance abuse facilities – each with workforce requirements to deliver care
– State laws/regulations about scope of practice –govern types of services that can provided and the extent to which clinicians can practice independently in different settings
• Levels of risk and responsibility depend upon the level of integration
• The use of paraprofessionals—common in the behavioral health setting—can be difficult to reimburse in a primary care site.
Workforce considerations
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Consumer Improvement Strategies
• Increase the focus on consumer satisfaction and consumer perception of care
• Increase the use of behavioral enhancement techniques (use of positive reinforcement techniques).
• Increase the use to strategies to increase consumer access to care and appreciation of care (eg. NIATx)
• Increase measurement of service effectiveness and greater provider accountability
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• Differing practice styles
• Differing practice cultures and language
• Difficulty in matching provider skills with patient needs
• Heavy reliance on physician services
• Tension between direct patient care services (reimbursable) and integrative (non-reimbursable) services
Provider/practice barriers
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• Lack of recognition of provider limitations
• Lack of MH knowledge in PC providers and lack of health knowledge in BH providers
• Lack of clinical competence in integrated service models (MH/SU and BH/PC) and selection of proper integration model based on practice context
• Differing coding and billing systems
• Provider resistance
Provider/practice barriers
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FINANCIAL BARRIERSFINANCIAL BARRIERS•Payors have strict requirements of who can bill for what service
•Increase in Medicaid necessitates provider and workforce capability to bill this payor
•Payment for health/recovery coaches and use of peers is slow to emerge
•Allowances for payment for services in new job classifications areas, such as Care Managers
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Value of Behavioral Health Services will depend upon our ability to:
1. Be accessible (Fast access to all needed services)
2. Be efficient (Provide high quality services at lowest possible cost)
3. Capacity to connect with other providers (Electronic health record)
4. Focus on episodic care needs/bundled payments
5. Produce Outcomes!
6. Engaged Clients and Natural Support Network
7. Help clients self manage their wellness and recovery
8. Greatly reduce need for disruptive/ high cost services
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Contact Information
• Thomas Freese• [email protected]• Beth Rutkowski
• www.psattc.org www.uclaisap.org