Transcript VII. Continuum of Care in a Medicaid Setting

The Continuum of Care in a
Medicaid Setting
David R Gastfriend MD
Scientific Advisor, Treatment Research Institute
Chief Architect, CONTINUUM – The ASAM Criteria
Decision Engine™
Medicaid National Meeting on Prescription Drug Abuse and Overdose
February 1, 2016
Disclosures: Shareholder and former employee of Alkermes, Inc.; Royalty recipient from the American Society of
Addiction Medicine for the licensing of CONTINUUM™; Consultant: Alkermes, Indivior, Kaleo
Challenges in the Opioid Epidemic
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Disease Denial/Stigma
Access: drugs & care
Adherence & retention
Little recovery support
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Frequent relapse
Little use of Meds
Poor program quality
No outcomes data
Brain Physiology of SUD treatment
Limbic Region
• Basic Drives
• Experience of
Reward & Euphoria
Interventions
– Agonist Medications
– Antagonist Medications
Source: NIDA Drugs, Brains, and Behavior – The Science of Addiction Website.
http://www.nida.nih.gov/scienceofaddiction/brain.html; Fowler JS et al. (2007). Sci Pract Prospect. 3;4:4-16
Cortex
• Decision making
• Thinking
• Reasoning
• Learning
Interventions
– Psychosocial
Therapies
– 12 Step
Programs
– Monitoring
– Contingencies
Best Practices in Addiction Treatment
Screen & Refer: Los Angeles Tele-Triage Tool
• Offering all options & key information for patients to make decisions
Desegregate/Integrate Care: Vermont Hub & Spoke Model
• Programs must offer ALL options (directly or via affiliations)
Provide Withdrawal Management, All Meds & Doses
• No prior authorizations, fail first, time limits, medical benefit
• Proactive MAT adoption: Missouri, Florida, Ohio
Determine & Publicize Program Specifications & Quality
• Conduct ASAM Level of Care Certification (Open Society Found’n)
• Use TRI’s Consumer Guide: Utah
Best Practices in Addiction Treatment
Individualize Level of Care: ASAM’s CONTINUUM Tool
• CMS 1115 Waiver requires ASAM Criteria use via 3rd party review
• Calculates Each Patient’s Need for Detox + MAT Stabilization
• Provide: Rehab, Intensive Outpatient, Outpatient, Opioid Treatment
Services, Recovery Support Services, Care Coordination
Rebuild Lives: Hawaii Hope & S. Dakota 24/7 Court Models
• GO system requires: rehab, counseling & recovery supports
• NO GO system requires: monitoring, contingencies, sanctions
Credential Counselors AND Treatment Programs
• Counselors (e.g., for MAT), Care Coordinators, Recovery Support Staff
• Use Consumer Guide or ASAM Level of Care Certification for quality
The Role of Insurance
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It is vital for Medicaid to make detox, rehab, counseling, recovery support
services and MAT access easy
for clinicians & patients who are ambivalent
– because of the disease’s nature.
CMS 1115 Waiver is an innovation opportunity
Don’t require fail first,
limits on dose, time, or
medical benefits
• Patients will fail
• Requirements are
futile & destructive
• Telephonic prior
authorization delays
care
Automate prior
authorizations
• Otherwise, patients
end up waiting
• Avoids discouraging
patients & drop-out
• But still uses
medical necessity
criteria
Link treatment program
data, including to
primary care
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Eases access to
longitudinal/maintenanc
e medical services
Reduces stigma
Increases accountability
by providing clinical &
cost outcomes
TRI Consumer Guide – Program Quality Ratings
Addiction assessment:
A sorry state of affairs
• Non-standard, “intuitive”, then “find out the rest later…”
• Managed Care wants more data: Telephone tag (90 min – 3 days)
• Most insurers’ medical necessity criteria are Proprietary
• Absent precision & validity, emphasis is on cost, not quality
• 1991: ASAM Patient Placement Criteria…a teaching tool
• States create their own Criteria (CASAM, MASAM, NYSAM,…)
• “ASAM” in Major US MCO: ~50% of cases were denials
• on appeal: ~50% reversed; on review ~50% reversed again!
• By 2000s, SAMHSA & CSAT called on ASAM for a standard
ASAM text: hundreds of decision rules
To place patients in the least intensive & restrictive care
that meets the patient’s multi-dimensional needs
and affords optimal treatment outcome
www.haworthpress.com
www.asamcriteria.org
ASAM Patient Placement Criteria
Screening
1
Intoxication
Withdrawal
4
Treatment
Acceptance/
Resistance
Diagnosis
Severity
Patient Placement Criteria
DIMENSIONS
2
Biomedical
5
Relapse
Potential
Readiness &
Relapse Potential
3
Emotional
Behavioral
6
Recovery
Environment
Decision Rules
LEVEL OF CARE
1. Outpatient
2. Intensive
Outpatient
3. Medically
Monitored
Intensive
Inpatient
4. Medically
Managed
Intensive
Inpatient
MGH-Harvard ASAM Criteria Validity Study
Gastfriend, et al. Supported by NIDA grants # R01-DA08781 & K24-DA00427
• Randomized controlled trial (RCT) in 3 cities in eastern MA
• Tested matched v. mismatched assignments with PPC-1
• Compared Levels II (IOP) & III (Residential)
• Outcomes: No-show to step-down care
• Balanced for gender, ethnicity (N=700)
• Used computerized algorithm with blinded raters, patients, treaters
– Based on instruments with known reliability
– B.A. level interviewers achieved inter-rater reliability of 0.77
(ICC)
Under-Matching Worsens No-Show to
Treatment
From Inpatient Detox to Either Residential Rehab or Day Treatment:
All Patients, High Frequency Cocaine Users and Heroin Users
60%
50%
40%
30%
20%
10%
Percent No-Shows to Next Treatment
70%
p≤.019
Undermatched
patients’
no-show
rate:
~25% worse
p≤.001
Undermatched
patients’
no-show
rate:
~100%
worse
p≤.001
Undermatched
patients’
no-show
rate:
~300%
worse
0%
All Patients (N=700)
Cocaine (N=183)
Mis-matched Matched
Heroin (N=279)
Predictive Validity: The Norwegian Study
Stallvik M, Gastfriend DR, Nordahl HM
Funded by the Central Norway Health Trust
• Prospective, double-blind, multi-site (n=10) naturalistic design
• N= 261, naturalistically placed by counselors across 3 counties
• Baseline (BL) interview & 3 mo. follow-up (F/U)
• Independent raters used ASAM Criteria Software 2nd Ed.-Rev.
• Outcomes at 3 month follow-up:
1) Dropout
2) ASI Composite Score Changes
3) Recommended level of care at F/U
3-mo Drop-Out, Improvement & Stepdown
Need
100%
% Drop Out
at 3-Mo F/U
90%
6
80%
5
70%
60%
50%
40%
30%
20%
10%
0%
7
# ASI Subscales
Improved at F/U
Matched patients
have 30% better
show rates
4
3
70%
60%
Match
yields
3X
better
outcomes
% of Patients Ready for
Stepdown at F/U (vs. BL)
Lower
Stepdown
Same
Same LOC
Higher
Higher LOC
50%
40%
30%
2
20%
1
10%
0
0%
Naturalistic Match Status – According to ASAM Software
A
significantly
higher
proportion
of matched
patients
were ready
for
stepdown
Bed-Day Utilization Over 1 Yr. in the VA
(J Add Dis 2003)
Supported by NIDA grants # R01-DA08781 & K24-DA00427
Bed-Day Utilization Over 1 Yr. in the VA
Bedford MA VA, N = 97 (Sharon et al., JAD 2003)
Bed-day Use Pre- vs. Post-Naturalistic L-III Placements
35
~24-mos Before
Annualized Bed-Days
30
~13 mos After

*
25
20

15
10
5
0
Adequate (II)
Matched (III)
Lesser LOC (IV)
Patients
given
residential
but who
needed
hospital
care
used more
bed-days
the next
year
(matched
patients
used fewer
days)
Conclusions
• The ASAM Criteria Software decision rules show face validity
• Technology provides good reliability & feasibility
• Comparison to other instruments shows good concurrent validity
• Predictive validity overall & with heroin, cocaine & comorbidity
• Valid for undermatching, AND for overmatching
• Predictive validity:
– in multiple cultures/systems: public/VA; MA/NYC; Belgium/Norway
– at multiple time-frames: immediate, 30-d, 90-d & 1-year
– with multiple outcomes:
no-show, global improvement, substance use,
step-down readiness, rehospitalization
Clinical Decision Support: Output
• DSM-IV and DSM-5 Substance Use Disorders: Diagnoses & Criteria
• CIWA-Ar & CINA withdrawal scores (alcohol/BZs, opioids)
• Addiction Severity Index (ASI) Composite Scores
• Imminent Risk Considerations
• Access & Support Needs/Capabilities
• ASAM Level of Care recommendations
– Including Withdrawal Management
– Including Biomedically Enhanced Sub-level
– Including Co-occurring Disorder Sub-levels (Capable, Enhanced)
• Also: If actual placement disagrees with Software,
the clinician gets to justify the discrepancy
Stakeholders in the Health IT Revolution
Client
Counselor
Researcher
Employer/
Payer
Managed
Care
Supervisor
Society
System
Accreditation Body,
Government
Implications & Opportunities
• Patient trajectories – reveal stepdown, step up, drop out & reentry
• Provides follow-up/reassessment & change over time analysis
• High resolution clinical data to combine with claims data
analyses
• Discrepancy Patterns: Generates real-time needs assessment
• Facilitates casemix analysis & trajectories
-- For planning capitated and value-based contracting
Implications & Opportunities
 Opioid Epidemic Ready: Indicates need for Opioid Treatment
Services
 Parity-Ready: Published, widely available medical necessity
criteria
 ACA Ready: Facilitates ACO, Health Home & related population
needs
 CMS 1115 Waiver Ready: Facilitates required 3rd party UR
review
Questions and Answers
[email protected]
www.ASAMcontinuum.org
– Knowledge base
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Webinars
Frequently asked questions
Training videos
Current list of Authorized CONTINUUM™ Distributors
Email: [email protected]
TM