Transcript Policies that promote greater quality and quantity in substance use

Policies that promote effective systems of care
for substance use disorders
Keith Humphreys
Senior Policy Advisor, White House ONDCP
Professor of Psychiatry, Stanford University
Career Research Scientist, Department of Veterans Affairs
Substance Use Disorder Care is a major
focus of NDCS, but not the only one
 Prevention
 Reduction
of Prescription Drug Abuse
 Drugged Driving
 New models of law enforcement and
community supervision
 Merida Initiative, CBSI, Afghanistan
 See www.whitehousedrugpolicy.gov for
the full National Drug Control Strategy
Can Countries Achieve “Tipping Points”
with Substance Use Disorder
Treatment?
 Some
nations have treatment on demand
and very high population penetrance
(Australia, Switzerland, The Netherlands)
 Others
invest some resources, but have
lower population penetrance (U.S.)
 Critical
question is whether there is a
“tipping point” with care expansion
In U.S., about one in six persons meeting diagnostic
criteria for illicit drugs received specialty treatment
Total needing treatment for illicit drugs = 7.559 million
.
8/2009
Source: SAMHSA, 2008 National Survey on Drug Use and Health (September 2009).
13
Proportion of all heroin addicted individuals
in methadone maintenance, 1993
Source: MacCoun, R. J., & Reuter, P. (2001). Drug war heresies. Cambridge, UK: Cambridge University Press.
France subsequently dramatically
expanded opiate agonist treatment
120000
100000
80000
60000
Patients
40000
20000
0
6
7
8
9
0
1
2
3
9
9
9
9
0
0
0
0
19
19
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Emmanuelli, J., & Desenclos, J-C. (2005). Harm reduction interventions, behaviours and associated
health outcomes in France, 1996-2003. Addiction, 100, 1690-1700.
..And apparently achieved a tipping
point 1996-2003
 Annual
heroin arrests dropped from
17,328 to 4,025
 Annual
overdose deaths declined from
465 to 89
Only historical U.S. example
10/1971 – 3/1973, federal government
expanded treatment slots 352%
 From
 First
national annual drop in street crime in
20 years occurred from 1972-1973
 Data
systems at the time too crude to
conduct more fine-grained analysis
References: Musto, D., & Korsmeyer, P. (2002). The quest for drug control. New
Haven: Yale University Press; Massing, M. (1998). The fix. New York: Simon and Schuster.
How will the Obama Administration
Increase the Quantity of Care for
Substance Use Disorder?
Patient Protection and
Affordable Care Act of 2010
 Specifies
that screening, brief intervention
and treatment for substance use disorders
are essential healthcare benefits
 Insures about 5M more people who have
substance use disorders
 Extends parity regulations to exchanges
 Expands Medicaid to 133% of FPL, covers
childless adults
The Spectrum of Substance Use Disorder
Specialty Treatment ~ 2,300,000
Abuse/Dependent – 25,000,000
“Harmful Users” – ??,000,000
Little or No Use
What is SBIRT?
 Screening,
Brief Intervention and Referral
for Treatment
 Targeted
 Strong
 Usable
at less dependent patients
evidence of effectiveness
in primary care, emergency rooms
and other
Administration SBIRT proposals
 CMS
continue to support billable codes
 President’s
budget request supports their
expansion with new funding for monitoring
and technical support
 Expand
program to train physicians in
SBIRT methods
Selected Administration initiatives
for treatment of addicted individuals
 Mental
health and substance abuse
parity regulations
 Expansion of funding in existing health
care systems (more on this later..)
 Re-entry/diversion initiative
 End of ban on federal funding for NEP
 Increase in NIH funding
 Medicaid expansion?
Will all this increase in
quantity produce a
“tipping point”?
A brief but important word about expanding treatment in developing countries
International Demand Reduction
 PEPFAR
new focus on medication
assisted treatment for IDUs
 Merida
Initiative includes support for
electronic linkage of 300 treatment centers
in Mexico
 NIDA
international scholars and research
programs
Expanding quantity does not
resolve concerns about quality
Alcohol dependence was last among 30 medical
conditions in proportion of care received as
evidence would recommend
Senile cataract
Breast cancer
Prenatal care
Hypertension
Asthma
Diabetes Mellitus
Urinary Tract Infection
Atrial Fibrillation
Alcohol Dependence
78.7%
75.7%
73.0%
64.7%
53.5%
45.4%
40.7%
24.7%
10.5%
Source: McGlynn E., et al., (2003). The quality of health care delivered to adults in In the United
States. New England Journal of Medicine, 348.
Common quality issues
 Isolation
of specialty addiction treatment
and mainstream health care
 Sub-optimal staff training, morale and pay
 Poor continuity of care
 Inadequate health information technology
 Minimal use of evidence-based practices
 High process regulation…with weak
performance standards
References:
Uchtenhagen A., Stamm R., Huber J., and Vuille R. (2008) A review of systems for continued education and training in the substance
abuse field. Substance Abuse 29, 95-102.
McLellan, AT, Carise, D, Kleber, HD. (2003). Can the national information treatment infrastructure support the public’s demand for quality care?.
.
Journal of Substance Abuse Treatment. 25, 117-21
What policies might
improve the quality of care?
Improving quality is a challenge:
Dr. Zoe D. Katze
Incentivizing particular care
processes: VA example
 Pool
of “off the top” funding set aside at
beginning of each year
 Meeting
standards on particular indicators
is rewarding financially
 Success
example: Alcohol screening and
identification of problem drinkers
Rates of identifying substance
abuse in VA versus other systems
Washington Circle Identification Measure
Percent
8
6
4
2
0
HMO1
HMO2
HMO3
Veteran's Affairs
Administration Proposal: P4P
for States
 President’s
Budget requests $6M for a
new pay for performance program
 States and Tribes would compete for the
funds
 Those selected would receive incentive
funds to reward quality in their systems
 Broad latitude allowed for the dimension of
care rewarded
A market-based approach to quality:
Access to Recovery

Individuals seeking care receive a voucher,
value varies, average around USD1600

For public sector, provides unusual freedom to
select (or switch) care options

About $100M annually in 3-year cycles, offers
services to about 160,000 individuals total

Obama Administration proposes $9.9M increase
for program
Embedding specialty care within
medicine to improve quantity and quality
at once
 Makes
specialty care subject to the quality
and process regulations of medicine
 Brings
in the staff and resources to meet
those standards
 But
allows choice because U.S. insurance
system is market based
Other potential advantages to
expanding substance use disorder care
within mainstream healthcare systems
 Better
integration of care from the outset
 Unified
 Less
health information technology
stigma to accessing care
Two care systems for such
expansion, proposed in President’s
2011 Budget
 HRSA’s
 Indian
Community Health Centers
Health Service
Summary

Obama Administration is emphasizing brief
interventions, and, treatment for people with
substance use disorder

A public health “tipping point” may be achievable
through treatment/brief intervention, but required
amount of expansion is unknown
Summary, continued

Administration proposing major investments in
expanding the quantity of treatment

Expansion of quantity does not necessarily
improve quality, hence some quality focused
proposals as well

Expansion of substance use disorder treatment
within mainstream healthcare systems may offer
quantity AND quality benefits