Transcript Super Better” SUD Treatment under Health Care Reform

“SUPERBETTER”
Integrating Substance Use Disorder Care
Dr. Jack McCarthy
Valerie Yv. Woolsey, MBA
BAART Programs
Overview
• BAART Programs
– Who we are
– What we do
• “What we talk about when we talk about SUD”
– Overview of MAT and Opioid Treatment
– Structured Narcotic Treatment Programs
– Compliance, Retention, and Key Predictors of success
• Managed Care and the Integrated Care Payor Mix
– Network adequacy
– SBIRT and Health homes
• PPACA in California: Federal vs. State legislation
– Network adequacy
– Drug Medi-cal and the 1115 Waiver
• Comments and Questions
Strategic Role of Community Clinics:
Meeting the Safety Net Provider Challenge
Who We Are
1
Community
health
providers are effective
because,
being
so
intertwined with their
neighborhoods,
have
been seen as the
original patient-directed
centers who identify
health needs earlier and
design
effective
community
based
solutions before others
even
understand
underlying dynamics
Safety Net Perspective
2
One of the biggest
challenges as we look at
ourselves as a safety
provider network is who
is driving the spend.
Our goal is to maximize
efficiency by making
sure members are tied
to
providers
who
effectively
manage
their care.
What That Means
3
That may mean we do
not
need
more
providers, just key ones
who are focused, and to
whom new members
can be directed in a way
that mimics medical
home
strategy
to
maximize coordination
of services. Simply
contracting with payors
offering products on the
Covered
California
exchange does not
address the full scope of
integrated care.
BAART Programs
•
Bay Area Addiction Research and Treatment “BAART” Programs was incorporated in 1977 to provide
methadone treatment to the opiate addicted population in San Francisco. Since inception, BAART has
grown in number of clinics and types of services it provides. We now operate 20 clinics in 5 states,
providing a range of MAT, primary care and mental health services.
•
Operating as a network of clinics that provide health care services to indigent populations, BAART’s
mission is to provide people with cost-effective, comprehensive medical and other health care services
through community linkages at its clinics and to make such services available to as many people as
possible that seek them. By doing so, BAART Programs can foster the health, happiness and longevity of
those individuals and can help them benefit our communities.
•
BAART programming is co-located in it’s clinics or is coordinated through formal arrangements with other
providers. We have the knowledge and resources to treat our patients from an integrative standpoint,
combining primary care, mental health and substance abuse treatment services. This “one-stop-shop”
approach to care decreases the likelihood of patients falling through the cracks when shuffled between
providers.
•
As a result, BAART clinics have become the medical home to many of the residents of our communities,
decreasing unnecessary emergency room use and hospitalizations and decreasing disjointed care through
our integrated care model.
SUD and Mental Health Disease State Parameters
Addictions are complex with multiple causes
1
Medications or psychotherapy can address
other symptoms or problems that are
discovered in the course of evaluation and
treatment.
SUD typically not an isolated problem
2
Commonly,
people
with
depressant
addictions are also struggling with other
mental disorders, such as anxiety or
depression
Counseling and tailored treatment help
3
A comprehensive evaluation (medical,
psychological and social) to identify the
variety of troubles that are fueling the
drug abuse or misuse is key.
According to the National Institute
on Drug Abuse (NIDA), addiction is
a chronic, relapsing disease
characterized by compulsive drugseeking abuse and by long-lasting
chemical changes in the brain.
While there is no cure for addiction,
users can get help to treat their
disease. Drug use and abuse
typically begins with a gateway drug,
typically tobacco products and
alcohol.
Multi-Disciplinary Approach to Treatment
•
•
•
Detoxification/Medically Supervised Withdrawal
– Uses a drug with a long half-life and low abuse potential
– Uses a drug that is smoothly eliminated
– Replaces abused drug with detox drub
– Initiates drug free treatment
– Taper the detox drug
Maintenance Therapy
– Prevents withdrawal
– Diminishes drug craving
– Blocks or attenuates the effects of heroin and other abused opiates
– Increases retention rates in treatment
– Is not a cure but allows participation in rehabilitation
– Drugs include methadone, naltrexone, and buprenorphine
Counseling – Establishing a Foundation of Recovery
– Remember, you are not just treating one person
Perspectives on Addiction
• Patient perspective, Descriptive model, personal
narratives
• Biological model,
Genes, endorphins, and mu opioid receptors
• Psychological model
Psychoanalytic model
Conditioned response model
Psychoanalytic Model: Deficits in Self-Care
• Suffering is at the heart of addictive disorders
• Addiction is not about pleasure (reward) seeking, selfdestructiveness, or oral dependency.
• Addicts have deficits in self-care. They struggle
regulating emotions, self-esteem, relationships, and
behaviors and they self-medicate distress and pain
related to these difficulties.
Consequences of Ignorance
•Addicts receive poor care in the medical/psychiatric system
(although it is getting better) because doctors/nurses are more
afraid of being ‘conned’ than helping the patient.
•In the criminal justice system ignorance translates into abuse
with the totally disproven notion that abuse serves deters drug
use. In fact, it merely promotes drug use.
•This is a life threatening illness, i.e. accidental and deliberate
overdoses, as well as neglect of other serious conditions.
The Etiology of Addiction
• Is it primarily bad behavior?
• Is it primarily genetic or is a developmental disorder related to
childhood abuse or neglect such that all it takes is exposure to
a vicodin to ‘normalize endorphin function’ and trigger
addiction?
• Is it primarily self-medication attempts to control mental
illness, anxiety, depression, bi-polar?
Biological Model
• The drug as neuro-transmitter or hormone which becomes
part of transmission system, e.g. endorphin system
• Chronic administration of opiates, legal or illegal, inhibits the
production of both endorphin and mu-opioid receptors. It
changes the chemistry and structure of the brain.
• Anxiety is the most devastating symptom of opiate
withdrawal.
The Categorical Imperative of Opiate
Dependence
• No treatment works, in more than a random
way which does not deal with the biology of
withdrawal.
• Leave the patient in withdrawal they will relapse
or worse
What Are the Similarities Between Methadone
and Buprenorphine?
• Both are long acting, compared to opiates of abuse, and can be
given once a day
• Neither cause an acute euphoria like short acting opiates and
so are not normally opiates of abuse.
• Both are effective treatments of opiate addiction
• Both are effective treatments of chronic pain
• Both are opiates and have a similar withdrawal if abruptly
stopped
What Are the Physiological Differences
Between Methadone and Buprenorphine
• Methadone is a pure opiate agonist.
• Buprenorphine is a mixed opiate with significant antagonist
effects if given to people already on other opiates, i.e. it can
cause an acute severe opiate withdrawal state, like narcan
• Buprenorphine is also a partial opiate, activating the opiate
receptor to a lesser degree than methadone (at least at higher
doses)
Trading One Addiction for Another??
• Common misperception
• Addiction is misuse and unless the patient is abusing
methadone or bup, this analogy is wrong
• Trading dependence on short acting opiates for
dependence on long acting opiates is accurate. This
allows for brain stability and a return to endorphin
homeostasis.
Considerations for Treatment Options
American Society of Addiction Medicine (ASAM) Criteria Levels of Care
Early intervention
Assessment and education for at-risk individuals who do not meet
diagnostic criteria for substance-related disorder
Outpatient services
Less than 9 hours of service/week for recovery or motivational
enhancement therapies/strategies
Intensive outpatient
9 or more hours of service per week in a structured program to treat
multidimensional instability
Partial hospitalization
20 or more hours of service per week in a structured program for
multidimensional instability not requiring 24 hour care
Clinically managed low-intensity residential
24 hour structure with available trained personnel with emphasis on reentry
to the community, at least 5 hours of clinical service per week
Clinically managed population-specific high intensity
residential
24 hour care with trained counselors to stabilize multidimensional imminent
danger. Less intense milieu and group treatment for those with cognitive or
other impairments unable to use a full active milieu or therapeutic
community
Clinically managed high-intensity residential
24 hour care with trained counselors to stabilize multidimensional imminent
danger and prepare for outpatient treatment. Able to tolerate and use a full
active milieu or therapeutic community
Medically monitored intensive inpatient
24 hour nursing care with physician availability for significant problems in
Dimensions 1, 2, or 3. 16 hours per day of counselor ability
Medically managed intensive inpatient
24 hour nursing care with physician care for severe, unstable problems in
Dimensions 1,2, or 3. Counseling available to engage the patient in
treatment
Opioid treatment program
Daily or several times weekly opioid medication and counseling abailable to
maintain multidimensional stability for those with opioid use disorder
Considerations for Treatment Options
•
ASAM talks about two different levels (ASAM Level 1 and ASAM level 2) and understanding the type of person
who falls into those categories is important to determining the "how and what" treatment options would be
appropriate.
•
ASAM Level 1 is a more counseling focused approach where someone is a walk in patient who registers for 9
hours of face-time that educates them about their disease, talks about the physiological and psychological aspects
of the disease, and how the effects can impacts them socially. It can also include medical discussions (translation:
alcohol consumption contributes to diabetes) The group in this category are typically employed and function with a
high level of self structure.
•
ASAM level 2 patients fall into intensive outpatient (IOP) needs. It is a more intensive program requiring 19 hours
of counseling and potentially medications. The primary difference with ASAM Level 1? People here are usually
unemployed, require more structure, have a high level of recidivism and present with concomitant disorders complicated social issues that require intensive work to understand what it is that is causing the behavior and
require a lot of work to make their lives manageable.
•
Comparatively, IOP has a very specific program structure and design. The list provided in a recent DHCS draft
waiver document is very accurate; however, there is a range of subsets for most of the components described.
While intake and the needs assessment that begin the process is fairly universal, it gets fuzzy after that. IOP
services can be based on whether you want physical health, psychological health, or social well being to be
addressed. Do you want a "low intensity" IOP (LIOP) for example? And counseling is also broad, where group
counseling can have a "recovery" focus, or with a "family" family focus for example.
•
In sum, FQHCs can do IOPs but it boils down to the business model an FQHC wants to design. It's about defining
how broad a scope the provider is both willing and able to fund. What kind of staff do you want to employ and what
is the cost? What kind of licensing will you require, especially if you are a medication assisted treatment facility,
and the type and the volume of clientele that would be coming through your doors. You can opt for a bare
minimum or a program that is highly matrixed and comprehensive, but you must then think through what the
operational/clinical/financial costs would be for the design and subsequently whether you can secure a patient mix
and payor reimbursement rate that will make the model financially feasible and sustainable.
Operational Anatomy of an Intake Process
A. Counselor Process:
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Assess patient for appropriateness of treatment-entails gathering using and treatment history
to ensure patient is physically dependent on opioids
Patient to breathalyzer
Consent for information to any prior treatment center
Complete intake packet on computer and print
Preliminary screening and check list-enter dates of prior treatment and state criteria
Sign up on medical board
Legal documents- HIPPA for
Authorization for use of protected health in formation
Acknowledgement of receipt of materials
Initial needs assessment and treatment plan
Consent packet done
Cal-OMS completed
Patient to front desk for UA and medical paperwork
Admissions data collection assessment
Fee assessment
Case note that details pertinent information gathered during intake
Assemble file and submit
Operational Anatomy of an Intake Process
B. Medical Process
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Blood is drawn for basic panel which included rpr, blood also drawn for HIV test (paid for by
DPH)
PPD is applied
Medical history and physical exam is conducted
Urine collected for tox screen
Urine collected for other analysis
When indicated/needed may dip urine for immediate drug screen results
EKG may be conducted if indicated
C. Intake
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H0001
80053
81001
85025
86592
99203
H0020
H0004
Substance Use Assessment (1 Unit = 15 minutes)
Comprehensive Metabolic
Urinalysis
CBC with differential
STS (RPR)
Physical Examination (25 minutes)
Methadone Dosing (1 Unit = 1 Dose)
Individual Counseling (1 Unit= 15 minutes) Meth Panel Toxicology
Operational Anatomy of an Intake Process
HCPCS Codes
Description
Billing Unit
Rate Per Unit
H0014-UA
21-day detox program, first 7 days
per dose
X
H0014-UB
21-day detox program, days 8-21 or all 21 days if recently seen
per dose
X
H0014-UC
21-day detox program, days 8-21, re-exam
per dose
X
H0001
Alcohol and Drug assessment
15 minutes
X
H0020
Methadone Dosing
per dose
X
H0004
Individual Counseling
15 minutes
X
H0004-HQ
Group Counseling
15 minutes
X
T1016
Case Management
15 minutes
X
CPT Codes (LCSW, Psychologist)
90791
Psychiatric Evaluation
90792
Psychiatric Evaluation with medical services
90832
Individual Counseling
16-37 minutes
90834
Individual Counseling
38-52 minutes
90837
Individual Counseling
52+ minutes
90853
Group Counseling
per event
Managed Care and Network Adequacy
•
Network adequacy refers to a health plan’s ability to deliver the benefits promised by
providing reasonable access to a sufficient number of in-network primary care and
specialty physicians, as well as all and other health care services included under the
terms of the contract. Taken together with the Essential Health Benefits (EHB)
package, now required as a benefit level floor under the Affordable Care Act (ACA),
network adequacy standards will determine what care is covered and how easily it
can be obtained.
•
States have taken different approaches in regulating the adequacy of health plan
networks. The variation is due, in part, to the need for states to maintain robust health
insurance markets by balancing access needs with the goals of controlling costs and
attracting a healthy number of insurers. In many states, network adequacy
requirements have historically applied only to Health Maintenance Organizations
(HMOs), and not to other managed-care products such as Preferred Provider
Organizations (PPOs). Because PPO products offer reimbursement for services
obtained from both in-network and out-of-network providers, they present additional
considerations and challenges.
•
There are discrepancies that can arise with varying network adequacy
standards and states have flexibility to resolve such issues individually.
Bridge to Reform Section 1115 Medicaid
Demonstration Waiver
•
Section 1115 of the Social Security Act gives the Secretary of Health and Human Services authority to waive
provisions of major health and welfare programs authorized under the Act, including certain requirements of
Medicaid Section 1115 also authorizes the Secretary to allow states to use federal Medicaid funds in ways that
are not otherwise allowed under federal rules. In both cases, the Secretary must determine that the initiative is an
“experimental, pilot, or demonstration project” that “is likely to assist in promoting the objectives of” the Medicaid
program.
•
The Bridge to Reform Medicaid Demonstration Waiver was approved in 2010 and made approximately $8 billion in
federal Medicaid matching funds available to California over 5 year period to expand coverage to low income
uninsured adults and preserve and improve the county based safety net. It allowed for the state to enroll Medicaid
eligible seniors and persons with disabilities in managed care plans that meet specific readiness criteria
•
Since 1994, California has developed what is arguably the most robust system of opiate treatment programs in the
Country. There are currently approximately 145 licensed programs spanning much of the state providing timely
access to major population centers and stretching into many suburban and rural areas such that a vast majority of
patients live within 10 miles of an OTP
•
The passage of legislation in 1997 establishing an evidence based FFS reimbursement system resulted in
improved patient outcomes. Specifically the current system pays for two distinct units of service,
medication administration and counseling services, each of which are empirically proven to result in the
best possible patient outcomes and ensure efficiency and cost effectiveness.
•
Rigorous multi-level oversight ensures program integrity. OTPs are regularly evaluated by county, state, federal
and accreditation entities to ensure compliance in fiscal, operations, quality of care, medication oversight, and
facility safety.
SUD and Primary Care Integration
Highly Concentrated Newly
insured and Medi-Cal patients
SBIRT, Treatment, and
Servics
Fragmented Provider, Hospital, Payor
Market
QUESTIONS?
Dr. Jack McCarthy, BAART Bi-Valley Medical Clinic
Valerie Yv. Woolsey, Director, Health Care Reform Strategy
BAART Programs
1111 Market Street 4th Floor San Francisco, CA 94103
Phone: 415-552-7914 (San Francisco)
Phone: 916-974-8090 (Bi Valley/Sacramento)