Transcript St Louis Integration Talk McLellan

Part I
Why Integrate Addiction Care
into Mainstream Medicine?
A. Thomas McLellan
Treatment Research Institute
3/27/2016
©Treatment
©Treatment
Research
Research
Institute,
Institute,
20132012
Closing Thoughts
Substance use disorders” will soon be a
regular part of mainstream healthcare:
1. SUDs are too omnipresent, dangerous &
expensive in healthcare to be ignored
2. Market forces will accelerate integration
o
Insurance benefits will bring new meds,
continuing care protocols & other tools
3. Mainstream healthcare can do this!
o Several protocols already fit into the system
Substance Use Among US Adults
Very
Serious
Use
In Treatment ~ 2,300,000
Addiction ~ 23,000,000
Harmful – 40,000,000
Use
Little/No
Use
Little or No Use
1
1. Because it will improve
general medical care
2. Because it will save money
3. Because it’s the law.
Substance Use Impact on Healthcare
Alcohol and drug use below “addiction” lead to:
misdiagnoses,
poor adherence to care,
interference with prescribed meds,
more physician time,
unnecessary medical testing,
poor outcomes
increased costs
Particularly in chronic illness.
Vinson D, Ann Fam Med, 2004. Brown RL, J Amer Board Fam Prac, 2001. Humeniuk R, WHO, 2006. Manwell LB, J
Addict Dis, 1998. Longabaugh R. Alcohol Res Health, 1999. Healthiest Wisconsin 2010, WI DHFS, 2000. USPSTF,
Screening for Alcohol Misuse, 2004. National Quality Forum, National Voluntary Consensus Standards, 2006. Bernstein
J, Drug Alcohol Depend, 2005. Saunders B, Addiction, 1995. Stephens RS, J Consult Clin Psychol, 2000. Copeland J, J
Subst Abuse Treat 2001. Fleming MF, Med Care, 2000. Fleming MF, Alcohol Clin Exp Res, 2002. Gentilello LM, Ann
Surg, 1999. Estee S, Medicaid Cost Outcomes, Interim Report 4.61.1.2007.2, Washington State Department of Social
and Health Services. Yarnall KSH, Am J Public Health, 2003. Solberg LI, Am J Prev Med, 2008. National Committee on 5
Prevention Priorities, http://www.prevent.org/content/view/43/71/.
1
Alcohol Use and Breast Cancer
Before Diagnosis – heavy drinkers
1.5 times chance of contracting
2.3 times chance w/BRCa2 gene
After Diagnosis – ANY Drinking
Increases risk of relapse
Interferes radio & chemo therapy
1
Potential impact on Safety: Fatal Medical Errors
FME Death Rate
1983 - 2004
Alc/Drg Related
Fatal Errors
Phillips, D. P. et al. 2008;168:1561-1566.
Drug-Drug Interactions – Safety Issues
• BU study of 87 patients with undisclosed opioid
use receiving primary care at BU Medical Center.
• 100% received at least one medication with a
significant drug-drug interaction
• Average number of significant interactions = 5
• 15 of 87 patients (17%) were treated by ED for
their interaction ($$$)
Walley et al., J. Gen Internal Medicine, 24(9): 1007-11, 2009
1
Causes of Accidental Death
#1 Medication Overdose
#2 Car Accidents
#3 Accidental Shooting
Source: CDC, 2013
Pain Society and State Guidelines
for Pain Management
Model policy for the use of opioids in the treatment of pain.
http://www.fsmb.org/pdf/2004_grpol_Controlled_Substance
s.pdf
Gilson AM, Joranson DE, Maurer MA. Improving state pain
policies: recent progress and continuing opportunities.
CA Cancer J Clin. 2007;57(6):341–353
1. Screening for & discussing substance use
2. Patient contract – Single doc & pharmacy
3. Patient & family education on safe storage
of medications
4. Urine Screening pre and during
prescribing (expanded test panel)
1
1. Because it will improve
general medical care
2. Because it will save money
3. Because it’s the law.
Substance Use Cost in Healthcare
In Treatment ~ 2,300,000
Very
Serious
$40B Addiction ~ 23,000,000
Use
Yr
$80 B
Yr
Little/No
Use
“Harmful – 40,000,000
Use”
Little or No Use
1
1. Because it will improve
general medical care
2. Because it will save money
3. Because it’s the law.
2009 Parity Act
“MHPAEA”
“If” a health plan covers MH/SA
benefits should be comparable to
those of similar physical
illnesses”
2010 Affordable Care Act
• Funds full continuum of care
•
Prevent, BI, Meds, Spec Care
• Significant change in benefit
•
The nature/number of benefits
•
The types of eligible providers
• SUD care is an
“Essential Service”
SUD Benefits Today
Very
Serious
Use
In Treatment ~ 2,300,000
Addiction
Addiction ~ 23,000,000
“Harmful – 40,000,000
Use”
Little/No
Use
Little or No Use
• Detoxification – 100%
– Ambulatory – 80%
• Opioid Substitution Therapy – 50%
• Urine Drug Screen – 100%
– 7 per year
1
Medicaid Diabetes benefit
• Physician Visits – 100%
• Clinic Visits – 100%
• Home Health Visits – 100%
• Glucose Tests, Monitors, Supplies – 100%
• Insulin and 4 other Meds – 100%
• HgA1C, eye, foot exams 4x/yr – 100%
• Smoking Cessation – 100%
• Personal Care Visits – 100%
• Language Interpreter - Negotiated
SUD Insurance Under ACA
Very
Serious
Use
Little/No
Use
In Treatment ~ 2,300,000
Addiction ~ 23,000,000
Insurance
for
“Substance
Use
Disorders”
“Harmful – 40,000,000
Use”
Little or No Use
• Physician Visits – 100%
– Screening, Brief Intervention, Assessment
– Evaluation and medication – Tele monitoring
• Clinic Visits – 100%
• Home Health Visits – 100%
– Family Counseling
• Alcohol and Drug Testing – 100%
• 4 Maintenance and Anti-Craving Meds – 100%
• Monitoring Tests (urine, saliva, other)
• Smoking Cessation – 100%
Substance Use Among US Adults
In Treatment ~ 2,300,000
Very
Chronic
Care
Serious
Addiction ~ 23,000,000
Model
Use
Early “Harmful – 40,000,000
InterventionUse”
Little or No Use
Prevention
Little/No
Use
Closing Thoughts
Substance use disorders” will soon be a
regular part of mainstream healthcare:
1. Too common, dangerous & expensive in
healthcare to be ignored
2. Public understanding that addiction is an
illness not a sinSUDs are too commo
3. Mainstream healthcare can do this!
o Chronic Care Management protocols are appropriate
1
How Can State Government
Improve Quality?
~12,000 specialty programs in US
• 31% treat less than 200 patients per year
• 77% primarily government funded
Private insurance <12%
1
1. Require state schools to teach
substance use disorders
2. Stop buying sub-standard care
3. Educate consumers to
demand quality
1
1. Require state schools to teach
substance use disorders
2. Stop buying sub-standard care
3. Educate consumers to
demand quality
Delaware’s Performance
Based Contracting
• 2002 Budget – 90% of 2001 Budget
• Opportunity to Make 106%
• Two Criteria for Outpatient Providers
– Full Utilization
– Active Participation
• Audit for accuracy and access
Delaware’s Results
Years 1 & 2
• One program lost contract
• Two new providers entered, did well
– Mental Health and Employment Programs
• Programs worked together
– First, common sense business practices
– Second, incentives for teams or counselors
• 5 programs learned MI and MET
Utilization
6500
Average Daily Census
6000
5500
5000
4500
4000
3500
3000
2001
2002
2003
2004
2005
2006
2007
% Attending
80
>30 days
>60 days
70
60
50
40
30
20
2001
2002
2003
2004
2005
2006
2007
Buy the Continuum of Care:
Not the Pieces
The Current Continuum of Care
Continuing Care
2x per mo
.
Outpatient Care
1 – 2 x per wk
.
Purchaser
Intensive OP
.
3x per wk
Residential Care
7 – 30 days
Functional Continuum of Care
Purchaser
Continuing Care
2x per mo
Outpatient Care
1 – 2 x per wk
Intensive OP
.
3x per wk
Residential Care
7 – 30 days
.
.
Why continue the segregation?
Crossing the Quality Chasm
a new HEALTH system for the 21st century (IOM, 2001)
CONCLUSION
“It
is not possible to deliver safe
or adequate healthcare without
simultaneous consideration of
general health, mental health
and substance use issues.”
QUESTION?
Sooo….why do states license
addiction programs that do NOT:
1. Offer ALL approved types of care
(medications, therapies, etc.)?
2. Treat physical AND psychiatric
illnesses that occur in >40% of their
patients?
1
1. Require state schools to teach
substance use disorders
2. Stop buying antiquated care
3. Educate Consumers – help
them understand & buy quality
All Programs Are Not Created Equal:
Using a Comparative Consumer Guide to measure the availability
of effective treatment for teens
Kathleen Meyers, PhD & John Cacciola, PhD
Supported by NIDA P50DA027841
44
©Treatment Research Institute, 2012
Why a Consumer Guide Approach to
Measuring (and Improving) Quality?
Simple Premise – Higher quality programs have more
quality elements than lower quality programs
Builds Upon Work of Mathea Falco & Drug Strategies’
“Treating Teens – A Guide to Adolescent Drug Programs”
 First comparative study of EBPs in 144 “highly regarded”
adolescent treatment programs
 Later studies confirm programs with more “quality
elements” or “evidence based practices” have better
outcomes (Knudsen et al., Duda et al.)
3/27/2016
©Treatment Research Institute, 2013
Why a Consumer Guide Approach to
Measuring (and Improving) Quality?
Consumer Guides
 Offer comparative information on features (e.g., relevance, quality, value)
 Inform and direct an individual consumer’s purchase (short-term)
 Improve the service marketplace (long-term)
EXAMPLE #1 – Comparative Guide to Cell Phone Service
3/27/2016
©Treatment Research Institute, 2013
Actual Data - Comparative Guide to Adolescent Addiction Treatment
[-----------------------PROGRAMS-----------------------]
A
87
B
51
C
81
D
35
E
55
F
49
G
30
H
44
I
35
Assessment
2
1
2
1
1
1
1
1
1
Attention to
Mental Health
2
1
1
0
1
1
0
0
0
Comprehensive Integrated
Treatment
2
0
1
0
0
1
0
0
0
Family
Involvement
1
0
1
0
0
0
0
0
0
Developmentally Informed
Programming
2
1
2
0
1
1
1
1
1
Engage and
Retain
1
1
1
0
1
1
0
0
0
Continuing
Care
1
1
1
1
0
0
0
1
0
Culturally
Informed
Programming
2
0
1
0
0
0
0
0
0
Staff
Qualifications
2
1
2
1
1
1
1
1
1
Program
Evaluation
0
0
0
0
0
0
0
0
0
Program:
CORE SERVICES
ENHANCEMENTS
ADMIN.
[------------------QUALITY DIMENSIONS-----------------]
Component Score Total:
Not Present /
Inadequate
Present /
Adequate
Present /
Good
1
Treatment of Addicted
Physicians
Physician Health Plans
• 49
PHPs
• All authorized by state licensing boards
• Most treat many types of health professionals
• Do NOT provide treatment
• Assess, Intervene, Evaluate, Refer, Monitor,
Report and Advocate
• All under authority of Board
McLellan, DuPont, Skipper 2008, BMJ
Evaluation and Contracting
• Phase
1 - Evaluation (1 month)
• Evaluate/diagnose referred physician
• Explain PHP and Contract
• Result
is signed contract
3 – 5 years in duration
•
• Protection from immediate adverse actions
• Monitoring with report to Board – 4 yrs
Treatment and Monitoring
• Phase 2 – ~1 yr
• Selected residential treatment 30 – 90 days
• Referral to IOP or OP ~ 6 months
• Return to practice ~ month 3
• Aftercare program ~ 3-6 months
•Phase 3 – 4 yrs
• AA attendance - Caduceus Society meetings
• Family Therapy
•Urine Drug Screenings - throughout
• Weekly - monthly (random during weekdays)
• Worksite visits
Results Through Five Years
No Positive Urine Over
5 Years
78%
Results Through Five Years
Second Positive Urine
After One Slip
26%