Transcript Medications and Substance Abuse Treatment

Greg Warren, MA, MBA
President/CEO
Baltimore Substance Abuse System, Inc.
Workshop Outline
 Introductions and objectives
 Baltimore Buprenorphine Initiative
 Review basic principles
 The Challenge of Change
 Practical issues
 Wrap up
Workshop Objectives
 Describe principles for thinking about incorporation of



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medications
Provide framework for change as related to
incorporation of medications
Share practical tools that can apply to incorporation of
medications
Describe real-life successful models for integrating
medications
Interactive sharing of ideas, challenges and solutions to
incorporating medications into substance abuse
treatment
Baltimore Achievements
 Innovative Practice by Agency recognition by federal
Agency for Healthcare Research and Quality 2008.
 National Association of County and City Health
Officials (NACCHO) Model Practice Award 2009.
 Network for the Improvement of Addiction Treatment
(NIATx) iAward for Innovation in Behavioral
Healthcare Services 2010.
5
 BSAS is a quasi-public agency incorporated in 1990. It was
established by the Baltimore City Health Department to manage the
Center for Substance Abuse Treatment’s Targeted Cities Project.
 In 1995, BSAS became responsible for the management of the
publicly-funded substance abuse treatment and prevention service
system and is now an independent 501 3-C organization.
 The Chairman of the 27 member Board is the City’s Health
Commissioner.
BSAS funds about 60 treatment,
prevention, and intervention programs.
• Prevention
•29 Residential
•35 Outpatient
•15 Medication Assisted
22 Ancillary Services
Need analysis based on:
The number of HIV cases
Number of drug arrests
Number of treatment
admissions
Darker areas have
high need
BSAS-Funded Programs
,
57%
arrested
in the
past 2
years
60%
male
77%
use
tobacco
70%
between 3050 years of
age
71% Unemployed
50% < $10,000 per yr.
Characteristics of Clients in
13%
Homeless
Baltimore City Programs
FY 2009
45%
less than a 12th
grade education
83% Black,
16% White
Less than 1% Hispanic
Treatment
Episodes
n = 21,000
.
Baltimore City
 Heroin addiction remains high
 Treatment capacity falls short of demand despite expansion in
treatment system
 Estimated 30,000 individuals with opioid dependence
 ~4,000 methadone treatment slots
 Over 8,000 treatment admissions for opioids in FY 2009
 Consequences from heroin addiction are severe
 Crime
 Family and community disruption
 Medical complications

1 in 48 Baltimore City residents are living with HIV and/or
AIDS
http://www.dhmh.state.md.us/AIDS/Data&Statistics/MarylandHIVEpiProfile122008.pdf
Principle #1: Change Happens
 Accept change as a reality and an
opportunity
“Nothing is permanent, but change”
Heraclitus 535-475 BCE
“It is not the strongest of the species that survive, nor the
most intelligent, but the one most responsive to change”
Charles Darwin 1809-1882
Grant to PAC Transition
 As of Jan 1, 2010, the Maryland Primary Adult Care
(PAC) Medicaid waiver program covers outpatient
addiction treatment
 Assessment
 IOP/OP
 OMT
 Significant transition from grant to Medicaid fee-for-
service funding mechanisms
Healthcare Reform
 H.R. 3590 Patient Protection and Affordable Care Act and
Reconciliation Bill H.R. 4872
 Implications for Substance Abuse Treatment
 Expands Medicaid eligibility to 133% of FPL
 SUD/MH services included in the basic benefits package
required in exchange and for Medicaid recipients
 All plans in exchange must adhere to Wellstone/Domenici
parity act provisions
Principle #2: Have a Method
 Use a systematic method for making changes to your program
 Individualize it
 Be flexible
 Acknowledge non-linear process of program change
 Examples
 NIATx model (www.niatx.net)

Transtheoretical models
(http://www.attcnetwork.org/explore/priorityareas/techtrans/tools/chan
gebook.asp)
TAP 31: Implementing Change in Substance Abuse Treatment Programs
www.samhsa.gov

Adaptive models
(http://www.drugabuse.gov/about/organization/despr/hsr/datre/DeSmetAdaptiveModels.html)
Common Change Principles
 Know, and involve, your population
 Including community, patients, and staff
 Culture, attitudes, and knowledge level
 Pick, and equip, at least one leverage and additionally
a change agent or champion in your program
 Given them appropriate authority and time
 Plan, do, reassess, revise – and repeat
Principle #3: Data is Your Friend
 Make it simple and relevant
 Know it
 Use it
 Update it
“Knowledge is power”
Sir Francis Bacon 1561-1626
Principle #4: Why and Why Not?
 Keep asking the Why? questions
 Improves the process and the outcome
 Encourages critical thinking by everyone
 Helps articulate program messages
“Millions saw the apple fall, but Newton was the
one who asked why”
Bernard M. Baruch 1870-1965
 Ask the Why Not? questions
 Clarifies program vision
 Prevents stagnation
“I dream of things that never were, and ask why not?”
Robert F. Kennedy 1925-1968
Case Scenario
 You are an administrator of an urban facility that has been
providing drug-free, outpatient substance abuse
treatment for 30 years. Sixty percent of the funding for
your organization comes from the state block grant. The
Governor of your state has recently announced that he
wants to double the number of individuals receiving
buprenorphine by the year 2012. Your state agency
enthusiastically supports this deliverable.
 How will your agency respond?
Questions for Consideration
 What does my program gain by incorporating
medications?
 What do individuals accessing services in my
program gain?
 What does my program risk by incorporating
medications?
 What are the costs and how does my program
sustain them?
 Others…………….
Questions for Case Scenario
 How will patients react to this?
 How will your staff react to this?
 What other issues do you need to consider?
 What are your next steps going to be?
Potential Challenges to Integrating Medications
 Program culture and philosophy
 Counselor attitudes and knowledge
 Patient , family, and community attitudes about
medications
Problem Solving
 Form change team with representation from key
stakeholder groups
 Gather and use data to identify critical measures to impact
 Patient surveys
 Staff surveys
 Relevant local and state data
 Outcomes for treatment as usual
 Ensure change team and others have sufficient
information on medications to make informed decisions
Prescription Opioids
 Growing problem among adolescents and young adults*
 Allegany County -- 20% of 12th graders reported ever
having tried prescription opioids for non-medical purpose
 Talbot County – 12% of 12th graders reported currently
using prescription opioids for non-medical purpose
 Effectively treated with buprenorphine**
*Maryland Adolescent Survey:
2007http://www.marylandpublicschools.org/NR/rdonlyres/852505C8-7FDB-4E4EB34E-448A5E2BE8BC/18944/MAS2007FinalReport_revised111808.pdf
**Woody G. et al. JAMA 2008;300(17):2003-2011
Outcomes for Treatment As Usual
 Of 3753 admissions to Level I treatment in FY08, 51%
retained for 90 days or more
 Of 11,013 treatment discharges in FY08, only Prince
George’s county had smaller change in substance use
 Relapse rates high
 In methadone studies, 50-80% relapse within one year after
detoxification
 91% of patients receiving buprenorphine for 4 months had
relapsed to prescription opioids within 2 months of taper*
*Weiss R. et al. NIDA CTN Prescription Opioid Treatment Study.
http://www.medscape.com/viewarticle/722342
Treatment Programs
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911 Broadway Center
A Step Forward
Baltimore City Needle Exchange
Baltimore Community Resource Center
Bon Secours – ADAPT Cares
Bon Secours – New Hope
Bon Secours - Next Passage
Daybreak/MBA
Dee’s Place
Family Health Centers of Baltimore
Harbel Prevention and Recovery
JH CAP
JH BPRU
Total Sites: 28
•
•
•
•
•
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•
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•
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IBR Reach
Man Alive
Partners in Recovery
Paul’s Place
Powell Recovery
Recovery in Community
Sinai SHARP – Bup
Sinai SHARP - OMT
Total Health Care
Tuerk House – ICF & HH
Tuerk House – OP
Turning Point
UMD - ADAP
UMD - DTC
Suboxone:
Methadone:
9
11
Drug Free: 5
Other:
3
27
Financial Considerations
for
Medication Assisted Treatment
Programs
BHCA and the PAC
expansion
Cost per client to have a BHCA advocate: $142.47
Outpatient Cost Savings (based on $5,500 cost per slot):
Cost of OP treatment with avg. LOS at 130 days:
Cost of OP treatment if client is insured within 60 days:
Cost of BHCA advocate + 60 days of OP Treatment:
Savings per patient:
Total savings in OP treatment, based on total of 50 OP slots,
turnover 2.8x annually:*
Estimated savings for 800 clients (2 advocates):
$1,964.00
$916.67
$1,059.14
$904.86
$126,680.40
$723,888
BHCA and the PAC
expansion
Cost per client to have a BHCA advocate: $142.47
Methadone Cost Savings:
Cost per patient in OMT Slot (avg) of 1 client per slot, annually: $4,000.00
Cost per patient if insured within 60 days:
$657.53
Cost of BHCA advocate + client who obtains
insurance within 60 days:
$800.00
Savings per patient:
$3,200.00
Total annual savings for 100 OMT slots:
$320,000.00
Estimated savings for 400 clients (1 advocate):
$1.28 million
What Does Your Program Look Like?
Other Issues
 Program policies on medication management
 Dispensing vs. only prescribing
 Clinical policies on medication recalls, pill counts, etc
 Laboratory testing
 Resources needed
 Additional staff
 Medication costs
 Supplies and equipment
 State and federal regulations and licensing requirements
Factors to Consider In Medication
Management Policies
 Risk of medication diversion
 Medication safety and side effect profile
 Staff input
 Existing policies
 Urinalysis testing
 Approach to positive urines
 Approach to late or missed payments for services
 Program behavior policies
Dispensing vs. Only Prescribing
 Pros of Dispensing
 Better control over patient adherence
 More control over medication
 Additional, potentially reimbursable, contacts with patients
 Cons of Dispensing
 Need more equipment
 More paperwork for labeling and tracking medication
 Cost of purchasing medications
Medication Costs
 Buprenorphine (Suboxone®™)
 8mg/2mg tablet -- $6.18 per pill ($371 per month for 16 mg daily)
 2mg/0.5mg tablet -- $3.35 per pill
 Naltrexone
 Oral (Revia®™) -- $170 per month for 50 mg per day
 Injectable (Vivitrol®)* -- $700 for once monthly injection
 Acamprosate (Campral®™) -- $360 per month for 666 mg thrice daily
 Topiramate (Topamax®™) -- $240 per month for 200 mg per day
 Buproprion SR (Zyban®™) – $300 per month for 150 mg twice daily
 Varenicline (Chantix®™) -- $110 per month for up to 1 mg twice daily
*MD Medicaid does not cover Vivitrol®
Resources Needed
 Physician to prescribe medication
 Physician coverage for vacations and emergencies
 Malpractice insurance
 Nurse to dispense and/or administer medication if
physician does not
 Supplies and equipment
 Appropriate storage of medications, if dispensing
 Bottles, caps, labels, label printing software, if dispensing
 POC buprenorphine urinalysis testing kits
Regulation and Licensure Requirements
 DATA 2000 allows qualified, office-based physicians to
prescribe approved medications for treatment of opioid
dependence
 Sublingual buprenorphine currently is only medication approved
for this purpose
 Nurse practitioners are currently not allowed to prescribe
buprenorphine
 Practices subject to regular DEA visits
 To prescribe SUD medications physicians need
 Active state medical license
 Current state controlled substances license
 Current Federal DEA license
Clinical Program Goals and
Medications
 Increase retention
 Improve counseling attendance
 Increase program completion rates
 Provide treatment options for patients
 Improve abstinence rates
 Others…………………………………………..
Buy-In and Mix of Patients
 Listen to staff concerns
 Start small
 Have clear program and clinical policies for selection and
management of patients on buprenorphine
 Model behavior
 Measure impact and celebrate successes
 Consult with peers
Resources
 Grant funds
 State
 Local government
 Foundations
 SAMHSA/CSAT
 Third party payers
 Bill for all reimbursable contacts
 Ensure patients enrolled in all entitlements they are eligible for
 Look at payer mix
 Partner with a community health center or local physician
practice
 Partner with another treatment program
Baltimore Buprenorphine Initiative
Business Case for BBI in 2006
 Baltimore needs more effective treatment for
opioid dependence
 Review of literature and studies by UMBC
 Medical costs are increased for patients with drug abuse
 Opioid addicts on methadone consume far fewer
Medicaid resources than addicts who go untreated
 Buprenorphine is economically viable alternative in city
with limited methadone treatment capacity
42
BBI Goals
 Expand treatment for heroin addiction
 Access funding from larger medical care system
 Increase retention in treatment
 Link patients with ongoing medical care
Link from Treatment Program
to Primary Care Is Key
 Initially 6 treatment providers
 In FY 2009 moved to 9 providers
 58 continuing care physicians
Transfer process
 Criteria for transfer
 Patient compliant with medication and counseling
 Patient opioid-free; reduced other drug use
 Patient responsible with take home medication and
prescriptions
 Patient has insurance
45
BBI Results
3,209 patients
treated
2,094 (65%) obtained or had
medical assistance
1,645 (79%) PAC
449 (21%)
HealthChoice
796 (38%)
transferred to
continuing care
•Currently, 357
patients receiving
full BBI services in
treatment program
•Approximately 6%
drop-out from
continuing care
Number of Clients Still in Counseling after
Transfer
Retention in Counseling After Transfer to Continuing Care
30 Days Retained in Counseling Post Transfer
% of Patients Retained in
Counseling
100%
100%
89%
83%
76%
80%
60%
40%
20%
0%
91-120 Days
121-150 Days
151-180 Days
> 180 Days
Number of Days in Treatment Upon Transfer
47
Achievements
 4 times as many buprenorphine slots in Baltimore
from 112 slots in 2008 to 506 slots in 2009
 Four-fold increase in physicians trained to provide
buprenorphine from 50 to 200
 Patients receive buprenorphine within 48 hours of
first treatment appointment
48
Sustaining Efforts
 Medicaid Primary Adult Care expansion
 Buprenorphine Medicaid Workgroup
 Increased Medicaid substance abuse service
reimbursement rates
 BBI Clinical Guidelines – Revise for PAC billing
 Recruiting for additional continuing care physicians 49
6 months later…………
 The demand for buprenorphine has been overwhelming
 Patients are not getting PAC as quickly as you expected
 Clinical supervisors are wondering what to do with patients
who continue to use cocaine or benzos
 BUT……..
 You just got your first check from Maryland Physician’s Care
for $20,000 and even got paid by Aetna for one patient
 Your treatment incompletion rate has gone from 50% to 39%
 You are getting many more self-referrals
 Staff morale has improved
Resources
 Healthcare Reform
 http://www.healthreform.gov/
 http://www.healthreform.maryland.gov/
 http://www.lac.org/index.php/lac/342
 http://www.saasnet.org/drupal-6.6/taxonomy/term/18
 ONDCP Drug Control Strategy Information:
http://www.whitehousedrugpolicy.gov/strategy/
Resources
 Buprenorphine Information
 http://buprenorphine.samhsa.gov/bwns/index.html
 http://buprenorphine.samhsa.gov/bwns/tip43_curriculum.pdf
 http://buprenorphine.samhsa.gov/bwns/presentations.html
 Dispensing Regulations
 COMAR Title 10, Subtitle 19 (10.19.03)
 COMAR Title 10, Subtitle 13 (10.13.01)
 Federal DEA Controlled Substances Act Title 21, Chapter 13,
Subchapter 1, Section C
(http://www.justice.gov/dea/pubs/csa.html)
Primary Adult Care
A Limited Medical Assistance benefit
Maryland Medicaid
 Provides benefits for an average more than 850,000
people – one in 7 Marylanders
 Costs nearly $7 billion in state and federal funds
 PAC covers approximately 42,000 people (or 4.8% of
the total Medicaid population)
54
Program Enhancements
 Effective January 1, 2010 substance rates were increased
for community providers
 HealthChoice and fee-for-service rates were
increased
 Substance abuse was added to PAC
55
What is PAC?
 The Primary Adult Care (PAC) Program began in July 2006
 Federal eligibility requires that adults have dependent children to
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

be Medicaid eligible. PAC was developed to provide benefits for
adults without dependent children.
Combined resources from state programs in public health and
Medicaid
A Medicaid program providing a limited benefit package for adults,
including primary care, pharmacy, and outpatient health benefits to
those over age 19
Eligible individuals must have incomes below 116% of the Federal
Poverty Level (FPL)
Administered through 5 participating Managed Care Organizations
(MCOs)
56
Who is eligible for PAC?
 Adults without dependent children 19 years or older who are:
Maryland residents,
 Not on Medicare, and
 U.S. Citizens and legal residents (≥ five years residency)
 Enrollees do not need to have a medical disability to qualify
 Original income and asset requirements:



For an individual: income less than 116% FPL and assets less than $4,000
For households greater than one: incomes less than 100% FPL and
assets less than $6,000
 April 1, 2009 - regulations changed to exclude asset requirements
and income threshold is 116% FPL for all family sizes.

This change mirrored standards for families with children. Most
persons with children were also given the opportunity to receive full
benefit package.
57
PAC Eligibility Income Limits
Person(s)
1
2
3
4
5
6
7
8
58
Monthly Income
$1,046
$1,408
$1,769
$2,131
$2,493
$2,854
$3,216
$3,577
Which health services are covered?
 PAC Covers the following health services:
 Free primary health care
 Prescriptions drugs
 Co-payment of up to $2.50 for generic drugs and $7.50 for brand name
drugs (pharmacist can deny drug if copayment is not paid)
 Free in-office mental health services through a counselor or
psychiatrist
 Limited lab and diagnostic services
 Community-based substance abuse services (January 2010)
 Facility fees for emergency room visits (January 2010)
 Some benefits are carved out and covered fee for service, including
Specialty Mental Health System services and drugs, and HIV/AIDS
drugs
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How are services provided?
 Managed Care Organizations receive a monthly capitation
payment for each enrollee
 All MCOs must participate in HealthChoice to serve PAC
enrollees
 5 MCOs currently provide services to PAC enrollees
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Maryland Physicians Care
Priority Partners
United
Jai (Baltimore City & County only)
Amerigroup
 To search participating providers by MCO online:
https://encrypt.emdhealthchoice.org/searchable/main.action
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PAC Expansion of Services
 PAC was scheduled to expand services to
enrollees in July 2009, but this has been
delayed due to budget limitations
 In January 2010, there were program changes,
including:
 Substance rates were increased for community
providers
 Substance abuse services are covered
 Some emergency room services are covered
61
Codes and Rates for Self-Referred
Community-Based Substance Abuse Services
Service
Code
Comprehensive
Substance Abuse
Assessment (CSAA)
H0001
Alcohol and/or drug assessment
Per assessment
$142
Individual Outpatient
Therapy
H0004
Behavioral health counseling and
therapy
Per 15 minutes
$20
Group Outpatient
Therapy
H0005
Alcohol and/or drug services; group
counseling by a clinician
Per 60-90
minute session
$39
Intensive Outpatient
H0015
Alcohol and/or drug services; intensive
outpatients (treatment program that
operates at least three hours/day and
at least three days/week and is based
on an individualized treatment plan),
including assessment, counseling, crisis
intervention, and activity therapies or
education.
Per diem
(minimum two
hours of service
per session)
$125
Alcohol and/or drug services;
methadone administration and/or service
(provision of the drug by a licensed
program)
Per week
Methadone
Maintenance
H0020
HCPC Description
Unit of Service
New Rate
Maximum four
days per week
$80
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Total PAC Enrollment
July 2006 – December 2009
50,000
41,008
40,000
30,000
36,020
27,351
29,087
24,093
20,000
10,000
0
Jul-06
63
Jul-07
Jul-08
Jul-09
Dec-09
Five Counties with Highest PAC
Populations
County
Baltimore City
July 2008
Share of
PAC
Population
Dec 2009
Share of
PAC
Population
14,586
50%
19,463
47%
Baltimore County
2,814
9%
4,261
10%
Prince George's
2,030
7%
3,126
8%
Anne Arundel
1,262
4%
2,335
6%
Montgomery
1,493
5%
2,027
5%
64