Transcript the big initiative, national sbirt attc, norc, naadac and national council

HOW TO PITCH SBIRT
TO PAYORS
PRESENTED BY:
THE BIG INITIATIVE, NATIONAL SBIRT
ATTC, NORC, and NAADAC
May 8, 2014
HOW TO PITCH SBIRT
TO PAYORS
PRESENTED BY:
THE BIG INITIATIVE, NATIONAL SBIRT
ATTC, NORC, and NAADAC
May 8, 2014
Webinar Facilitator and Presenter
Eric Goplerud
Senior Vice President
Director, Substance Abuse,
Mental Health and Criminal
Justice Studies
[email protected]
301-634-9525
Produced in Partnership…
2014 SBIRT Webinar Series


Archived - ACA and Addiction Treatment:
Implications, Policy and Practice Issues
Archived - Overview of SBIRT: A Nursing Response
to the Full Spectrum of Substance Use

Archived - SBIRT in the Criminal Justice System

Archived - Reducing Opioid Risk with SBIRT

Today – How to Pitch SBIRT to Payors



5/14/14 - Treatment of Tobacco Dependence in the
Healthcare Setting: Current Best Practices
6/11/14 - Applying SBIRT to Depression,
Prescription Medication Abuse, Tobacco Use, Trauma
& Other Concerns
7/9/14 - Training Integrated Behavioral Health in
Social Work

8/6/14 - Why Integrative Care?

hospitalsbirt.webs.com/webinars.htm
Access Materials

PowerPoint Slides
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CE Quiz

Recording
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Technical Facilitator
Misti Storie, MS, NCC
Director of Training &
Professional Development
NAADAC, the Association
for Addiction Professionals
[email protected]
HOW TO PITCH SBIRT
TO PAYORS
Alcohol as a cause or contributor to more than 70
diseases and injuries
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10
Top 10 Leading Causes of Death in the United States for 2005 (CDC)
Estimated Percentage of Adolescents and
Adults with a Substance Use Disorder
(primarily alcohol use disorders)
8%
Recent estimates
suggest that almost
8% of the US adults
has a diagnosable
substance use disorder
(NSDUH, 2011)
92%
12
How Many Get Identified?
<0.8% of
commercial
health plan
members,
1.2% Medicaid
plan members
are diagnosed
(NCQA, 2010)
13
Substance use screening and treatment in health
care: Adding burdens or solving problems
: Guwande’s Handwashing and Anaesthetics 14
Where are the patients?
Settings where Unhealthy or Dependent Use is common
50%
Ambulatory Medical
40%
Inpatient Medical
30%
Emergency Dept
20%
Outpatient Mental
Health
Inpatient Psychiatry
10%
Trauma Center
0%
Hotspot 1: Hospitals
16
Screening and Treating Acutely Ill and Injured
Patients with Comorbid Substance Use
Cochrane Collaboration review (McQueen et al, 2011)
14 RCTs, adults and adolescents
Outcomes favor BI over non-treatment controls
• Significant drop in 6 month alcohol consumption
• Significant drop in alcohol
consumption at 9 months
• Self Report at 1 year favor BI
• Significantly fewer deaths at
6 months and 1 year
17
Trauma Centers: 60% injured
have substance use disorders
Alcohol Disease Management Utilization and Costs to a
Health Insurance Plan
• Rehabilitation facilities days decreased
67%
• BH inpatient days decreased
68%
• Medical inpatient days decreased
4%
• ER visits decreased
24%
• Partial Hospital and IOP visits decreased
69%
• Psychiatrist visits increased
44%
• Therapist visits increased
35%
• AUDIT score decrease
80%
Net total medical cost savings (ROI 2:1)
34%
(N = 358, 12 month continuous enrollment prior and post enrollment)
18
Trauma Recidivism - Statewide
intervention
control
0.05
injury
recurrence
0.025
0
0
250
500
750
days follow-up
1000
Changes in Alcohol Intake
25
intervention
control
15
5
2.3
0
-5
-14.1
(p = 0.01)
-15
-25
-17.9
6 month follow-up
-21.6
12 month follow-up
Net cost savings -- $89/patient screened, or
$330/patient offered a brief intervention
Savings of $3.81/$1 spent
Potential savings if universal trauma center SBI
-- $1.82 billion annually (2000 $)
9 NNT to reduce 1 DUI arrest
~2000 DUI incidents/arrestee
Screening and Brief Interventions in Hospital
Emergency Departments
Systematic review of ED SBI
12 RCTs with pre- and post-BI results
11 or 12 observed significant effects on
alcohol intake, risky drinking practices,
alcohol related negative
consequences,
injury frequency
Nilsen et al, J Sub Ab Treat. 2008
Consequences that matter to hospitals
Unstable discharges, rehospitalization risk
Crude Rates and Risks of Recurrent Acute Care Hospital Utilization Within 30 Days After Index
Hospitalization
No SUDs (n = 615)
SUDs(n = 123) P
Rates of reutilization
Acute care reutilizations*: visits/patient/30 days
ED visits: no. visits/patient/30 days
Rehospitalization: visits/patient/30 days
0.32
0.16
0.16
0.63
0.37
0.26
<0.01
0.02
0.09
Risks of reutilization
Subjects with any acute care reutilization* in 30 days
Subjects with any ED visit in 30 days
Subjects with any rehospitalization in 30 days
38%
23%
23%
52%
34%
33%
<0.01
<0.01
0.02
Forsythe S, Chetty VK, Mitchell S, Jack BW. Acute care hospital utilization among medical inpatients discharged with a
substance use disorder diagnosis. J Addict Med 2012;6:50-56. Rubinsky AD, Sun H, Blough D et al. AUDIT-C alcohol screening
results and postoperative inpatient health care use. J Am Coll Surg 2012;213:296-305.
24
Hospital Accreditation and Performance Metrics
American College of Surgeons-Committee on Trauma
Accreditation Requirements
Joint Commission SBIRT Metrics
CMS Inpatient Psych
Incentive 2014 SUB-1
25
Practical Examples of Hospital SBIRT
• Falmouth Hospital (MA)
• Denver General Hospital (CO)
• Gunderson Lutheran Hospital (WI)
• Oregon Health Sciences University (OR)
• Christiana Hospital (DE)
• Salina Regional Hospital (KS)
• Temple University Hospital (PA)
26
Collaborations between Substance Use Programs
and Hospitals: Gosnold-Falmouth Hospital
100 Bed Med-Surg Hospital; 50 Bed Addiction
Treatment Center
Courteous but Distant Neighbors since 1982
Mutually Necessary but not Collaborative
Gosnold “a place to send ‘those’ people”
SO WHAT CHANGED???
ICU Transfers -- Pre & Post Project
PRE
POST
Went to ICU
10%
Did not go to
ICU
Went to ICU
Did not go to ICU
50%
90%
Cost per day
Med-Surg Floor vs. ICU
30%-40% LOWER IN MED-SURG
Average Length of Stay
Before Collaboration
14.6 Days
After Collaboration
6.2 Days
0
2
4
6
8
10
12
14
16
Project Engage at Christiana (DE) Hospital
•Targeting hospitalized substance users at
withdrawal risk, significant comorbid
addiction
•Bedside Peer-to-Peer intervention using
Motivational Interviewing
•Addictions Community Social Worker to
assist in removing barriers to transition to
care and help with integration into the
hospital milieu
Preliminary Claims Analysis
Claims from June 1, 2009 - November 30, 2009
3 months before and after claims review, n = 18
Metric
Pre
Post
Finding
Medical inpatient
admits
12
8
33% decrease
$35,938
ER visits
54
33
38% decrease
$4,248
BH/SA inpatient admits
7
10
43% increase
($1,579)
BH/SA outpatient visits
12
16
33% increase
($847)
PCP office visits
27
51
88% increase
($1,281)
Total Savings =
$36,479
Modified from Wright, Delaware Physicians Care Inc, 2010
Claims From Next 2 Cohorts
Claims from January 1, 2010 - December 30, 2010
6 months before and after claims review, n = 25
Metric
Pre
Post
Finding
Medical inpatient admits
17
7
58% decrease : $68,422 saved
ER visits
133
116
12.7% decrease : $3,308 saved
Total Savings = $71,730
Claims from January 1, 2011 - December 30, 2011
6 months before and after claims review, n = 30
Metric
Pre
Post
Finding
Medical inpatient admits
42
22
48% decrease : $184,236
saved
ER visits
153
151
1% decrease : $8,690 saved
Total Savings = $192,926
Modified from Wright, Delaware Physicians Care Inc, 2010
Salina Regional Health
Center
• 199 Bed Acute Care Regional
Health Center-Level III Trauma
Center
• 27,000 ED presentations per year
• Alcohol/Drug DRG was 2nd most
frequent re-admission
• Services provided
 24-7 coverage of ED
 Full time SUD staff on medical
and surgical floors
 Warm hand off provided to all
SUD/MH services
 Universal Screening and SBI
beginning in 2013
Outcomes
• Re-admission DRG moved
from 2nd to 13th
• 70% of alcohol/drug
withdrawal LOS were 3 days
or less
• 83% of SUD patients triaged
in ED were not admitted
• 58% of patients recommended
for further intervention
attended first two
appointments (warm hand off)
• Adverse patient and staff
incidents decreased by 60%.
• CKF detox admissions
increased 450% in first year
• 300% increase in commercial
insurance reimbursement
Hotspot 2:
Prenatal Screening and Case Management
34
Kaiser-Permanente Northern California’s Early Start:
A transformational program that is cost beneficial
• Universal Screening of ALL
pregnant women
• Screening questionnaire
• Urine toxicology (with consent)
• Place a licensed mental health
provider in the department of
OB/GYN
• Link the Early Start appointments
with routine prenatal care
appointments
• Educate all women and providers
Rate of Preterm Delivery (<37 Weeks)
17.4%
20.0%
15.0%
9.7%
10.0%
8.1%
6.8%
5.0%
0.0%
SAF
SA
S
Controls
Note: The rate of Preterm Delivery is 2.1 times higher
in S group than SAF (Early Start patients)
RATE OF NEONATAL ASSISTED VENTILATION
8.0%
6.9%
6.0%
4.2%
4.0%
3.2%
2.2%
2.0%
0.0%
SAF
SA
S
Controls
The rate of the babies needing a ventilator is 2.2 times higher in
the S group that the SAF and 3.1 times higher than the controls.
RATE OF INTRAUTERINE FETAL DEMISE (stillborn)
Stillborns (IUFDs) were 14.2 times more likely in the S group
than the SAF or C groups
Maternal and Infant Mean Costs Comparison
Positive
Screen, No SA
Treatment
$30,000
$25,000
$20,000
$15,000
$10,000
$5,000
$0
SAF
Maternal Total Costs
SA
Infant Total Costs
S
Controls
Maternal and Infant Costs Combined
Hotspot 3:
Youth and Young Adult High Risk Users
40
Teen and Young Adult School Health and
Ambulatory Health SUD Treatment
• Data were pooled from 16,915 adolescents from 148 local
CSAT-funded programs and followed quarterly for 6 to 12
months
• In 2009 dollars, adolescents averaged $3,908 in costs to
taxpayers in the 90 days before intake ($15,633 in the year
before intake).
• This would be $3.9 Million per 1,000 adolescents served.
• Within 12 months, the cost of treatment was offset by reductions
in other costs producing a net benefit to taxpayers of $4,592 per
adolescent.
Hotspot 4:
Ambulatory Primary Care SBIRT
42
Screening and Brief Substance Use Treatment Reduces
Healthcare Costs
Study
Cost Savings
Reference
Randomized trial of
primary care brief
treatment in the UK
Reductions in one-year healthcare
costs
UKATT, 2005
Project TREAT randomized
clinical trial: Screening,
brief counseling in 64
primary care clinics
Reductions in future healthcare costs
Randomized control trial of
SBI in a Level I trauma
center
Reductions in medical costs
Propensity matched
Medicaid disabled adults in
Washington State
Emergency Departments,
Reductions in Medicaid costs
$336 per member per month post SBI
for all patients
$542/member/month if no prior SA tx
$2.30 cost savings for each $1.00 spent in
intervention
Fleming et al,
2003)
$4.30 cost savings for each $1.00 spent in
intervention (48-month follow-up)
Gentilello et al,
2005
$3.81 cost savings for each $1.00 spent in
intervention.
Estee et al,
2010
Impact of SBI on Utilization in an
Employment-Based Health Plan
• BH inpatient days decreased
63%
• Medical inpatient days decreased
51%
• ER visits decreased
20%
• Partial Hospital and IOP visits increased
81%
• Psychiatrist visits increased
31%
• Therapist visits increased
22%
• Net total medical cost savings
15%
(N = 247, 12 month continuous enrollment prior and post SBI)
Hotspot 5: Treatment of SUDs with
Medications
45
Admissions in 6 months post index date
900
Admissions/1000 patients
800
700
600
500
400
300
200
100
0
Depot NTX
Oral NTX
Bupe
Meth
Drug-free
Detox/Rehab
69
84
79
101
770
Inpatient -Opiate
93
145
249
198
677
Inpatient -Other
234
387
397
561
731
Baser O, Chalk M, Fielin DA, Gastfriend DR. Cost and utilization outcomes of opioid-dependence treatments.
Am J Managed Care, 2011:17(6);S235-248.
Inpatient Costs/Opiate-Dependent Patient in 6
months post index date
9000
Cost/Patient in 6 months $
8000
7000
6000
5000
4000
3000
2000
1000
0
Depot NTX
Oral NTX
Bupe
Meth
Drug-free
Detox/Rehab
216
193
219
264
2082
Inpatient -Opiate
213
137
440
457
1823
Inpatient -Other
2003
3428
2290
7976
4184
Baser O, Chalk M, Fielin DA, Gastfriend DR. Cost and utilization outcomes of opioid-dependence treatments.
Am J Managed Care, 2011:17(6);S235-248.
Total Cost/Opiate Dependent Patient in 6 months post
18000
16000
Cost per patient $
14000
12000
10000
8000
6000
4000
2000
0
Depot NTX
Oral NTX
Bupe
Meth
Drug-free
8582
8903
10049
16752
14353
Baser O, Chalk M, Fielin DA, Gastfriend DR. Cost and utilization outcomes of opioid-dependence treatments.
Am J Managed Care, 2011:17(6);S235-248.
Comparison of Massachusetts Medicaid
Treatment Alternatives: 2003-2007
Buprenorphine Methadone Drug Free
No Tx
Medicaid expenditures/
person/month in 6
months post-index date
(average $1,220/month)
$0.00
$28.70
$50**
$148.5***
Relapse Odds Ratio in 6
months post-index date
1.0
0.72***
1.25***
2.97***
Deaths Odds Ratio in 6
months post-index date
1.0
0.91
1.75***
2.25***
Clark RE, Samnaliev M, Baxter JD, Leung GY. The evidence doesn’t justify steps by state Medicaid programs to restrict
opioid addiction treatment with buprenorphine. Health Affairs. 2011:30(8);1425-1433.
6 Month Post-index Inpatient Utilization per 1,000 AlcoholDependent Patients
700
visits/1000 patient
in 6 months
600
500
400
300
200
100
0
Depot NTX
Oral NTX
Disulfiram
Acamprosate
Drug-free
Detox/Rehab
Alcohol-related Inpatient
42
76
98
120
563
82
184
268
317
660
Non-alcohol-related
Inpatient
109
205
250
343
407
Baser O, Chalk M, Fiellin DA, Gastfriend DR. Alcohol dependence treatments: comprehensive healthcare costs, utilization
outcomes, and pharmacotherapy persistence. Am J Manag Care. 2011:17(8);S222-234.
6 Month Post-index Inpatient Cost/Alcohol-Dependent Patient
8000
7000
Cost per
patient
in 6 months
6000
5000
4000
3000
2000
1000
0
Detox/Rehab
Depot NTX
Oral NTX
Disulfiram
Acamprosate
Drug-free
105
192
203
288
1350
Alcohol-related
Inpatient
474
618
874
1168
2646
Non-alcoholrelated Inpatient
730
1092
1498
3885
2751
Total Inpatient
1309
1902
2575
5341
6747
Baser O, Chalk M, Fiellin DA, Gastfriend DR. Alcohol dependence treatments: comprehensive healthcare costs, utilization
outcomes, and pharmacotherapy persistence. Am J Manag Care. 2011:17(8);S222-234.
6 Months Post-index Total Cost/Alcohol Dependent Patient
$14,000
$12,000
Cost per
patient
in 6 months
$10,000
$8,000
$6,000
$4,000
$2,000
$0
Depot NTX
Oral NTX
Disulfiram
Acamprosate
Drug-free
$6,757
$6,595
$7,107
$10,345
$11,677
Baser O, Chalk M, Fiellin DA, Gastfriend DR. Alcohol dependence treatments: comprehensive healthcare costs, utilization
outcomes, and pharmacotherapy persistence. Am J Manag Care. 2011:17(8);S222-234.
Investing in Substance Abuse Treatment Results in a
Positive Return on Investment (ROI)
• Substance abuse treatment has an ROI of between $1.28
to $7.26 per dollar invested.
• Consequently, for every treatment dollar cut in the
proposed budget, the actual costs to taxpayers will
increase between $1.28 and $7.26.
• How will this happen? Individuals needing substance
abuse treatment will not disappear but instead interface
with much more expensive systems such as emergency
rooms and prisons.
Source: Bhati et al., (2008); Ettner et al., (2006)
Discussion: Practical experiences talking
with Payers
Les Sperling
Central Kansas Foundation
Jim Winkler
Oregon Health Sciences U
Roger Kathol
Cartesian Solutions
Citations and a website
• Smyth, Hoffman, Fan, Hser, Years of potential life lost among heroin addicts 33 years after treatment. Prev. Med, 2007; 44(4)
132-140.
• Jones, Moore, Sindelar, O’Connor, Schottenfeld, Fiellin. Cost analysis of clinic and office-based treatment of opioid
dependence. Drug Alcohol Depend. 2009;99(1-3): 132-140
• Knudsen HK, Abraham AJ. Perceptions of state policy environment and adoption of medications in treatment of substance use
disorders. Psych Services. 2012:63(1);19-25.
• Baser O, Chalk M, Fielin DA, Gastfriend DR. Cost and utilization outcomes of opioid-dependence treatments. Am J Managed
Care, 2011:17(6);S235-248.
• Clark RE, Samnaliev M, Baxter JD, Leung GY. The evidence doesn’t justify steps by state Medicaid programs to restrict opioid
addiction treatment with buprenorphine. Health Affairs. 2011:30(8);1425-1433.
• Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999—2008 MMWR, November 4, 2011 /
60(43);1487-1492
• Baser O, Chalk M, Fiellin DA, Gastfriend DR. Alcohol dependence treatments: comprehensive healthcare costs, utilization
outcomes, and pharmacotherapy persistence. Am J Manag Care. 2011:17(8);S222-234.
• Bhati et al (2008) To Treat or Not To Treat: Evidence on the Prospects of Expanding Treatment to Drug-Involved Offenders.
Washington, DC: Urban Institute. Health Serve Res. 2006 February; 41(1): 192–213.
• Susan L Ettner, David Huang, Elizabeth Evans, Danielle Rose Ash, Mary Hardy, Mickel Jourabchi, and Yih-Ing Hser The
economic costs of substance abuse treatment: Updated estimates and cost bands for program assessment and
reimbursement, Journal of Substance Abuse Treatment(2008)
• Information about the Hospital SBIRT Initiative
is posted at http://hospitalsbirt.webs.com/.
Join in monthly conference calls on integrating
SBIRT into routine hospital practice:
http://hospitalsbirt.webs.com/progress.htm
Eric Goplerud Senior Vice President
Substance Abuse, Mental Health and Criminal Justice Studies
NORC at the University of Chicago
4350 East West Highway 8th Floor, Bethesda, MD 20814
[email protected] | office 301-634-9525 | mobile 301-852-8427
Thank You!
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Follow-up Email
hospitalsbirt.webs.com/pitchingsbirt.htm
2014 SBIRT Webinar Series


Archived - ACA and Addiction Treatment:
Implications, Policy and Practice Issues
Archived - Overview of SBIRT: A Nursing Response
to the Full Spectrum of Substance Use

Archived - SBIRT in the Criminal Justice System

Archived - Reducing Opioid Risk with SBIRT

Today – How to Pitch SBIRT to Payors



5/14/14 - Treatment of Tobacco Dependence in the
Healthcare Setting: Current Best Practices
6/11/14 - Applying SBIRT to Depression,
Prescription Medication Abuse, Tobacco Use, Trauma
& Other Concerns
7/9/14 - Training Integrated Behavioral Health in
Social Work

8/6/14 - Why Integrative Care?

hospitalsbirt.webs.com/webinars.htm
Thank You for Attending!
www.norc.org
hospitalsbirt.webs.com
www.naadac.org
www.ireta.org/ATTC