Healthcare ReformThe “Affordable Care Act”

How Will It AffectSubstance Abuse Care?

Population Prevalence

Addiction ~ 25,000,000

“Harmful – 60,000,000 Use”

Little or No Use

Diabetes ~24,000,000

LITTLE

LOTS

In Treatment ~ 2,300,000

President’s 2012 Budget

Healthcare

23%

Poverty Assist.

17%

Defense

19%

Social Secur.

21%

The Presentation

1 - The Basic Elements2 – Changes Expected3 – The Implications

2010 Healthcare ReformThe “Affordable Care Act”

Transformative for MH/SA •SA care is “Essential Service” •Funds full continuum of care

• Prevent, BI, Meds, Spec Care•Focus on Primary Care

• Part of “Medical Home”• Information management

Insure ~45 million uninsured

Reduce Costs of Healthcare

Correct Insurance Problems

Improve Care Quality

~32 million newly insured

Admin Costs, Prevention, Tech.

Pre-exist cond, dropping, portability

Ev Based Pract., Technology

Expanded Insurance

Health Exchanges

“Medical Home”

Electronic Health Record

Prevention Emphasis

• Training Emphasis

–Significant grants for provider training

–On-line Medicaid billing requirement

• Federal/State funding “match”

–“Essential services” 100% federal

– Most prevention is 100% federal

The Presentation

1 - The Basic Elements2 – Changes Expected3 – The Implications

Addiction

“Substance Use Disorders”

XXXXXXXX

1

A “Bad Habit” not an Illness

Leads to a Special Approach

A Nice Simple Rehab Model

NTOMS Sample of 250 Programs

Treatment

Substance Abusing Patient

Non- Substance Abusing Patient

ASSUMPTIONS• Some fixed amount or duration of

treatment will resolve the problem

• Clinical efforts put toward correctly placing patients and getting them to complete treatment

• Evaluation of effectiveness should occur following completion

– Poor outcome means failure

Addiction Treatment

Very Rare Use

Very Frequent Use

In Specialty Treat.

~ 2,300,000

• Detoxification – 100%

– Ambulatory – 85%

• Opioid Substitution Therapy – 50%

• Urine Drug Screen – 100%– 7 per year

Note – Great variability state to state

• Virtually all these are hospital benefits

• Very few are “visit” benefits – almost all are program benefits

• Very few care options, little variety within options

• Comparatively little acknowledgement of patients’ rights, little help with access

Treatments For Other Illnesses

Why it matters

A Continuing Care Model

PrimaryContinuing Care

Primary Care

Specialty Care

In Chronic Illnesses….1 – There is no Cure - the effects of treatment do not last very long after care stops

2 – Patients who are out of contact are at elevated risk for relapse: Retention is essential

In Chronic Illnesses….3 – Early, intensive stages prepare patients for less intensive care:

– ultimately Self-Management

4 - Evaluation is a clinical duty:Good function = continue care

Poor function = change care

• 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

• Virtually all these are in primary care

• Most are “visit benefits” not packaged

• The term “dual disorder” originated here as diabetes and hypertension

• Note patients have rights and benefits designed to help them access care and to benefit from it

• 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

• Virtually all these are in primary care

• Most are “visit benefits” not packaged

• The term “dual disorder” originated here as diabetes and hypertension

• Note patients have rights and benefits designed to help them access care and to benefit from it

• 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%

• Smoking Cessation – 100%

~ 500,000 Primary Care Physicians + CNPs

1. Prevention ServicesScreening and Brief Intervention - UPHS

2. Early InterventionBrief Counseling / Treatment

3. Office-Based TreatmentMedications, Monitoring, Management

4. Referral to Specialty CareReferral Back for Continuing Care

The Presentation

1 - The Basic Elements2 – Changes Expected3 – The Implications

• New market for prevention research

– Very significant funding in ACA

– new initiatives to drive down cost and improve personal responsibility

– Challenge – What is prevention – just vaccines or community focus – wellness

• Need “intervention research” with PCPs

– Adherence assistance

– Tele-health and Tele monitoring

• New market for medications

– 500,000 PCPs – other “prescribers”

• Research on counseling in primary care

– “Behavioral Health” focus? Family focus?

• Adaptation of Health Homes to SUD

– 90% Federal funding for Health Home services

– Emphasis on care integration and transition

– Addition of case management services

• Information exchange and decision support research– New information will be in EMR

– Need standard “performance measures”

• Most “treatment” funding will come from Medicaid and private health insurance

– New populations – medical referrals

– New billing requirements – reporting requirements

– Emphasis upon Outpatient care integrated into “Medical Home”

• Emphasis on “Evidence Based” Practices

• What is a profitable outpatient model?

• Emphasis/expansion home health services – Will “specialty care” fill this role?

• Role of Block Grant could change

– Recovery-Oriented services NOT covered in healthcare

• Budget negotiations may change some of this

• State variability will continue but ultimately reduce