Advances in TreatingChronic Pain and Addiction

Presenters:• Michael Gavin, MBA, President, PRIUM

• Jennifer Saddy, Director of Workers’ Compensation, American Airlines

• David R. Gastfriend, MD, Scientific Advisor, Treatment Research Institute

Third-Party Payer Track

Moderator: Michael C. Barnes, JD, Executive Director, Center for Lawful Access and Abuse Deterrence, and Member, Rx and Heroin Summit National Advisory Board

Disclosures

• Michael Gavin, MBA; Jennifer Saddy; and Michael C. Barnes, JD, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.

• David R. Gastfriend, MD – Future royalty: American Society of Addiction Medicine

Disclosures

• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

• The following planners/managers have the following to disclose:– John J. Dreyzehner, MD, MPH, FACOEM – Ownership interest:

Starfish Health (spouse)– Robert DuPont – Employment: Bensinger, DuPont &

Associates-Prescription Drug Research Center

Learning Objectives

1. Outline mental and behavioral issues and their influence on chronic pain.

2. Identify strategies to address psychosocial pain issues when managing chronic pain and claims involving chronic pain.

3. Explain the basis and impacts of the new federal requirements for state Medicaid directors to implement the ASAM Criteria.

4. Describe a tool for implementing the new ASAM Criteria requirement.

5

THIRD-PARTY PAYER TRACK: ADVANCES IN TREATING CHRONIC PAIN AND ADDICTION

Michael Gavin, PRIUM

Disclosure Statement

Michael Gavin, President of PRIUM, wishes to disclose that PRIUM is a wholly owned subsidiary of Ameritox. Michael will present this content in a fair and balanced manner.

Learning Objectives

1. Outline mental and behavioral issues and their influence on chronic pain.

2. Identify strategies to address psychosocial pain issues when managing chronic pain and claims involving chronic pain.

3. Explain the basis and impacts of the new federal requirements for state Medicaid directors to implement the ASAM Criteria.

4. Describe a tool for implementing the new ASAM Criteria requirement.

Comorbid AMI, SUD, CNCP

“ 9 million persons in the United States report long-term medical use of opioids.”- CDC MMWR 2012

Each of the individual populations drives significant healthcare costs; the intersections of the populations represent particularly complex patients that require innovative and focused management

9

A. Disease impacts mental health• 30% of those living with a non-communicable disease report a

concurrent mental disorder.1

B. Mental Health impacts physical health• Conversely, more than two-thirds of people with a mental

disorder have been shown to have at least one other chronic NCD. 1

C. Psychosocial and Socioeconomic status modify both effects

• An individual of lesser social and economic status is more likely to suffer comorbid mental illness with a non-communicable disease or disorder. 2

1. (Druss BG, Mental disorders and medical comorbidity.)2. (Marnett K, Epidemiology of multimorbidity and

implications for health care, research, and medical education: a cross-sectional study.)

Bidirectional AssociationPhysical health and mental health are intrinsically linked. Psychological factors are reciprocally interactive in the initiation and expression of the pathology of chronic disease.

10

• Adverse Childhood Exposures• The most prevalent of the 7 measured exposures was

substance abuse in the household at (~26%)• Likelihood of childhood exposure:

• 25% chance to have been exposed to 1 category• 6% chance to have been exposed to 4 or more categories

• Likelihood of illicit drug use:• 11% with 1 exposure• 28% with 4 or more exposures

Predicting Substance AbuseThe ACE study followed Kaiser patients from 1995-97. While chronic disease and risky health behaviors are strongly predicted by ACEs, interventions focused on children are far from implementation.

11

A. Duration1

• 1-year disability risk is doubled by each of:– Receiving more than 7 day supply of opioids within the first 6 weeks post injury.– Receipt of 2 opioid prescriptions in 6 weeks post injury.– Receipt of >150mg MED in 6 weeks post injury.

B. Mortality2,3

• Nationally, persons with anxiety/depression have a 60% higher mortality and die an average of 8 years earlier than persons without these illnesses.

• Anxiety/depression attribute to 88,000 deaths each year.• Prescription painkillers killed more than 16,000 in 2013 or 44 people/day.

C. Expenditures4,5

• Employees treated for depression (most commonly occurring) incurred annual per capita health and disability costs of $5,415.

• Compared with claims not prescribed opioids, claims prescribed SA opioids are 2.8 times more expensive and claims prescribed LA opioids are 9.3 times more expensive.

1. GM Franklin et al., “early opioid prescription and subsequent disability among workers with back injuries: the Disability Risk Identification Study Cohort.” Spine 33.2 (2008)

2. Pratt, Laura A., et al., “Excess mortality due to depression and anxiety in the United States.” General Hospital Psychiatry (2015)3. CDC. National Vital Statistics System mortality data. (2015)4. Druss, BG et al., “Health and disability costs of depressive illness in a major US corporation.” Am. Journal of Psychiatry 157.8 (2000)5. White, JA., et al., “Thhe effect of opioid use on workers’ compensation claim cost in the state of Michigan. “J. of Occ and Env. Med (2012)

Impact on ClaimsComorbid AMI and CNCP are synergistically disabling and treated as a single disease state using opiates. Co-occurring AMI and CNCP cause greater disability than each condition taken separately.

Primary Care Problem?Family practice and internal medicine doctors are responsible for about 28 million opioid claims vs. a little over 3 million for pain management and interventional pain management combined.

• Stigma contributes to a host of adverse outcomes for people with SUD: – Poor mental and physical health.1,2

– Non-completion of treatment for SUD.3

– Delayed recovery and reintegration.4,5

• Stigma also presents a barrier to treatment:– Causing lowered utilization,6,7

– And differential treatment.8

Influence of Stigma

1. Stigma, discrimination and the health of illicit drug users. Ahern J., Stuber J., Galea S. Article Drug Alcohol Depend, 20072. On stigma and its consequences: evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse

Link B., Struening E. L., Rahav M., Phelan J. C., Nuttbrock L. Article J Health Soc Behav, 19973. Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: utility of a mixed methods approach

Brener L., von Hippel W., von Hippel C., Resnick I., Treloar C. Article Drug Alcohol Rev, 20104. The contextual factors that foster and hinder the process of recovery for alcohol dependent women

Brewer M. K. Article J Addict Nurs, 20065. Nowhere to go: how stigma limits the options of female drug users after release from jail

van Olphen J., Eliason M. J., Freudenberg N., Barnes M. Article Subst Abuse Treat Prev Policy, 20096. Utilization of drug treatment programs by methamphetamine users: the role of social stigma

Semple S. J., Grant I., Patterson T. L. Article Am J Addict, 20057. Equity of access to treatment, and barriers to treatment for illicit drug use in Australia

Digiusto E., Treloar C. Article Addiction, 20078. Are drug treatment services only for ‘thieving junkie scumbags’? Drug users and the management of stigmatised identities

Radcliffe P., Stevens A. Article Soc Sci Med, 2008

14Havassy BE, Alvidrez J, Mericle AA. Disparities in Use of Mental Health and Substance Abuse Services by Persons with Co-occurring Disorders.Psychiatric services (Washington, DC). 2009;60(2):217-223. doi:10.1176/appi.ps.60.2.217.

Comorbid Treatment RatesPatients with co-occurring disorders need to navigate two systems of care to obtain treatment. Those who receive treatment in one sector may not receive adequate treatment in the other sector.

Political Hope?

“…we need a revolution in this country in terms of mental health treatment.“

- Sen. Bernie SandersDemocratic Presidential Debate, 1/17/16

"We have to move away from treating the use of drugs as a crime and instead, move it to where it belongs, as a health issue.”

- Sec. Hillary Clinton Democratic Presidential Debate, 1/17/16

"You have the most conservative Republican governors and the most

liberal Democratic governors agreeing" on the urgent need to get something done.

- Gov. Pete Shumliin, VT, NY Times, 2/22/16

“The victims of addiction deserve treatment...“

- Gov. Chris ChristieABC News, 1/12/16

“It’s very debilitating when you have a loved one who’s struggling and you can’t control it. I don’t know what it’s like to

lose a daughter. But I almost did.”Gov. Jeb Bush

Huffington Post, 11/5/15

“This is a problem that, for me, I understand firsthand.”

- Sen. Ted CruzRepublican Presidential Debate, 2/6/16

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• Web: www.prium.com

• Blog: www.priumevidencebased.com

• Twitter: @PRIUM1

• LinkedIn: https://www.linkedin.com/company/prium-medical-cost-management

Connect with PRIUM

THIRD-PARTY PAYER TRACK: ADVANCES IN TREATING CHRONIC PAIN AND ADDICTION

Jennifer Saddy, American Airlines

17

Learning Objectives

1. Outline mental and behavioral issues and their influence on chronic pain.

2. Identify strategies to address psychosocial pain issues when managing chronic pain and claims involving chronic pain.

3. Explain the basis and impacts of the new federal requirements for state Medicaid directors to implement the ASAM Criteria.

4. Describe a tool for implementing the new ASAM Criteria requirement.

• Redesign of the American Airlines Workers’ Compensation (WC) program in 2014 after merger with US Airways– Redefined the roles of the WC team– Program covers over 120,000 employees and 3 wholly

owned subsidiaries.– At least 15 union groups.

• New program focused on 2 claim tracks:– New workers’ compensation claims,– And the legacy on-going existing claims.

American Airlines WC

• Early intervention of the claim process and additional resources provided for the employee– Provide more meaningful interaction with the injured

employees– Employer, Adjuster and Nurse Case Manager

• Direction of care & partner with the treating physician (to the extent that is allowable per state law).

• Collaboration and open communication between all parties in the claims process

New WC Claims

• Early intervention is key to meaningful impact for the injured employee– Need to identify early red flags such as unclear diagnosis and

increasing opioid usage

• Provide the additional resources early in the process to ensure appropriate treatment plan– Treating physician– Physician to physician discussions– Nurse Case Manager– Utilization Review

Chronic Pain Claims

• 5,874 WC claims open December 2013 some over 20 years old

• Goal was to resolve these claims but chronic pain and pharmacy usage was a significant challenge

• Significant pharmacy usage in claims 2+ years old and growing pharmacy trend and ongoing disability

• Engaged pharmacy experts and physician resources in attempts to change trajectory of medical care to allow more function of the injured employee

Existing WC Claims

• 40% reduction in open Workers Compensation claims for American Airlines since December 2013

• Reduction in pharmacy costs by 5% (even with 30% more claims with the US Airways merger)

• Reduced disability by an average of 11 days or 25%

Results

Precise Data for Imprecise Behavior: Why National Standards

Make a Difference

David R. Gastfriend MDChief Architect, CONTINUUMTM – The ASAM Criteria Decision EngineScientific Advisor – Treatment Research Institute

Disclosure of Relevant Financial Relationships

Name Commercial Interests

Relevant Financial

Relationships: What Was Received

Relevant Financial

Relationships: For What Role

No Relevant Financial

Relationships with Any

Commercial Interests

David Gastfriend RecoverySearchAlkermes

KaleoIndivior

Royalty from ASAM, Inc.Stock,Consulting

ConsultingConsulting

Pres. & CEO

Former VP, Sci. CommunicationsAdv. BoardAdv. Board

ACA, Parity & Health IT Acts: Huge Implications

The Affordable Care Act (2010)• Phasing-out fee-for-service• Penalties now charged for preventable readmissions• By 2018, 50% of CMS funds will be paid

through alternative payment methods• Value-based payment, Case-based rates, Pay-for-performance• Elevates importance of SUD because tens of millions

with higher SUD prevalence become insured• SUD gets a seat at the table

…but will it be THE HOT SEAT???

ACA, Parity & Health IT Acts: Huge Implications

The Mental Health Parity and Addiction Equity Act (2008): • Rules & lawsuits – slow in coming, but THEY’RE HERE• Published medical necessity criteria, e.g., ASAM Criteria• Equal coverage for SUD as for medical/surgical care• No “non-quantitative treatment limits”

if not used for med/surg benefits (e.g., prior authorization)• Kennedy Forum & TRI Online Appeals Guide • SUD finally gets a seat at the table

www.thekennedyforum.org

www.tresearch.org

ACA, Parity & Health IT Acts: Huge Implications

The Health InfoTech (HITECH) Act (2009): Nowhere to hide• Incentives for EHR adoption in general healthcare • SUD behind the curve – competitive pressures now driving• Data integration on the way…HIPAA & 42CFR – being resolved:

• SAMHSA’s Consent to Share (C2S) web-app is coming:Patient selects which data can be shared between which providers & systems

• Not only data storage/retrieval, but also clinical decision support and quality/outcomes tracking…for pay-for-performance

PREVALENCE OF CO-MORBIDITY(Medicaid; Percent with Chronic Medical +/- Behavioral Disease)

29

Hypertension

Diabetes

Coronary Heart Disease

Congestive Heart Failure

Asthma and/or COPD

31.4%

32.1%

26.3%

30.1%

23.8%

68.6%

67.9%

73.7%

69.9%

76.2%

No Behavioral Health Problem With 1 or More Behavioral Health Problem

29

Boyd, C., Clark, R., Leff, B., Richards, T., Weiss, C., Wolff, J. (2011, August). Clarifying Multimorbidity for Medicaid Programs to Improve Targeting and Delivering Clinical Services. Presented to SAMHSA, Rockville, MD.

IMPACT OF CO-MORBIDITY ON PER CAPITA COSTS (Medicaid-Only Beneficaries with Co-Occurring Disorders)

30Boyd, C., Clark, R., Leff, B., Richards, T., Weiss, C., Wolff, J. (2011, August). Clarifying Multimorbidity for Medicaid Programs to Improve Targeting and Delivering Clinical Services. Presented to SAMHSA, Rockville, MD.

30

Addiction Assessment & Treatment Planning:

• Non-standard, “intuitive”, then “find out the rest later…” • Managed Care wants more data: Telephone tag (90 min – 3 days)• Most insurers’ medical necessity criteria are proprietary• Absent precision & validity, emphasis is on cost, not quality• 1991: ASAM Patient Placement Criteria…a teaching tool• States create their own Criteria (CASAM, MASAM, NYSAM…)• “ASAM” in Major US MCO: ~50% of cases were denials

• on appeal: ~50% reversed; on review ~50% reversed again!• By 2000s, SAMHSA & CSAT called on ASAM for a standard

Modality Matching: Many studies, e.g., Project MATCH – but few findings

(Gastfriend & McLellan, Med Clin NA, 1997)

Placement Matching: Multiple studies; ASAM model – consistent signals (Gastfriend, Addiction Treatment Matching, Haworth Press, 2004)

Support:• NIDA: Validation - R01-DA08781 & K24-DA00427• NIAAA: ASAM Software - SBIR grant R44-AA12004• CSAT: Access to Recovery Initiative - grant 270-02-7120• Belgian National Fund for Scientific Research• Belgian American Educational Foundation• Central Norway Health Trust /Rusbehandling Midt-Norge• SAMHSA: Open Behavioral Health IT Architecture Program

Advances in Treatment Matching

ASAM Text: Hundreds of Decision Rules To place patients in the least intensive & restrictive care

that meets the patient’s multi-dimensional needs and affords optimal treatment outcome

www.ASAMcriteria.org

www.haworthpress.com

Screening Diagnosis Severity Readiness &Relapse Potential

Patient Placement Criteria DIMENSIONS

IntoxicationWithdrawal

Biomedical EmotionalBehavioral

TreatmentAcceptance/Resistance

RelapsePotential

RecoveryEnvironment

Decision Rules

LEVEL OF CARE

1. Outpatient 2. IntensiveOutpatient

3. MedicallyMonitoredIntensiveInpatient

4. Medically Managed Intensive Inpatient

ASAM Patient Placement Criteria

21 3

4 5 6

ASAM PLACEMENT CRITERIA LEVELS OF 1. OUTPT 2. INTENSIVE 3. MED 4. MED

OF CARE OUTPT MON INPT MGD INPT CRITERIA

Intoxication/ Withdrawal

no risk minimal some risk severe risk

Medical Complications no risk manageable

medical monitoring

required

24-hr acute med. care required

Psych/Behav Complications no risk mild severity moderate

24-hr psych. & addiction Tx required

Readiness For Change cooperative

cooperative but requires

structure

high resist., needs 24-hr motivating

Relapse Potential

maintains abstinence

more symptoms, needs close monitoring

unable to control use in

outpt care

Recovery Environment supportive

less support, w/ structure

can cope

danger to recovery, logistical

incapacity for outpt

• DSM-5 Substance Use Disorders: Diagnoses & Criteria• CIWA-Ar & CINA withdrawal scores (alcohol/BZs, opioids)• Addiction Severity Index (ASI) Composite Scores• Imminent Risk Considerations• Access & Support Needs/Capabilities• ASAM Level of Care recommendations

– All adult admission levels and sub-levels– Including Withdrawal Management– Including Biomedically Enhanced Sub-level– Including Co-occurring Disorder Sub-levels

(Capable, Enhanced)

• Also: If actual placement disagrees with Software, the clinician gets to justify the discrepancy: Generating needs analysis data

Clinical Decision Support Software

Under-Matching Worsens No Show to Treatment

All Patients (N=700) Cocaine (N=183) Heroin (N=279)0%

10%

20%

30%

40%

50%

60%

70%

From Inpatient Detox to Either Residential Rehab or Day Treatment:

All patients, High Frequency Cocaine Users and Heroin Users

Mis-matched Matched

p≤.001

p≤.001

p≤.019 Under-matched patients’

no-show rate: ~25% worse

Under-matched patients’

no-show rate: ~100% worse

Under-matched patients’

no-show rate: ~300% worse

Perc

ent N

o-Sh

ows t

o N

ext T

reat

men

t

3-mo Drop-Out, Improvement & Stepdown Need

Under- Matched Over-0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Under- Matched Over-0

1

2

3

4

5

6

7

% of Patients Ready for Stepdown at F/U (vs. BL)

# ASI Subscales Improved at F/U% Drop Out at 3-Mo F/U

Under- Matched Over-0%

10%

20%

30%

40%

50%

60%

70%StepdownSame LOCHigher LOC

Naturalistic Match Status – According to ASAM Software

Adequate (II) Matched (III) Lesser LOC (IV)0

5

10

15

20

25

30

35 ~24-mos Before~13 mos After

Bed-day Use Pre- vs. Post-Naturalistic L-III Placements

Ann

ualiz

ed B

ed-D

ays *

Bed-Day Utilization over 1-Yr in the VABedford MA VA, N = 97

Conclusions• ASAM Criteria: Parity-ready, published, medical necessity criteria• The decision rules show face validity• CONTINUUM™ technology provides good reliability & feasibility• Good concurrent validity vs. other instruments • Good Predictive validity overall, w/heroin, cocaine & comorbidity• Studies show validity for undermatching, AND for overmatching• Predictive validity found:

– across cultures/systems: public/VA; MA/NYC; Belgium/Norway

– at multiple time-frames: immediate, 30-d, 90-d & 1-year

– with multiple outcomes: no-show, global improvement, substance use, step-down readiness, rehospitalization

Stakeholders in the Health IT Revolution

Client

Counselor

Supervisor

SystemManaged Care

Employer/Payer

Researcher

Accreditation Body, Government

Society

• Operates 145 sites treating 30,000 people

• Largest behavioral health provider in U.S.

• Devotes significant resources to payer approval

• Each center has 3-5 FTEs dedicated to UR

• ~20% of cases are contested by payers

• ~30% of MD time is lost interacting w/payers

• If this administrative time is reduced only slightly, the ASAM Software could yield substantial savings.

Case Study: CRC Health (now Acadia)

HARVARD | BUSINESS | SCHOOL

ASAM’s CONTINUUM™:(compared to usual assessment/placement)• 25% - 300% reductions in no shows to next stage of treatment• 30% reduction in dropout from treatment• 3X improvement in addiction severity outcomes at 3 months• 25% increase in numbers of patients ready for stepdown

Leading to…• Increased patient flow & revenues• Staffing efficiencies (fewer incomplete intakes & UR delays)• Improved morale & bottom line

Addiction assessment:A new, state-of-the-art standard

Survey of Addiction Providers with an EHR

83%

14%3%

Have you asked your EHR technology vendor(s) if they can provide CONTINUUM™ to you?

No, but I would like them to have this capabilityYesNo, I am not interested

OPTIONS for States/Counties implementing the 1115 Waiver:1. Managed care organization vendor contract – at a cost of millions2. OR, ASAM’s CONTINUUM™ - at a fraction of the cost

July 27, 2015 SMD # 15-003 Re: New Service Delivery Opportunities for Individuals with a Substance Use Disorder

Dear State Medicaid Director:

…States should use the ASAM Criteria as they develop a residential or inpatient SUD service continuum…In order to receive approval…the assessment for all SUD services, level of care and length of stay recommendations must be performed by an independent third party that has the necessary competencies to use ASAM Patient Placement Criteria. Specifically, an entity other than the rendering provider will use the ASAM Criteria...

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850

A National Addictions Patient Registry

Client

Counselor

Supervisor

SystemManaged Care

Employer/Payer

Researcher

Accreditation Body, Government

ASAM’s National Coalition

Treatment Program

Protected Raw Data

(Identifiers + Health Info)

Copied Data(Stripped of Identifiers

but with Unique Case #)

EHR

Addiction assessment:A new, state-of-the-art standard

THE PAST…• Non-standard, intuitive • Telephone tag• Proprietary criteria• Emphasis: cost, not quality• 1991: ASAM…teaching tool• State-by-state Criteria• Managed Care Study:

~50% of denials reversed• By 2000s, SAMHSA wants

a standard

NOW…• Standardized, quantitative• Rapid Prior Authorization• Published criteria• Emphasis on cost AND quality• 2015: ASAM…a decision tool• A national standard for Criteria• Managed care: Willing to pilot

AUTOMATIC prior authorization • 2015, SAMHSA

has a standard

Addiction assessment: A Sea Change

• Enough legislation already: Begin the quality change process!

• Consumers/Providers: Push for parity in managed care UR

e.g., via the Kennedy Forum/TRI Online Appeals Guide

• Payers/States/Accreditors: Measure program services,

e.g., TRI’s ASAM Level of Care Certification Program

• Payers/MCOs: Standardize medical necessity criteria/reform UR

– drop phone prior authorization

– manage by data: via ASAM’s CONTINUUM™ data registry

For more information:

gastfriend@gmail.com

www.ASAMcontinuum.org

Advances in TreatingChronic Pain and Addiction

Presenters:• Michael Gavin, MBA, President, PRIUM

• Jennifer Saddy, Director of Workers’ Compensation, American Airlines

• David R. Gastfriend, MD, Scientific Advisor, Treatment Research Institute

Third-Party Payer Track

Moderator: Michael C. Barnes, JD, Executive Director, Center for Lawful Access and Abuse Deterrence, and Member, Rx and Heroin Summit National Advisory Board