Whats Wrong With

1
Whats Wrong With Addiction Treatment
What Are New Opportunities?
2
Part I

• The Specialty Care System A Customer
  Perspective
• Patient Survey
• Care Provided
• Infrastructure

3
Addiction Specialty Care

• 13,200 specialty programs in US
• 31 treat less than 200 patients per year
• 65 private, not for profit
• 80 primarily government funded Private
  insurance lt12
• Sources NSSATS, 2002 DAunno, 2004

4
Substance Use Pyramid
In Spec Treatment 2,100,000
?
Abuse/Dependent 23,000,000
Harmful Users ??,000,000
5
Referral Sources

• Source 1990 2004
• Criminal Justice 38 59
• Employers/EAP 10 6
• Welfare/CPS 8 16
• Hosp/Phys 4 3

6
Why Dont Patients Want Treatment?
Sources 4 Review Articles Rapp et al. JSAT
2005 Stanton JMFT 2004 Appel et al. AJDA
2004 Tsogia et al. JMH 2001
7
Top Patient Reasons

• 1) No Problem/Can Handle 58
• 2) No Confidence in Trt 51
• 3) Bad Trt Experience 36
• 4) Abstinence-Only Goal 31

8
WHY? Wont programs deliver quality care?
CANT
9
Three Reasons

• a. The Infrastructure
• b. The Acute Care Model
• The Way it is Evaluated

10
Program Infrastructure

• Phone Interviews With National Sample of 175
  Programs regarding personnel, management,
  information
• McL, Carise Kleber JSAT, 2003

11
The Treatment System

• Modality 1975 1990 2006

Residential 64 39 8
Outpatient 27 59 79
Methadone 9 10 13
12
STAFF TURNOVER!

• Counselor turnover 50 per year
• 50 of directors have been there Less Than 1
  year

13
Other Staff

• 54 Had no physician 34 Had P/T
  physician 39 Had a Nurse (part of full time)
• lt 25 Had a SW or a Psychologist
• Major professional group Counselors
• (Average Age 54)

14
Information Systems

• Modest Computer Availability
• Mostly For Administrative Work
• 80 Had a Computer
• 50 had Web Access
• Still very little computer/software availability
  for CLINICAL STAFF

15
The Acute Care Model

• The Acute Care Model
• Treatment Models for Other Illnesses

16
A Nice Simple Rehab Model
Substance Abusing Patient
Medications, Therapies, JCAHO, CARF, WC Ev. Based
Prac.
Treatment
NTOMS Sample of 250 Programs
Non- Substance Abusing Patient
17
How Do Other Treatments Work? Chronic Illness
Continuing Care
18
A Continuing Care Model
Primary Care
Specialty Care
Primary Continuing Care
19
In Chronic Illnesses.
1 The effects of treatment do not last very
long after care stops 2 Patients who are out
of treatment/contact are at elevated risk for
relapse
20
So, For Treatment.
1 One goal is to retain patients at an
appropriate level of care and monitoring 2
Another goal is to prepare patients to do well in
the next level of care 3 - The effects of
treatment are evaluated during treatment not
post-discharge
21
The Way it is Evaluated
I

• Implications of How We Evaluate
• Differences in Outcome Expectations

22

• Studies show few differences between
• Brief and Intensive Treatments
• Inpatient and Outpatient Treatments
• Conceptually Different Treatments
• Matched and Mismatched Trt.
• Gender or Culturally Oriented Trt.

23
Outcome In Hypertension
Pre - During - Post
Treatment Research Institute
24
Outcome In Addiction
Pre - Post
Treatment Research Institute
25
Maybe this is why
26

• Studies show few differences between
• Brief and Intensive Treatments
• Inpatient and Outpatient Treatments
• Conceptually Different Treatments
• Matched and Mismatched Trt.
• Gender or Culturally Oriented Trt.

27
Part II

• Are there new opportunities to show the value of
  treatment?
• Primary Care
• Different Treatment Model
• New Purchasing Methods

28
Why How to Work With Primary Healthcare?
1 New Proc/Pay Codes 2 Medications 3 PRISM
29
New Procedure Codes

• Effective January 2008
• Separate Billing Codes for
• Screening of alcohol problems
• Brief Interventions (advice and counsel)
• Non-Physician Assistant Codes
• Behavioral and Lifestyle Factors

30
FDA-Level Evidence

• Medications
• Alcohol (Disulfiram, Naltrexone, Accamprosate)
• Opiates (Naltrexone, Methadone, Buprenorphine)
• Cocaine (Disulfiram, Topiramate, Vaccine?)
• Marijuana (Rimanoban)
• Methamphetamine Nothing Yet

31
But
32
Referral Sources

• Source 1990 2004
• Criminal Justice 38 59
• Employers/EAP 10 6
• Welfare/CPS 8 16
• Hosp/Phys 4 3

33
WHY? Cant physicians do SBIRT?
WONT
34
Top Physician ReasonsSource 426 PCPs _at_ SGIM

• 1) Dont know what to do 69
• 2) No Effective Treatment 55
• 3) Not really a medical prob 26
• 4) No time 19

35
Disorders with Higher Prevalence Among Substance
Abusers
Percent
Substance abusing patients 747 Matched
controls 3,690
Weisner et al. Arch Intern Med. In press.
36
Non-compliant patient
John Johnson, 61 y/o, diabetes resulting in a leg
amputation when doctors urged him to mind his
diet, I told them I eat what I want to eat and
the hell with them. Ive been smoking for 50
years why should I stop now? he added for good
measure. This is supposed to be a free
world. New York Times, 12/1/2006, p.1 Online
version, accessed at http//www.nytimes.com/2006/1
2/01/us/01medicaid.html on 12/6/06
37
PRISM
Chronic Illness Care

• Program of Research to Integrate Substance Use
  Information into Mainstream Healthcare

38
Substance Use Prevalence
In Spec Treatment 2,300,000
Focal Group
Low Level Use
39
The PRISM Approach

• Physicians want better information to manage
  chronic illnesses
• Commission systematic reviews of the role of
  substance use in those illnesses
• Goal improve management of chronic illnesses, by
  managing substance use

40
Systematic Reviews

• Diabetes
• Howard et al. Ann Intern Med.
• Hypertension
• McFadden et al. Am J Hypertens.
• Chronic pain
• Martell et al. Ann Intern Med.
• Breast cancer
• Terry et al. Ann Epidemiol.
• Sleep
• Dinges et al. JAMA

41
Risk of Mortality Drinks/Day
1.4
1.3
1.2
1.1
Risk of Mortality
1.0
0.9
0.8
0.7
0.6
3
4
7
6
5
0
2
1
Drinks per Day
Di Castelnuovo et al. Arch. Int. Med.
2006166(22)2437
42
Results to Date

• Working with 4 primary care societies 225,000
  physicians
• American College of Physicians
• American Geriatrics Society
• Society of General Internal Medicine
• American Academy of Family Physicians
• Practice initiatives
• New guidelines to manage chronic illnesses

43
How Does Specialty Care Work In the Rest of
Medicine?
44
A Continuing Care Model
Primary Care
Specialty Care
Primary Continuing Care
45
Example.

• PCP - 58 y/o male reports ringing in ears,
  dizziness/nausea
• Actions -
• Order/refer for testing on EHR
• Results to PCP from EHR
• Working Dx discuss w/pt
• Refer to specialist on EHR

46
Example Contd.

• Specialist - Reads all testing and notes on
  EHR
• Actions -
• Writes note to PCP using EHR
• Tests/Prescribes/tortures
• Evaluate discuss w/pt - repeat
• Refers w/note back to PCP - EHR

47

• Cultural Assumptions
• Its the PCPs patient
• Specialist is available, and will communicate in
  same language and on same EHR
• Patient will return to PCP no matter what for
  continuing care/mgmt

48
Maybe this is why
49
Referral Sources

• Source 1990 2006
• Criminal Justice 38 59
• Employers/EAP 10 6
• Welfare/CPS 8 16
• Hosp/Phys 4 3

50
Re-Thinking Treatment for Serious Addiction
Lessons from Physician Health Plans
51
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

DuPont et al., 2008, (in review).
52
Evaluation and Contracting

• Phase 1 - Evaluation (1 2 mos.)
• Evaluate referred physician
• Explain PHP and Contract
• Full diagnostic evaluation often with family
• Intervention where appropriate
• Result is signed contract
• 3 5 years in duration
• Protection from immediate adverse actions
• Monitoring with report to Board 4 yrs

53
Formal Treatment

• 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

54
Monitoring Support

• Phase 3 3 - 4 yrs
• AA attendance - usually mandatory
• Caduceus Society meetings - mandatory
• Personal Therapist
• Family Therapy
• Worksite visits
• Urine Drug Screenings
• Weekly - monthly (random during weekdays)
• 20 panel testing

55
Results During Contract

904 Physicians Consecutively Enrolled into 16
state Physician Health Programs
Continuers 132 - Still being monitored 132
(15)
Completed 448 - No Longer Being
Monitored 67 - Completed but monitored
voluntarily 515 (57)
Non-Completers 85 Voluntarily stopped /
Retired 48 Failed, License Revoked 22
- Died (6 suicides) 102 Transferred/Moved 257
(28)
56
Urine Testing Over 4 years
57
Results at 5-7 Years
Practicing Medicine Completers 92 Continuers
73 Non-Completers 28
58
Results at 5-7 Years
Revoked License Completers
2 Continuers 11 Non-Completers 32
59
New Purchasing Methods
Performance Contracting In Delaware
60
Addiction Specialty Care

• 13,200 programs in US
• 65 private, not for profit
• 80 primarily government funded Private
  insurance lt12
• 31 treat less than 200 patients per year
• Sources NSSATS, 2002 DAunno, 2004

61
Delaware Situation 2002

• 11 Outpatient Providers
• Limited Budget
• No success with outcome evaluation
• Providers wont/cant use EBPs

62
Delawares Performance Based Contracting

• 2002 Budget 90 of 2001 Budget
• Opportunity to Make 106
• Two Criteria 80 Utilization/Occupancy
  Active Participation
• Audit for accuracy and access

63
Delawares ResultsYears 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

64
Utilization
65
Attending
66
CONCLUSIONS

• Specialty care system is in trouble
• Customers Do Not Want the Product
• Ruled by Gov, Not Market Forces
• System Change is Necessary
• Public Health Value thru Patient Value
• Reach Deeper into Problem User group
• Meet Customer Needs Offer New Options

67

- The End -
68
Substance Use Pyramid
In Spec Treatment 2,100,000
?
Abuse/Dependent 23,000,000
Harmful Users ??,000,000
69
Whats Different Since 2000

• Five pharmaceutical companies
• Push for Evidence Based Practices
• National Parity Legislation
• SBIRT Physician Pay Codes
• Prescrip. opiates as entry drug
• Performance Contracting

70
Forces That May Affect Addiction Treatment

• Conceptual Shifts
• Addiction is a bad habit Addiction is a
  chronic illness
• Addiction treatment is an art Addiction
  treatment is a science
• Patient progress judged by provider Progress
  judged on standard measures
• Addicted patients need special
  program Patients need generic care/services

71
Forces That May Affect Addiction Treatment

• Scientific Discoveries
• Medications (4 cos now many considering)
• Look for Vaccines w/in 5 years
• Cheap, effective monitoring
• Internet information for purchasers
• Brain/Genetic science may consolidate addictions
  with other impulse disorders

72
Forces That May Affect Addiction Treatment

• Market Forces
• Consumers Report information
• Performance Contracting
• Bundled Purchasing
• May force consolidation
• Carve In of Behavioral Health
• Entry of Primary Care (medications)
• Sentence Reform/Prison Overcrowding
• Drug Court models

73
Forces That May Affect Addiction Treatment

• Other Forces
• IOM 2006 Report
• Pending Suits
• Insurance Parity