Navigating the New Environment for Addiction Treatment
Steve Allen, PhD
UC Berkeley Extension
What is now The Past
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1970’s and 80’s: Private insurance often covered 28-day
inpatient stays for 12 Step based Minnesota Model treatment.
Public, government-funded treatment services also provided
28-day residential treatment, and even longer-term stays.
A great many alcohol and drug counselors came into the
profession via their own recoveries which began in such
residential programs, and many of them have continued to
work in these settings.
Beginning in the 90’s, both insurance companies and public
agencies began to question the need for residential programs,
and began to extend more support to day treatment and
intensive outpatient services.
Many traditional programs then began to expand their
services to include these new modalities. Counselors have
continued to play large roles in these expanded services,
often adapting the same techniques used in residential
services.
What is now The Past
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Addiction treatment has always been segregated from the rest
of healthcare, and almost always provided in separate
specialty care addiction treatment programs.
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Financing for addiction treatment was also separated from
other healthcare coverage, typically “carved out” and
managed separately from the larger healthcare plan.
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Many private insurance plans have not covered addiction
treatment at all. Over 80% of addiction treatment financing
has come from government sources (Block grants, VA, etc.)
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Whether public or private, coverage has always been
restricted to only the most advanced and severe form of
substance use problem: addiction. Coverage for less severe but
far more common forms of substance use disorders has never
been included.
PPACA Basics
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Requires all Americans to purchase healthcare insurance, with
subsidies provided to lower-income people.
Requires all health plans and systems to cover ten “essential
services”—including “substance use disorders.” (We’ll come back to
that term later.)
No annual or lifetime dollar limits on coverage of any of these
essential services
No denial of coverage for pre-existing conditions, and no dropping
of those who acquire a chronic condition.
Assures portability of of insurance when changing jobs.
Family coverage can include all children through age 26.
Increases primary prevention services—available to all insured with
no co-pays; 100% Federally funded.
Greatly expands eligibility for Medicaid. (We’ll come back to that
later too.)
Substance Use Disorders
under PPACA
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Requires health insurers to cover, and healthcare
organizations to provide, prevention, screening and brief
interventions for the full spectrum of substance use disorders,
not just “addiction.”
Care for these disorders must have the same type, duration,
range of services and patient financial burden as the care
currently available to patients with other physical illnesses.
Chronic disease management is incentivized to provide teambased, proactive management through electronic health
records, patient registries, improved outcome monitoring
systems, and waiver of copays for patients.
Substance Use Disorders
under PPACA
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Integrates insurance coverage for substance use disorders into
general medical insurance policies.
Expands care delivery into mainstream medical settings such
as primary care and team-based chronic disease management
programs.
By providing treatment of the full spectrum of substance use
disorders, some of the stigma of these disorders will be
removed.
Greatly increases the number of individuals now eligible for
some type of substance use disorder treatment, and
facilitates their access to such treatment.
So what does this mean for
“traditional” addiction
treatment services?
Opportunities & Hazards
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There will still be even more people with severe and advanced
addictions– at least for a while. And there will be many more of
these who are newly insured for addiction treatment, with benefits
at parity with rates for other chronic illnesses.
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Insurance carriers will be even more interested in the varying
levels of care that may be necessary and sufficient. High quality
diagnosis and assessment will be increasingly important, both for
admission and for timing of “step-downs.”
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The traditional addiction treatment programs will have to
“medicalize” their care, adopting more of the methods and
language of clinical specialties to their care patterns.
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There will likely be increased competition from mental health
providers, who may lack direct clinical experience with addicted
patients, but are much more sophisticated in working with other
medical specialties and medical care organizations.
Opportunities & Hazards
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There will also be opportunities for counselors currently
employed in traditional programs to become involved with
delivery of other levels of care in other settings.
Accountable Care Organizations (Medical Homes, Health
Maintenance Organizations, and other integrated care
networks) will be strongly supported by the ACA, and much
of the early intervention work will be carried out in these
organizations. Primary Care physicians will play key roles in
the provision of this care, and substance use counselors—if
properly trained and oriented—could also be involved at this
level.
Integrated treatment of co-occurring psychiatric and medical
disorders will also become increasingly common, and it will
be important for counselors to obtain the knowledge and
develop the collaborative skills necessary to participate with
other providers from a variety of disciplines.
In the Supreme Court’s 2012 decision upholding the
Affordable Care Act, it gave the states the choice to opt
out of Medicaid expansion. It is now rests with governors
and state legislatures to decide whether it is in the best
interest of the state to implement the Medicaid portion
of the law that affords health coverage to those in need.
Medicaid Expansion
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Medicaid currently requires coverage for certain groups of
individuals: low-income children and some of their parents;
poor pregnant woman; certain low-income seniors; and some
individuals with disabilities who are under the age of 65.
Under the Affordable Care Act, Medicaid eligibility would be
extended to all individuals with incomes up to 138% of the
federal poverty level --$26,347 for a family of three and
$15,417 for an individual.
As of June 2014, Medicaid expansion in several Western
states, as an example, provided new coverage for 175,000
people in Nevada, 345,000 in Oregon, 403,000 in Washington,
and 1,743,000 in California.
In states that have not expanded Medicaid, many people are
caught in a coverage gap: unable to obtain Medicaid
benefits, and too poor to qualify for ACA insurance subsidies.
Pennsylvania expanded Aug 28
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Previous Versions
• Levels of care and lengths of stay originally based on what
insurance companies would pay for (eg, Minnesota Model
inpatient)
• In early ‘90s, ASAM developed a single set of criteria for
levels of care
• PPC: Patient Placement Criteria
• Three editions of PPC: 1991, 1996, 2001
What’s new?
• Not just a checklist—a 465 page book
• Shifted from “placement” criteria to
“treatment criteria”
• Shift from program-driven treatment to individualized,
clinically-driven treatment
• Updated terminology, eg
• “Resistant” now “not interested in stopping use”
• “Inappropriate use” now ‘High-risk use”
• Sections on special populations
Efficacy vs Effectiveness
• Efficacy = a treatment or intervention produces positive
results in a controlled experimental research trial.
• Effectiveness = a treatment or intervention produces positive
results in a usual or routine care setting (i.e., in the real
world).
Research-only approach to EBPs
• Emphasizes scientific research and contrasts scientific
evidence with approaches based on “global subjective
judgment,” consensus, preference, and other forms of
“nonrigorous” assessment.
• Criticism: The true performance of an intervention often
remains uncertain even when research evidence is available.
• Criticism: Certain types of interventions are more amenable
to research than are others and are therefore more likely to
be supported by research evidence.
• Criticism: Definitions of successful outcomes are not
universally shared, especially in behavioral health.
• Criticism: Clinical decision-making and health policy involve
factors and trade-offs related to patient and community
values, culture, and competing priorities that are not
generally informed by research.
Multiple Streams of Evidence
• The Institute of Medicine has argued for an approach that
reflects “multiple streams of evidence”:
1. Best research evidence—the support of clinically relevant
research, especially that which is patient centered
2. Clinician expertise—the ability to use clinical skills and past
experience to identify and treat the individual client
3. Patient values—the integration into treatment planning of
the preferences, concerns, and expectations that each
client brings to the clinical encounter
http://www.nrepp.samhsa.gov
DISCLAIMER
NREPP rates the quality of the research supporting intervention outcomes
and the quality and availability of training and implementation materials.
NREPP ratings do not reflect an intervention's effectiveness. Users should
carefully read the Key Findings sections in the intervention summary to
understand the research results for each outcome.
NREPP does not provide an exhaustive list of interventions or endorsements
of specific interventions, since NREPP has not reviewed all interventions.
Policymakers and funders in particular are discouraged from limiting
contracted providers and/or potential grantees to selecting only among
NREPP interventions.
Review of interventions and their posting on the NREPP Web site do not
constitute an endorsement, promotion, or approval of these interventions
by NREPP or SAMHSA.
http://www.healthquality.va.gov/guidelines/MH/sud/
DISCLAIMER
The Department of Veterans Affairs (VA) and The Department of Defense
(DoD) guidelines are based on the best information available at the time
of publication. They are designed to provide information and assist in
decision-making.
They are not intended to define a standard of care and should not be
construed as one. Also, they should not be interpreted as prescribing an
exclusive course of management.
Variations in practice will inevitably and appropriately occur when
providers take into account the needs of individual patients, available
resources, and limitations unique to an institution or type of practice.
Every healthcare professional making use of these guidelines is
responsible for evaluating the appropriateness of applying them in any
particular clinical situation.
!
Table&A(4:&Final&Grade&of&Recommendation!
!
The&net&benefit&of&the&intervention!
Quality(of!
Evidence!
Good!
!
Substantial!
A!
!
!
Moderate! Small!
B!
C!
Zero&or!
Negative!
D!
Fair!
B!
B!
C!
D!
Poor!
I!
I!
I!
I!
!
Evidence&Rating&System!
!
A! A!strong!recommendation!that!the!clinicians!provide!the!
intervention!to!eligible!
patients.!
!
B! A!recommendation!that!clinicians!provide!(the!service)!to!
Good&evidence&was&found&that&the&intervention&improves&
eligible!patients.!
important&health&outcomes&and&concludes&that&benefits&
!substantially&outweigh&harm.!
least&fair&evidence&was&found&that&the&intervention&
C! At&
No!recommendation!for!or!against!the!routine!provision!of!
improves&
health&outcomes&and&concludes&that&benefits&
the!intervention!is!made.!
!outweigh&harm.!
At&least&fair&evidence&was&found&that&the&intervention&can&
improve&health&outcomes,&but&concludes&that&the&balance&of&
benefits&and&harms&is&too&close&to&justify&a&general&
recommendation.!
D! Recommendation!is!made!against!routinely!providing!the!
intervention!to!asymptomatic!patients.!
!
At&least&fair&evidence&was&found&that&the&intervention&is&
ineffective&or&that&harms&outweigh&benefits.!
I!
!
!
!
The!conclusion!is!that!the!evidence!is!insufficient!to!
recommend!for!or!against!
routinely!providing!the!intervention.!
!
Evidence&that&the&intervention&is&effective&is&lacking,&or&poor&
quality,&or&conflicting,&and&the&balance&of&benefits&and&harms&
cannot&be&determined.!
VA/DoD Clinical Practice Guideline For Management of Substance Use Disorders
Appendix C: Addiction-Focused Psychosocial Interventions
Summary of Effectiveness of Psychosocial Interventions during early recovery (first 90
days) on condition specific outcomes of SUD (use or consequences) or general
psychosocial functioning
First line alternatives at least as
effective as other bona fide active
interventions or treatment as usual
(TAU)
Added effectiveness as
adjunctive interventions
in combination with
pharmacotherapy and/or
other first line
psychosocial
interventions
Interventions Alcohol Opioids Stimulants Cannabis Alc Ops Stim Cann
Comments
(alphabetical)
/mixed
Behavioral
Couples
Therapy
+++
N/A
+++
N/A
+/-
+
?
Cognitive +++
Behavioral
Coping Skills
Training
N/A
+++
++
+
+++ N/A
++
Contingency N/A
Management/
Motivational
Incentives
N/A
N/A
N/A
+
+++ +++
N/A
Community +++
Reinforcement
Approach
N/A
+
N/A
N/A
N/A +
N/A
Complex intervention
Motivational +++
Enhancement
Therapy (MET)
N/A
N/A
?
+++
?
+
May improve treatment
engagement as adjunct to
TAU for stimulants; Some
evidence for those with low
readiness
or high anger
Twelve-Step +++
Facilitation
N/A
N/A
N/A
++
N/A +
N/A
AA participation is
correlated with outcome –
appears to mediate TSF
effects
+/-
N/A
Effective for male or female
patients with SUD and
partners; improves marital
satisfaction
+++
based on meta analysis of comparison with bona fide alternative interventions
+ or ++ Based on one (+) or more (++) individual trials in comparison with bona fide alternatives
N/A: evidence not available; +/- evidence inconsistent across outcomes; ?: benefit questionable
Predictions
• Evidence Based Practices will increasingly be developed to
target more specific problems and levels of severity.
• All treatments will be increasingly subject to accountability
standards. That is, we must be able to demonstrate that the
treatments we are providing are effective, producing
measurable positive changes. EBPs will play an important
role in these accountability standards
* Of particular importance to all providers will be the ability to
offer an attractive and evidence-based set of treatment
services to the new and more diverse, educated and consumer
savvy population of insured patients.
Predictions
• The well-established failure of the traditional addiction
specialty programs to offer evidence based medications,
individual therapies and continuing care services has been
variously attributed to treatment philosophy,ideology,
inadequate economic resources, and/or workforce
limitations.
• Regardless, the new marketplace is likely to be much more
sophisticated, and payers and referral sources are likely to
know more about state-of-the-art care methods; and
justifiably ask for proof of effectiveness. Again, traditional
addiction treatment providers currently have the clear
historical and experiential advantage
• …but Kodak and Polaroid once held similar technological and
experiential precedence in the camera industry