integration and payment in primary care settings

Transcription

1 May 9, 2015 substance abuse treatment integration and payment in primary care settings Michael S. Shafer, Ph.D.

2 Learning Objectives At the conclusion of this session, if I have done my job, you will: Demonstrate improved awareness and knowledge of the SBIRT Screening, Brief Intervention and Referral to Treatment model for integrating substance abuse treatment into primary care. Demonstrate improved knowledge of the payment and policy implications of the Patient Protection & Affordability Care Act (PPACA) upon primary care physicians and addiction treatment.

3 part 1: substance abuse 101

4 substance abuse is prevalent and undertreated

5 undertreated condition National Institute on Drug Abuse researchers estimate only 11% of individuals requiring substance abuse treatment services receive them.

6 50% 20% 34% PREVALENCE OF ALCOHOL ABUSE 30% 5%

7 10% 2 x year 100,000 14/100 ALCOHOL RELATED DEATHS & INJURIES

8 9.2% 21.2% 27.1% 98.4% Illicit & Prescription Drug Abuse

9 substance abuse treatment is effective recovery is possible

10 part II: SBIRT 101

11 history stems from the public health arena identify risky use prior to dependence intervene with individuals engaging in risky behaviors SAMHSA definition: comprehensive, integrated, public health approach to the delivery of early intervention for individuals with risky alcohol and drug use, and the timely referral to more intensive substance abuse treatment for those who have substance abuse disorders. uniqueness of SBIRT: focus on universal screening

12 key terms screening: brief tool used to identify those at risk for substance use disorders brief intervention: brief interaction that serves to educate the patient and motivate them to move in the direction of healthier behaviors brief treatment: ongoing intervention, 5-12 sessions (onsite), cognitive-behavioral in nature referral for treatment: referral to an offsite intensive substance abuse treatment program for individuals requiring more extensive treatment than the current setting can offer

13 settings hospitals community health centers primary care settings emergency departments trauma centers public health settings dental clinics schools specialty clinics (i.e. HIV clinics) community behavioral health agencies

14 identifying the at-risk user at moderate risk for a substance use disorder patients who are not dependent at increased risk for health problems (i.e. hypertension, liver damage, etc.) at increased risk for mental health problems may be sufficient to provide brief intervention without a referral (i.e. education) Primary target for the SBIRT model

15 S - screening SAMHSA model promotes universal screening may utilize pre-screening (often shorter versions of existing screening tools) preferably validated screening tools screening tools you can repeat to capture changes are ideal screening tools may identify those needing a full assessment

16 types of screening tools questionnaire (self-report) perhaps completed in the waiting room interview (3-5 questions the clinician asks) biological markers i.e. breathalyzer, urine analysis, blood alcohol content

17 alcohol screening tools Alcohol Use Disorders Identification Test (AUDIT) identifies problem drinkers or those with alcohol dependence appropriate for adults or adolescents 10 items domains (e.g. frequency, quantity, morning drinking, guilt) sum the scores scoring: 0-7 (low), 8-15 (low-moderate), (moderate), 20+ (high)

18 alcohol and drug screening tools Drug Abuse Screening Test-10 (DAST-10) 10 items captures drug use/misuse does not capture alcohol & tobacco use domains: poly-substance use, relational problems, withdrawal, etc. self-administered or interview appropriate for adults yes = 1 point (reverse scoring for #3, no = 1 point) scoring: 1-2 (low risk); 3-5 (moderate risk); 6-8 (substantial risk), 9-10 (severe)

19 screening decision tree or reinforce their healthy use

20 safe drinking limits Body text More body text Even more body text In case that wasn t enough Almost done Sooooo close FINALLY finished

21 BI brief interventions for moderate risk patients minutes; 1-5 sessions assist patients in seeing a connection b/w their substance use and health/wellbeing might include: educational intervention: i.e. providing an informational brochure, discussing what constitutes risky drinking/drinking limits motivational intervention: Motivational Interviewing goal: abstinence or cutting back target 1-2 risky behaviors (i.e. drinking and driving, combining sedatives & alcohol, overuse of pain medication)

22 brief interventions educational brochures or handouts education using visual aides (standard drink sizes, risky drinking levels, etc.) recommendations for cutting back readiness rulers tips & hints: use the stages of change to inform your approach ideally, the conversation would incorporate a motivational interviewing style

23 cutting down vs. abstinence which patients should be encouraged to be abstinent? pregnant women dependent individuals; those at high risk for dependence those susceptible to a medication interaction those with a health or mental health condition exacerbated by alcohol encourage cutting down if they are not open to abstaining

24 R - referrals only 3-4% of those screened will require a referral who should be referred: dependent users (those meeting DSM-5 criteria) those with a comorbid mental health disorder high-risk users (e.g. drunk drivers, those who have contracted an infectious disease, etc.)

25 warm handoffs arrange transportation call together to make initial intake appointment provide written information for the provider address barriers (i.e. insurance) call patient to ensure they attended intake schedule follow-up with referring clinician

26 benefits of SBIRT ROI: every $1 spent, $3-5 is saved Absenteeism & presenteeism: $771 per employee Arrests: 46% reduction ED visits: 20% reduction Hospitalization: 37% reduction Moto Vehicle Accidents: 50% reduction MVA related injuries: 33% reduction Reduced substance use

27 the evidence for alcohol interventions Fleming and colleagues treated alcohol use in primary care (Fleming et al., 1997; Fleming et al., 2000) intervention: brief intervention, patient workbook, two 15 min. visits, 2 nurse follow-up calls results: reduced weekly drinking from 19/week to 11.5 (at 12 mos) reduced binge drinking from 5.7x/month to 3.1 (at 12 mos) 6:1 cost savings for treatment group; $56K saved for every $10K spent

28 part III: PPACA and financing addiction treatment

29 Policy Developments Reflected in PPACA 1. Universal Insurance Coverage and Extension of Parity 2. No Pre-Existing Condition Exclusions 3. Fostering Medical and Health Homes 4. Disease Prevention and Health Promotion 5. Achieving Recovery and Resilience

30 Coverage Reform Eliminates pre-existing condition clauses Requires parity in annual and lifetime caps between physical and behavioral health

31 Elements of Expanded Coverage 1/1/2014 Below 133% FPL Medicaid Expansion to Childless Adults MH/SUD at parity in benchmark plans Up to $14,400 individual $29,400 family of % FPL State Exchanges individuals or small employer buy or get assistance through Essen@al MH/SUD at parity in qualified plans Up to $43,300 individual $88,000 for family of 4 Employer Sponsored Plans No employer mandate Not excluded for pre- exis@ng, etc.; no annual or life@me limits Plans spend most on services If employee cannot get or cannot afford health plan, may go to Exchange

32 2013 Federal Poverty Guidelines Household Size 100% 133% 400% 1 $11,770 $15,654 $47,080 2 $15,930 $21,187 $63,720 3 $20,090 $26,720 $80,360 4 $24,250 $32,253 $97,000 Source: h*p:// reform- central/

33 Arizona Substance Abuse & Mental Health Essential Benefits Benefit Mental Health Outpatient Mental Health Inpatient Substance Abuse Outpatient Substance Abuse Inpatient Limits? No No No 90 days per year

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35 Source: Cover Arizona: h`p://coveraz.org/

36 Payment for SBIRT must be a min. of 15 mins. can bill for follow- up if 15 mins. or longer must u@lize an evidence- based tools (e.g. AUDIT, DAST) and procedures (e.g. mo@va@onal interviewing) Medicare codes for non- hospital/outpa@ent seengs not all states have approved Medicare/Medicaid SBI codes alterna@ve: not billing for SBIRT services; funding via cost- offset

37 Acknowledgements & Disclaimer These slides and associated materials were developed by: Michael S. Shafer, Ph.D. Center for Applied Behavioral Health Policy (CABHP) Pacific Southwest Addiction Technology Transfer Center College of Public Service and Community Solutions Arizona State University The slides in this presentation and associated materials were developed for the ASU CABHP. They may not be reproduced, distributed, transmitted, displayed, published or broadcast without prior permission from CABHP.