Include Substance Use Disorder Services in New Hampshire Medicaid Managed Care

Transcription

1 Include Substance Use Disorder Services in New Hampshire Medicaid Managed Care New Futures mission is to advocate, educate, and collaborate to reduce alcohol and other drug problems in New Hampshire. Expanding the availability of effective prevention, treatment, and recovery support services for all New Hampshire citizens is one of New Futures top strategic priorities. Therefore, New Futures is advocating for inclusion of an array of effective, integrated substance use disorder services in the upcoming Medicaid managed care services contracts. The importance of including the management of substance use disorders in the earliest phase of development of care management of Medicaid beneficiaries in New Hampshire cannot be overstated. The following is the rationale for this position: 1. Addiction is a disease which can be effectively managed and treated like other chronic conditions such as diabetes and heart disease, 2. NH Medicaid is currently spending millions on substance use disorders but not effectively or efficiently diagnosing, treating, and managing the care of beneficiaries with these disorders; 3. Cost offsets in Medicaid are significant when a robust array of substance use disorder services are included; 4. Parity for mental health and substance use disorders is required for Medicaid Managed Care plans under federal law. Absent regulations regarding the monitoring of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), the obligation for parity in Medicaid Managed Care still exists and MCO s are obligated to comply; and 5. Preparation for substance use disorder services requirements under the Affordable Care Act need to start immediately as a robust array of reimbursable services and providers is not currently widely available in NH and must be in place by January To provide these vital services, NH Medicaid Managed Care must include: a robust service array; a specialty provider network; an integrated resiliency and recovery oriented system of care; and adequate reimbursement. The following explains New Futures position in support of inclusion of comprehensive services in Phase 1, to begin in July 2012, and vision for an adequate services array and provider network within an integrated resiliency and recovery oriented system of care.

2 November 2011 Substance Use Disorder Services in Medicaid Managed Care Page 2 of 5 1. Addiction is a Disease Addiction is a chronic, relapsing brain disease that has a significant adverse impact on the health, wellbeing and safety of New Hampshire and its citizens. The link between substance use disorders, mental illness and other chronic illnesses is well documented. Seventy percent of individuals with a significant mental health or substance use disorder have at least one chronic health condition (45% have two and almost 30% have three or more). 1 Given this data, it is not surprising that people on Medicaid with substance use disorders have significantly higher expenditures for health problems than do other beneficiaries Current Substance Use Disorders Spending in NH Medicaid In 2010, New Futures commissioned the NH Center for Public Policy Studies to explore the available data on alcohol and other drug related services paid for through the state s Medicaid program. The resulting report, Payment for Alcohol and Other Drug Related Services by New Hampshire s Medicaid Program May 2010, analyzes Medicaid claims data for Medicaid eligible adults for calendar year 2005 (the most recent year for which fully scrubbed data was available at that time). 3 Diagnosis codes used to group and categorize diseases for billing and research purposes were the primary data source of evidence of a substance use disorder and/or a mental illness. It should be noted that the Report does not include expenditures for pharmaceuticals or dental services, and that the Report includes information on Medicaid eligible adults but not on beneficiaries under 18. The major findings of the Report were: In calendar year 2005, Medicaid expenditures for alcohol and other drug claims totaled almost $9 million (approximately 1% of total Medicaid expenditures) for 2600 individuals (less than 3% of all Medicaid enrollees) at an average annual cost per person of $3,437. Approximately 53% of the expenditures were for inpatient services; 25% were for services provided in a nursing home or long term care facility; and 20% were for outpatient or homebased services. Adult Medicaid recipients who had evidence of a substance use disorder (SUD) used more Medicaid services on average than those who did not have a SUD and those individual s average costs per person were higher ($9,965 versus $7,603) 3. A Tool for Savings Untreated substance use disorders are a major driver of health care costs. Analysis of the impact of substance use disorders on Medicaid health care expenditures has shown that Medicaid beneficiaries have a higher rate of substance use disorders than in Medicare or privately insured populations and that there are significantly higher costs among Medicaid beneficiaries with substance use disorders. 4 One of the many goals of NH Medicaid Managed Care is cost containment. Investing in substance use disorder services is one of the mechanisms that could be utilized to bend the cost curve. In a December 2010 report, the Center for Health Care Strategies clearly articulates that the most expensive Medicaid beneficiaries with disabilities have clinically complex multi-morbidities, 12.4% of which include drug and alcohol use disorders. 5 This finding confirms the need for programs that integrate physical, mental health and alcohol and other drug use disorder care policies, programs,

3 November 2011 Substance Use Disorder Services in Medicaid Managed Care Page 3 of 5 and service delivery. The authors conclude, [B]y enhancing care for Medicaid s highest-need, highest-cost subsets, states can potentially achieve not only better outcomes, but also substantial cost savings through more efficient care and reduced utilization. 6 In states such as Washington, cost offsets associated with including an array of substance use disorder services in Medicaid have been substantial. Cost offsets per adult disabled beneficiary have continued to grow each year that comprehensive substance use disorder services have been available through Medicaid, from $287 per patient per month in the first two years to $321 per patient per month in the fourth year. 7,8 4. Parity is Required The federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) intended to end the discrimination in insurance coverage that prevented many people from receiving the recommended type, level and amount of care needed to be and stay well. MHPAEA mandates that group health plans must provide mental health and substance use disorder (MH/SUD) benefits that are equitable to other medical and surgical benefits. The Patient Protection and Affordable Care Act (ACA) extends these requirements to qualified health plans in the statebased health insurance exchanges and Medicaid benchmark coverage offered through Medicaid expansion. Plans may use cost containment techniques but must manage MH/ SUD benefits in the same way that other medical conditions are managed. Further, MHPAEA parity in Medicaid managed care plans must be fully implemented and effective now, under the ACA. 5. Preparation for the Expansion Population The Patient Protection and Affordable Care Act of 2010 provides unprecedented opportunity to mainstream alcohol and other drug problems and close the addiction treatment gap. The ACA incentivizes a retooling of the health care delivery system to include robust primary care that does not just include, but will focus on prevention and early management of chronic diseases including substance use disorders. As stated earlier, NH has significantly high rates of alcohol and drug problems and untreated substance use disorders. Further demonstrating the pervasiveness of this problem, 28% of young adults in New Hampshire report needing but not receiving treatment for alcohol or drug use. 9 It can be anticipated that a higher percentage of those with untreated substance use disorders will be in the NH ACA Medicaid expansion population in January 2014 as many in this cohort are anticipated to be younger and have received little or no healthcare treatment in recent years. To build an accessible, effective, integrated provider system, managed care companies must start preparation immediately. Necessary Service Array When substance use disorders are treated like other chronic disorders such as diabetes, hypertension, obesity, or heart disease with quality treatment and recovery support the outcomes are comparable or even better. Medical consensus that treatment works is well documented. 10 Although addiction is a chronic disease, it can be and is treated successfully. Like other chronic diseases, addiction can successfully be addressed through illness prevention, early

4 November 2011 Substance Use Disorder Services in Medicaid Managed Care Page 4 of 5 detection, education, on-going treatment, disease management, acute care, recovery support, and rehabilitation. The MHPAEA requires that substance use disorders be treated in this manner, like other chronic conditions. To be effective, substance use disorder treatment must also include this array of effective accessible services, all of which are defined and reimbursable through Medicaid: Screening, Brief Intervention, and Referral to Treatment (SBIRT) 11 implemented throughout the existing and expanded Medicaid provider network, particularly in primary care, emergency department, and pediatric (adolescent) settings. Outpatient Services in a wide array of settings to provide access and reduce stigma. Intensive Outpatient Services specialized for adolescents, young adults, adults and women at accessible locations throughout the state. Services to include individual, family, and group counseling and appropriate recovery supports necessary to participate in that level of care (such as case management, childcare and transportation). Medication Assisted Treatment and Recovery Services covering medications (for opiate dependence, alcohol dependence, etc.) and appropriate level of care and recovery supports. Recovery Support Services by trained, supervised personnel, both peer and non-peer. Medical Detoxification Services accessible through hospital and outpatient providers. Community Based Detoxification Services in specialty, short-term residential settings. Adequate, Accessible Specialty Provider Network The current provider network is inadequate to meet the substance use disorder screening, intervention, treatment, and recovery support needs of NH Medicaid beneficiaries. The network needs to be expanded to include specialty alcohol and other drug treatment programs and professionals. NH law provides for specialized licensure and certification of alcohol and other drug services professionals through the New Hampshire Board of Licensing for Alcohol and Other Drug Use Professionals. 12 The Board credentials and regulates the following alcohol and other drug services professionals: Certified Recovery Support Worker (CRSW); Licensed Drug and Alcohol Counselor (LADC); and Master Licensed Drug and Alcohol Counselor (MLADC). In addition, to be effective and efficient, the network must include: Peer Recovery Support Workers, trained and supervised by certified Recovery Support Organizations; Specialty trained clinicians licensed by the NH Board of Mental Health such as social workers, mental health counselors, and psychologists; and State certified Alcohol and other Drug Treatment Programs (such as members of NH Providers Association 13 and others). Integration within a Resiliency and Recovery-oriented System of Care The New Hampshire Department of Health and Human Services supports the creation of a resiliency and recovery oriented system of care for alcohol and other drug problems. Integration among potential service providers is imperative under this model. Recovery from substance use disorders is strengthened through effective collaboration among beneficiaries, their families, healthcare

5 November 2011 Substance Use Disorder Services in Medicaid Managed Care Page 5 of 5 providers, mental health specialists, substance use disorder specialists and other recovery supports. There should be no wrong door to access to needed care. New Futures strongly recommends that substance use disorder providers be integrated into the healthcare system through direct hire, colocation, and collaboration within Community Mental Health Centers, Community Health Centers, Hospitals, and Primary Care Practices. Adequate and Equitable Reimbursement Equity demands that reimbursement for behavioral health services, including substance use disorder services, be fair and adequate. To provide the services outlined above innovative reimbursement practices may be employed but must ensure that substance use disorder services are equitably reimbursed and that non-profit providers are adequately paid. CONCLUSION New Futures supports the building of comprehensive Phase 1 care management proposals, within the existing funding structure, that include a robust array of comprehensive, effective, integrated substance use disorder services and specialized providers. The public asked for these heretofore uncovered and unmanaged services during the public input process. These services have been proven to improve health and save money, are required under federal law, and will have a dramatic impact on the health outcomes and cost of healthcare for this population Payment for Alcohol and Other Drug Related Services by New Hampshire s Medicaid Program May 2010, NH Center for Public Policy Studies. 3 Payment for Alcohol and Other Drug Related Services by New Hampshire s Medicaid Program May 2010, NH Center for Public Policy Studies. 4 Clark, Robin, and Mihail Samnaliev and Mark McGovern. Impact of Substance Disorders on Medical Expenditures for Medicaid Beneficiaries With Behavioral Health Disorders. Psychiatric Services 60, no. 1 (January 2009): Boyd, Cynthia, and Bruce Leff, Carlos Weiss, Jennifer Wolff, Allison Hamblin, and Lorie Martin. Clarifying the Multimorbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations. Faces of Medicaid Data Brief Center for Health Care Strategies, Inc. (December 2010): 4. 6 Ibid Mancuso, David, and Daniel J. Nordlund, and Barbara E.M. Felver, in collaboration with DSHS Health and Recovery Services Administration, Division of Alcohol and Substance Abuse. DASA Treatment Expansion: The First Two Years (May 2007): 2. 8 Mancuso, David, and Daniel J. Nordlund, and Barbara E.M. Felver, MES, MPA in collaboration with DSHS Health and Recovery Services Administration, Division of Alcohol and Substance Abuse. DASA Treatment Expansion: Spring 2009 Update (June 2009): 3. 9 National Survey on Drug Use and Health, National Academy of Sciences. Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Prepared for the Institute of Medicine by the Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders. Washington, DC, The New Hampshire Alcohol and other Drug Services Providers Association,