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The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.
By Brandon Danz
April 26, 2016
More than 100 Americans die from drug overdoses each day. “How do we stop that?” asks a 2014 Washington Post headline. Several states have taken innovative approaches to treat substance use disorders in a quest to answer this very question. One solution: recognizing addiction exists within—not outside—the continuum of one’s health care needs.
A History of Isolation:
For decades, addiction treatment has existed in discreet, isolated settings that have been relatively unconnected to the rest of health care—as if a person’s substance use habits had little or no relation to their physical or mental health. Substance abuse was seen as a bad choice made by individuals—on the same level as car theft. To combat these bad choices, the war on drugs prescribed a treatment that further separated addiction from proper health care: incarceration.
Barriers that have contributed to this siloed approach include the stigma that accompanies treatment. Individuals who seek addiction treatment generally do not want to broadcast it, even to their other health care providers. For this reason, drug and alcohol treatment data continue to be super-protected at the federal and state levels. In fact, even in 2016, many physicians have no knowledge of their patient’s enrollment in an addiction program without the patient volunteering the information.
A New Approach:
Following passage of the Affordable Care Act (ACA), a new person-centered approach to care has weaved its way throughout the health care industry, recognizing the interdependence of mental, physical and psychosocial health to a person’s overall wellbeing. New accountable care organizations, patient-centered medical homes and value-based reimbursement models incentivize providers to manage and improve a person’s overall health, taking the place of a traditional disease-focused approach to care.
Fortunately, substance use disorder treatment has not escaped these reforms. Nineteen states have launched health home initiatives to provide person-centered care for Medicaid recipients with serious mental illness and co-occurring chronic conditions. Three of those states – Maryland, Rhode Island and Vermont – have included individuals with substance use disorders in their eligible populations. A fourth state, Pennsylvania, recently launched a similar model that folds care management of substance use disorders into a person-centered approach. These models acknowledge that substance abuse exists within the continuum of (and not separate from) a person’s spectrum of health care needs.
Maryland: targets Medicaid recipients with serious mental illness or opioid substance use disorder and are at risk for another chronic condition. The program currently has 4,553 individuals enrolled. Managed care plans and the state’s behavioral health office use claims data to identify and refer potentially eligible individuals from among their members. A strict opt-in process assures data is exchanged only after a patient consents.
Rhode Island: targets Medicaid enrollees with opioid substance use disorder who currently receive or meet criteria to receive medication assisted therapy. Unlike Maryland, this is an opt-out model where individuals are auto-assigned to health homes with the ability to select a different health home. The program currently has 2,657 individuals enrolled. One unique feature of Rhode Island’s model is the presence of a single statewide coordinator whose responsibility it is to oversee health home implementation across all providers and act as a liaison between the health homes and the state. This produces an economy of scale in administrative functions, which has enabled the state to produce a lower capitated payment for health home services.
Vermont: targets Medicaid enrollees who receive medication assisted therapy for opioid addiction. Most beneficiaries are identified through providers, clinical assessment, the prior authorization process for prescriptions and/or enrollment in methadone treatment. They are then auto-assigned to a health home with the ability to opt out or select another health home. Vermont provides intensive care management to the highest risk individuals in “hubs,” which are specialty treatment centers, and offer a less intensive form of care management in “spokes,” which are physicians’ offices.
Pennsylvania: just two weeks ago announced the creation of 50 Centers of Excellence to improve treatment for addiction to opioids. Although not a health home model, this state has accepted federal funding to develop centers that will be team-based and whole person focused, with the goal of integrating behavioral health, primary care and substance use treatment. Each center will be awarded $500,000 in funding to deploy community-based care management teams, track and report outcomes of care management interventions, and meet standards related to drug and alcohol and mental health counseling.
As policymakers continue to combat the growing substance abuse epidemic in the U.S., they should look to person-centered models such as these to align each individual’s health care needs behind a single, person-centered strategy.
Author: Brandon Danz, M.H.A., M.P.A., is a senior associate at OPEN MINDS and an ASPA member. He is a graduate of the master of health administration program at the Pennsylvania State University and the master of public administration program at Shippensburg University of Pennsylvania. Danz can be reached at www.linkedin.com/in/brandondanz/