What’s Wrong With Addiction Treatment:

What Are New Opportunities?

The Specialty Care SystemA “Customer” Perspective

• Patient Survey • Care Provided• Infrastructure

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 <12%

Sources – NSSATS, 2002; D’Aunno, 2004

Substance Use Pyramid

In Spec Treatment – 2,100,000

Abuse/Dependent – 23,000,000

“Harmful Users” – ??,000,000?

Referral Sources

Source 1990 2004

Criminal Justice 38% 59%

Employers/EAP 10% 6%

Welfare/CPS 8% 16%

Hosp/Phys 4% 3%

Why Don’t

Patients Want

Treatment?Sources: 4 Review ArticlesRapp et al. JSAT 2005 Stanton JMFT 2004

Appel et al. AJDA 2004 Tsogia et al. JMH 2001

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%

WHY?Won’t programs deliver quality

care?CAN’T

Three Reasons

a. The Infrastructure

b. The Acute Care Model

c. The Way it is Evaluated

Phone Interviews With National Sample of 175 Programs regarding personnel, management, information

McL, Carise & Kleber JSAT, 2003

The Treatment System

Modality 1975 1990 2006

Residential 64% 39% 8%

Outpatient 27% 59% 79%

Methadone 9% 10% 13%

• Counselor turnover 50% per year

• 50% of directors have been there Less Than 1 year

STAFF TURNOVER!

Other Staff • 54% Had no physician

34% Had P/T physician39% Had a Nurse (part of

full time)

• < 25% Had a SW or a Psychologist

• Major professional group – Counselors(Average Age – 54)

• Modest Computer Availability– Mostly For Administrative Work

– 80% Had a Computer

– 50% had Web Access

• Still very little computer/software availability for CLINICAL STAFF

Information Systems:

• The Acute Care Model

• Treatment Models for Other Illnesses

A Nice Simple Rehab Model

NTOMS Sample of 250 Programs

Treatment

Substance Abusing Patient

Non- Substance Abusing Patient

Medications,Therapies,JCAHO, CARF, WCEv. Based Prac.

How Do Other

Treatments Work? Chronic Illness & Continuing Care

A Continuing Care Model

PrimaryContinuing Care

Primary Care

Specialty Care

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

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

• Implications of How We Evaluate

• Differences in Outcome Expectations

I

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.

0

2

4

6

8

10

Pre During During During Post

Treatment Research Institute

Outcome In Hypertension

0

2

4

6

8

10

Pre During During During Post

Treatment Research Institute

Outcome In Addiction

Maybe this is why…

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.

Are there new opportunities to show the value of treatment?

• Primary Care• Different Treatment Model• New Purchasing Methods

1 – New Proc/Pay Codes2 – Medications3 – PRISM

Effective January 2008

• Separate Billing Codes for– Screening of alcohol problems

– Brief Interventions (advice and counsel)

• Non-Physician Assistant Codes– Behavioral and Lifestyle Factors

• Medications– Alcohol (Disulfiram, Naltrexone, Accamprosate)

– Opiates (Naltrexone, Methadone, Buprenorphine)– Cocaine (Disulfiram, Topiramate, Vaccine?)

– Marijuana (Rimanoban)

– Methamphetamine – Nothing Yet

But…

Referral Sources

Source 1990 2004

Criminal Justice 38% 59%

Employers/EAP 10% 6%

Welfare/CPS 8% 16%

Hosp/Phys 4% 3%

WHY?Can’t physicians do SBIRT?WON’T

Top Physician ReasonsSource 426 PCPs @ SGIM

1) Don’t know what to do 69%

2) No Effective Treatment 55%

3) Not really a medical prob 26%

4) No time 19%

Disorders with Higher Prevalence Among Substance Abusers

0

1

2

3

4

5

6

7

8

Chronic Pain Arthritis Asthma Diabetes HTN

Substance abusing patients = 747Matched controls = 3,690

Perc

ent

Weisner et al. Arch Intern Med. In press.

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.” “I’ve 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.1Online version, accessed at http://www.nytimes.com/2006/12/01/us/01medicaid.html on 12/6/06

Program of Research to Integrate Program of Research to Integrate Substance Use Information into Substance Use Information into

Mainstream HealthcareMainstream Healthcare

PRISM

Chronic Illness Care

Substance Use Prevalence

In Spec Treatment – 2,300,000

Low Level Use

Focal Group

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

The PRISM Approach

Systematic ReviewsDiabetes:

– 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

Risk of Mortality & Drinks/Day

1.0

1.3

1.2

1.1

1.4

0.6

0.9

0.8

0.7

7650 21

Drinks per Day

Ris

k of

Mor

talit

y

3 4

Di Castelnuovo et al. Arch. Int. Med. 2006;166(22):2437

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

How Does Specialty Care Work In the

Rest of Medicine?

A Continuing Care Model

PrimaryContinuing Care

Primary Care

Specialty Care

Example….PCP - 58 y/o male reports ringing

in ears, dizziness/nausea

Actions - 1. Order/refer for testing – on EHR2. Results to PCP – from EHR3. Working Dx – discuss w/pt4. Refer to specialist – on EHR

Example Cont’d….Specialist - Reads all testing

and notes – on EHR

Actions - 1. Writes note to PCP – using EHR2. Tests/Prescribes/tortures3. Evaluate – discuss w/pt - repeat4. Refers w/note back to PCP - EHR

Cultural Assumptions…

• It’s the PCP’s 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

Maybe this is why…

Referral Sources

Source 1990 2006

Criminal Justice 38% 59%

Employers/EAP 10% 6%

Welfare/CPS 8% 16%

Hosp/Phys 4% 3%

Lessons from Physician Health Plans

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).

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

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

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

`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%)

Urine Testing Over 4 years

78

260

10

20

30

40

50

60

70

80

No Positive Repeat Positive

Results at 5-7 Years

Practicing Medicine

Completers 92%

Continuers 73%

Non-Completers 28%

Results at 5-7 Years

Revoked License

Completers 2%

Continuers 11%

Non-Completers 32%

Performance ContractingIn Delaware

13,200 programs in US• 65% private, not for profit

• 80% primarily government funded Private insurance <12%

• 31% treat less than 200 patients per year

Sources – NSSATS, 2002; D’Aunno, 2004

Delaware Situation 2002

• 11 Outpatient Providers

• Limited Budget

• No success with outcome evaluation

• Providers won’t/can’t use EBPs

Delaware’s Performance Based Contracting

• 2002 Budget – 90% of 2001 Budget

• Opportunity to Make 106%• Two Criteria:

80% Utilization/OccupancyActive Participation

• Audit for accuracy and access

Delaware’s 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

Utilization

3000

3500

4000

4500

5000

5500

6000

6500

Ave

rage

Dai

ly C

ensu

s

2001 2002 2003 2004 2005

% Attending

20

30

40

50

60

70

80

2001 2002 2003 2004 2005

>30 days >60 days

• 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

Substance Use Pyramid

In Spec Treatment – 2,100,000

Abuse/Dependent – 23,000,000

“Harmful Users” – ??,000,000?

What’s 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

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

Forces That May Affect Addiction Treatment

• Scientific Discoveries• Medications (4 co’s 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

Forces That May Affect Addiction Treatment

• Market Forces• Consumer’s 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

Forces That May Affect Addiction Treatment

• Other Forces• IOM 2006 Report

• Pending Suits• Insurance Parity