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Health reform and other policies around substance abuse treatment systems ondcp 4.2010


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White House Office of National Drug Control Policy on the implications of health reform in substance abuse prevention and treatment.

(Keith Humphreys
Senior Policy Advisor, White House ONDCP)

Published in: Health & Medicine
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Health reform and other policies around substance abuse treatment systems ondcp 4.2010

  1. 1. Policies that promote effective systems of care for substance use disorders Keith Humphreys Senior Policy Advisor, White House ONDCP Professor of Psychiatry, Stanford University Career Research Scientist, Department of Veterans Affairs
  2. 2. Substance Use Disorder Care is a major focus of NDCS, but not the only one <ul><li>Prevention </li></ul><ul><li>Reduction of Prescription Drug Abuse </li></ul><ul><li>Drugged Driving </li></ul><ul><li>New models of law enforcement and community supervision </li></ul><ul><li>Merida Initiative, CBSI, Afghanistan </li></ul><ul><li>See for the full National Drug Control Strategy </li></ul>
  3. 3. Can Countries Achieve “Tipping Points” with Substance Use Disorder Treatment? <ul><li>Some nations have treatment on demand and very high population penetrance (Australia, Switzerland, The Netherlands) </li></ul><ul><li>Others invest some resources, but have lower population penetrance (U.S.) </li></ul><ul><li>Critical question is whether there is a “tipping point” with care expansion </li></ul>
  4. 4. In U.S., about one in six persons meeting diagnostic criteria for illicit drugs received specialty treatment Total needing treatment for illicit drugs = 7.559 million . Source: SAMHSA, 2008 National Survey on Drug Use and Health (September 2009). 8/2009 13
  5. 5. Proportion of all heroin addicted individuals in methadone maintenance, 1993 Source: MacCoun, R. J., & Reuter, P. (2001). Drug war heresies . Cambridge, UK: Cambridge University Press.
  6. 6. France subsequently dramatically expanded opiate agonist treatment Emmanuelli, J., & Desenclos, J-C. (2005). Harm reduction interventions, behaviours and associated health outcomes in France, 1996-2003. Addiction, 100 , 1690-1700.
  7. 7. ..And apparently achieved a tipping point 1996-2003 <ul><li>Annual heroin arrests dropped from 17,328 to 4,025 </li></ul><ul><li>Annual overdose deaths declined from 465 to 89 </li></ul>
  8. 8. Only historical U.S. example <ul><li>From 10/1971 – 3/1973, federal government expanded treatment slots 352% </li></ul><ul><li>First national annual drop in street crime in 20 years occurred from 1972-1973 </li></ul><ul><li>Data systems at the time too crude to conduct more fine-grained analysis </li></ul>References: Musto, D., & Korsmeyer, P. (2002). The quest for drug control . New Haven: Yale University Press; Massing, M. (1998). The fix . New York: Simon and Schuster.
  9. 9. How will the Obama Administration Increase the Quantity of Care for Substance Use Disorder?
  10. 10. Patient Protection and Affordable Care Act of 2010 <ul><li>Specifies that screening, brief intervention and treatment for substance use disorders are essential healthcare benefits </li></ul><ul><li>Insures about 5M more people who have substance use disorders </li></ul><ul><li>Extends parity regulations to exchanges </li></ul><ul><li>Expands Medicaid to 133% of FPL, covers childless adults </li></ul>
  11. 11. The Spectrum of Substance Use Disorder Specialty Treatment ~ 2,300,000 Abuse/Dependent – 25,000,000 “ Harmful Users” – ??,000,000 Little or No Use
  12. 12. What is SBIRT? <ul><li>Screening, Brief Intervention and Referral for Treatment </li></ul><ul><li>Targeted at less dependent patients </li></ul><ul><li>Strong evidence of effectiveness </li></ul><ul><li>Usable in primary care, emergency rooms and other </li></ul>
  13. 13. Administration SBIRT proposals <ul><li>CMS continue to support billable codes </li></ul><ul><li>President’s budget request supports their expansion with new funding for monitoring and technical support </li></ul><ul><li>Expand program to train physicians in SBIRT methods </li></ul>
  14. 14. Selected Administration initiatives for treatment of addicted individuals <ul><li>Mental health and substance abuse parity regulations </li></ul><ul><li>Expansion of funding in existing health care systems (more on this later..) </li></ul><ul><li>Re-entry/diversion initiative </li></ul><ul><li>End of ban on federal funding for NEP </li></ul><ul><li>Increase in NIH funding </li></ul><ul><li>Medicaid expansion? </li></ul>
  15. 15. Will all this increase in quantity produce a “tipping point”?
  16. 16. A brief but important word about expanding treatment in developing countries
  17. 17. International Demand Reduction <ul><li>PEPFAR new focus on medication assisted treatment for IDUs </li></ul><ul><li>Merida Initiative includes support for electronic linkage of 300 treatment centers in Mexico </li></ul><ul><li>NIDA international scholars and research programs </li></ul>
  18. 18. Expanding quantity does not resolve concerns about quality
  19. 19. Alcohol dependence was last among 30 medical conditions in proportion of care received as evidence would recommend Source: McGlynn E., et al., (2003). The quality of health care delivered to adults in In the United States. New England Journal of Medicine, 348 . Senile cataract 78.7% Breast cancer 75.7% Prenatal care 73.0% Hypertension 64.7% Asthma 53.5% Diabetes Mellitus 45.4% Urinary Tract Infection 40.7% Atrial Fibrillation 24.7% Alcohol Dependence 10.5%
  20. 20. Common quality issues <ul><li>Isolation of specialty addiction treatment and mainstream health care </li></ul><ul><li>Sub-optimal staff training, morale and pay </li></ul><ul><li>Poor continuity of care </li></ul><ul><li>Inadequate health information technology </li></ul><ul><li>Minimal use of evidence-based practices </li></ul><ul><li>High process regulation…with weak performance standards </li></ul>References: Uchtenhagen A., Stamm R., Huber J., and Vuille R. (2008) A review of systems for continued education and training in the substance abuse field. Substance Abuse 29 , 95-102. McLellan, AT, Carise, D, Kleber, HD. (2003). Can the national information treatment infrastructure support the public’s demand for quality care? . Journal of Substance Abuse Treatment. 25, 117-21 .
  21. 21. What policies might improve the quality of care?
  22. 22. Improving quality is a challenge: Dr. Zoe D. Katze
  23. 23. Incentivizing particular care processes: VA example <ul><li>Pool of “off the top” funding set aside at beginning of each year </li></ul><ul><li>Meeting standards on particular indicators is rewarding financially </li></ul><ul><li>Success example: Alcohol screening and identification of problem drinkers </li></ul>
  24. 24. Rates of identifying substance abuse in VA versus other systems
  25. 25. Administration Proposal: P4P for States <ul><li>President’s Budget requests $6M for a new pay for performance program </li></ul><ul><li>States and Tribes would compete for the funds </li></ul><ul><li>Those selected would receive incentive funds to reward quality in their systems </li></ul><ul><li>Broad latitude allowed for the dimension of care rewarded </li></ul>
  26. 26. A market-based approach to quality: Access to Recovery <ul><li>Individuals seeking care receive a voucher, value varies, average around USD1600 </li></ul><ul><li>For public sector, provides unusual freedom to select (or switch) care options </li></ul><ul><li>About $100M annually in 3-year cycles, offers services to about 160,000 individuals total </li></ul><ul><li>Obama Administration proposes $9.9M increase for program </li></ul>
  27. 27. Embedding specialty care within medicine to improve quantity and quality at once <ul><li>Makes specialty care subject to the quality and process regulations of medicine </li></ul><ul><li>Brings in the staff and resources to meet those standards </li></ul><ul><li>But allows choice because U.S. insurance system is market based </li></ul>
  28. 28. Other potential advantages to expanding substance use disorder care within mainstream healthcare systems <ul><li>Better integration of care from the outset </li></ul><ul><li>Unified health information technology </li></ul><ul><li>Less stigma to accessing care </li></ul>
  29. 29. Two care systems for such expansion, proposed in President’s 2011 Budget <ul><li>HRSA’s Community Health Centers </li></ul><ul><li>Indian Health Service </li></ul>
  30. 30. Summary <ul><li>Obama Administration is emphasizing brief interventions, and, treatment for people with substance use disorder </li></ul><ul><li>A public health “tipping point” may be achievable through treatment/brief intervention, but required amount of expansion is unknown </li></ul>
  31. 31. Summary, continued <ul><li>Administration proposing major investments in expanding the quantity of treatment </li></ul><ul><li>Expansion of quantity does not necessarily improve quality, hence some quality focused proposals as well </li></ul><ul><li>Expansion of substance use disorder treatment within mainstream healthcare systems may offer quantity AND quality benefits </li></ul>
  32. 32. - The End -