Recovery, Opportunities under Health Care Reform

Behavioral Health & Addiction Treatment Opportunities under Health Care Reform

Los Angeles, CA September 30, 2011

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director

Center for Substance Abuse TreatmentSubstance Abuse Mental Health Services Administration

U.S. Department of Health & Human Services

3

Without effective treatment, abuse of alcohol, illicit drugs, or prescription medications can devastate the mind and

body. With treatment, substance use disorders can

be managed, giving individuals the effective tools

necessary to address their addiction.

President Barack ObamaAugust 31, 2009

4

Kathleen SebeliusSecretary

U.S. Department of Health & Human Services

“Faith leaders are trusted partners in local communities.  You have a unique ability to reach people, especially the most vulnerable, with

the tools and information they need

to get healthy, stay well, and thrive.”

March 2010

5

“In 2011, and beyond, SAMHSA will work to improve

understanding about mental and substance use disorders, promote

emotional health and the prevention of substance abuse

and mental illness, increase access to effective treatment,

and support recovery.”

SAMHSA

Pamela S. Hyde, J.D.Administrator, SAMHSA

Excerpt from Leading Change: A Plan for SAMHSA’s Roles and Actions 2011-2014

6

SAMHSA’s Role in Improving the Nation’s Health

Behavioral health services improve health status and reduce health care and other costs to society.

SAMHSA is charged with effectively targeting substance abuse and mental health services to the people most in need and to translate research in these areas more effectively and more rapidly into the general health care system.

Continued improvement in the delivery and financing of prevention, treatment and recovery support services provides a cost effective opportunity to advance and protect the Nation’s health.

7

SAMHSA’s Strategic Initiatives

Prevention of Substance Abuse and Mental Illness Trauma and Justice Military Families Recovery Support Health Reform Health Information Technology Data, Outcomes, and Quality Public Awareness and Support

8

SAMHSA’s Health Care Reform Strategic Initiative

Purpose:• Increase access to appropriate high quality

prevention, treatment, and recovery services;• Reduce disparities that currently exist between the

availability of services for mental and substance use disorders compared with the availability of services for other medical conditions; and

• Support integrated, coordinated care, especially for people with behavioral health and co-occurring health conditions, such as HIV/AIDs.

9

SAMHSA’s Health Care Reform Strategic Initiative - Goals

Strategic Initiative Goals: • Ensure that behavioral health is included in all aspects of

health reform.• Support Federal, State, Territorial, and Tribal efforts to

develop and implement new provisions under Medicaid and Medicare.

• Finalize and implement the parity provisions in the Mental Health Parity and Addiction Equity Act and the Affordable Care Act.

• Develop changes in SAMHSA Block Grants to support recovery and resilience.

• Foster the integration of primary and behavioral health care.

10

Challenges Remain

In 2010, an estimated 22.1 million persons were classified with substance abuse or dependence.

• 2.9 million of them were dependent upon or abused both alcohol and illicit drugs.

And, during 2009, there were an estimated 11 million adults (18 or older) in the U.S. – 4.8% of adults -- with serious mental illness in the past year.

Source: 2009 & 2010 NSDUH

11

Past Month Alcohol Use - 2010

Any Use: 51.8% (131 million)

Binge Use: 23.1% (59 million)

Heavy Use: 6.7% (17 million)

Source: NSDUH 2010

(Current, Binge, and Heavy Use estimates are similar to those in 2009)

12

Past Month Use of Selected Illicit Drugs among Persons Aged 12 or Older: 2002-2010

8.9%

6.9%

2.7%

8.7%8.0%8.3%8.1%7.9%8.2%8.3% 8.0%

6.6%5.8%6.0%6.0%6.1%6.2%6.2% 6.1%

2.8%2.8%2.9%2.7%2.5%2.7%2.7% 2.5%

0.6%0.7%0.8%1.0%1.0%0.8%1.0%0.9%0.7%

0.5%0.5%0.4%0.4%0.4%0.4%0.4%0.5% 0.4%0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

2002 2003 2004 2005 2006 2007 2008 2009 2010

Perc

ent U

sing

in P

ast M

onth

Illicit Drugs Marijuana Psychotherapeutics Cocaine Hallucinogens

Source: NSDUH, 2010

13

Concurrent Illicit Drug and Alcohol Use

Illicit Drug Use concurrent with Last Alcohol use among Past Month Alcohol Users aged 12+

31.8%

17.7%

6.8%

4.0%

0% 5% 10% 15% 20% 25% 30% 35%

Heavy Alcohol Use

Binge Alcohol Use (butnot heavy)

Current Alcohol Use (butnot heavy or binge)

No Alcohol in PastMonth

Source: NSDUH 2010

Percentage of Illicit Drug use Concurrent with Past Month Alcohol Use

Perc

ent o

f Alc

ohol

use

rs w

ho a

lso

used

Ill

icit

Dru

gs –

pas

t m

onth

14

Past Month Nonmedical Use of Prescription Drugs (Psychotherapeutics) among Persons 12+:2002-2009

Source: NSDUH 2009

2.1%

0.8%

0.5%

0.1%

1.9%2.1%2.1%

1.9%1.8%

2.0%1.9%

0.7%0.7%0.7%0.7%0.7%0.8%0.8%

0.4%0.4%0.6%0.5%0.5%0.6%0.6%

0.1%0.1%0.2%

0.1%0.1%0.1%0.2%

0%

1%

1%

2%

2%

3%

2002 2003 2004 2005 2006 2007 2008 2009

Perc

ent U

sing

in P

ast M

onth

Pain Relievers Tranquilizers Stimulants Sedatives

15

California State Indicators vs. National Average

Source: NSDUH, 2008-2009 average

Percent of clients reporting… California National Average

Binge Alcohol Use in Past Month 16.74% 23.46%

Any Illicit Drug Use in the Past Month

10.0% 8.34%

Alcohol or Drug Dependence or Abuse in Past Year

9.48% 8.92%

Needing, but not receiving treatment for illicit drug use

2.76% 2.53%

Needing, but not receiving treatment for alcohol use

7.50% 6.98%

16

Past Year Initiates for Specific Illicit Drugs among Persons Aged 12 or older: 2010

45

140

252

377

624

637

937

1,238

2,004 2,426

793

0 500 1,000 1,500 2,000 2,500

PCP

Heroin

Sedatives

LSD

Stimulants

Cocaine

Inhalants

Ecstasy

Tranquilizers

Pain Relievers

Marijuana

Numbers in ThousandsSource: NSDUH 2010

Number of Individuals nationally reporting first use of substance in past year

1717

22.4%

8.2% 8.6%

2.2%

18.3%

7.0%

0%

5%

10%

15%

20%

25%

30%

% D

epen

dent

on

or A

busi

ng S

ubst

ance

Drug or AlcoholDependence or Abuse

Drug Dependence orAbuse

Alcohol Dependence orAbuse

Had Major Depressive Episode in Past Year Did NOT Have Major Depressive Episode in Past Year

Source: SAMHSA NSDUH 2009

Substance Dependence or Abuse among Adults Aged 18 or Older, by Major Depressive Episode in the Past Year: 2009

18

Where Past Year Substance Use Treatment Was Received among Persons 12+: 2010

Numbers in Thousands

1,689 2,334

342

467

653

731

986

999

0 500 1000 1500 2000 2500

Prison or Jail

Emergency Room

Private Doctor's Office

Hospital Inpatient

Inpatient Rehabilitation

Outpatient MH Center

Outpatient Rehabilitation

Self-Help Group

Source: NSDUH 2010

19

20.5 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use

3.3%

Felt They Needed Treatment and Did

Make an Effort

Did Not Feel They Needed

Treatment

Felt They Needed Treatment and Did Not

Make an Effort

1.7%95.0%

Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving

Treatment for Illicit Drug or Alcohol Use: 2010

(683,000)

(341,000)

( 19.5 Million)

Source: NSDUH 2010

20

Reasons for Not Receiving Substance Use Treatment: Persons Aged 12+

Percent Reporting Reason

Not Ready to Stop Using

No Health Coverage and Could Not Afford Cost

No Transportation/Inconvenient

Might Cause Neighbors/Community to Have Negative Opinion

Able to Handle Problem without Treatment

7.1%

6.5%

38.1%

30.3%

9.0%

8.4%

7.9%

7.4%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Those who Needed & Made the Effort to Get Treatment But Did Not Receive Specialty Treatment

Source: NSDUH, 2006-2010 combined

Might Have Negative Effect on Job

Did Not Feel the Need for Treatment at the Time

Had Health Coverage but Did Not Cover Treatment or Did Not Cover Cost

21

Payment for Substance Abuse Treatment – U.S.

In 2009, persons who received their most recent substance use treatment at a specialty facility in the past year reported the following method of payment.

Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to 2009

27.0%

7.8%

1.0%14.1%

28.8%

12.3%

8.9%Self-pay

Blue Cross/Blue Shield, Other Health Insurance

Medicare, Worker's Compensation

Medicaid

Other Government Payments

No Charge

Other

22

The Uninsured – U.S.

More than 18.4 million full-time employees (18-64) had no health insurance coverage -- 54.5% of the Nation’s uninsured adults.

24.4%

15.5%

6.9%

19.2%

11.2%

6.9%

14.4%12.1%10.5%

0%

5%

10%

15%

20%

25%

30%

Aged 18-25 Aged 26-49 Aged 50-64* Male Female

Full-time Employees, Uninsured

Perc

ent

Need for SA Treatment Receipt of SA Treatment

*Receipt of treatment data for the 50-64 age group were suppressed because of low precision.Source: 2007 & 2008 SAMHSA NSDUHs

23

Patient Protection and Affordable Care Act (ACA)

38.1% of those needing substance abuse treatment did not receive it because they did not have health insurance coverage or couldn’t afford the cost.

Another 7.4% had health insurance, but it didn’t cover the cost of treatment.

The Affordable Care Act (ACA) Does Several Things:• Expands Insurance Coverage• Institutes Insurance Reforms• Builds Infrastructure To Provide Improved Health

Outcomes• Puts In Motion Structural Changes To How Healthcare

Delivery Is Structured & Financed

24

Expanded Health Insurance Coverage - 2014

Insurance Coverage Expands From 83% to 94%• 21% of non-elderly Californians (or 6.9 million) are

currently uninsured. (Kaiser Family Foundation)

Individual Mandate Applies Subsidies For Those Under 400% FPL Medicaid Eligibility Set At 133% FPL

• For California, this means approximately 3 million new residents will be eligible for Medicaid (Kaiser Family Foundation)

25 Million nationally get insurance through state exchanges

25

What Do We Know About the Newly Covered?

In 2014 —16 million will become newly eligible under the expansion in Medicaid.

An estimated 1.8 million uninsured have a serious addiction and 3.3 million uninsured have a mental illness

Individuals Near the Federal Poverty Level—More diverse group than we think: 40% under the age of 29, 56% are employed or living with their families, conditions are more acute when they present, and care is more costly

>100% FPL >100 – 200% FPL >200% FPL

Poor or fair physical health

25% 18% 11%

Poor or fair mental health

16% 11% 6%

Source: Center on Budget and Policy Priorities

26

The Social Determinants of Health*

* Adapted from the World Health Organization

INTERMEDIARY DETERMINANTS OF HEALTH

SOCIOECONOMICPOLITICAL

CONTEXT

Governance

Macroeconomic Policies

Social PoliciesLabor Market,Housing, Land.

Public Policies,Education, Health,Social protection, Drug Laws*, Immigration laws*

Culture and Societal Value

Socioeconomic Position

Social ClassGenderEthnicity (racism)Sexual Orientation*Age*Legal Status*

Education

Occupation

IncomeHealth System

IMPACT ON EQUITY IN HEALTH AND WELL-BEING

Material Circumstances(Living and Working Conditions, Food & Water Availability, etc)

Behaviors and Biological Factors(including alcohol and drug use)*

Behaviors and Biological Factors(including alcohol and drug use)*

Psychological FactorsPsychological Factors

STRUCTURAL DETERMINANTS OF HEALTH INEQUITIES

Social cohesion & Social Capital

We must remember that mental illness and substance abuse are determinants of health

We must remember that mental illness and substance abuse are determinants of health

27

Upstream vs. Downstream

Traditionally, individuals presenting with co-occurring disorders were “downstream.”– Providers could expect that symptoms reflected more acute

conditions. Increased access to health care, as well as an

emphasis on early screening will result in more individuals entering treatment “upstream.”– Providers need to be flexible and not assume that these

individuals have co-occurring conditions.– At the same time, working with individuals upstream means

providers can proactively meet other needs, such as recovery support services,

28

Recovery Support & Health Reform

Assess &Link to Service Recovery HousingPrevention & Screening EmploymentStress Management Drug Free RecreationFamily/Relationship Groups Drop In Centers orRole Modeling & Mentoring Cyber CafeRecovery Coaching Peer Council

Spiritual Support

Medical Model Social Services

Instead of Disease Model, Need Health/Wellness Model

29

ACA and Integrated Care

ACA programs focus on coordination between primary care and specialty care through:Significant enhancements to primary care

• Workforce enhancements• Mental illness and substance abuse treatment in primary care

through Federally-Qualified Health Centers (FQHCs)• Primary care in MH/SUD settings through community mental

health centers & other agencies• Services and technical assistance

Health Homes and Accountable Care Organizations

30

ReducedCriminalInvolvement

Stability inHousing

Cost Effectiveness

PerceptionOf Care

Retention Abstinence

Employment/Education

Evidence-Based Practice

Social ConnectednessAccess/Capacity

Ongoing Systems Improvement

Recovery

Health

Wellness

Outcomes

Mental Health

Primary Care

Housing

Human Services

Educational

Criminal Justice

Employment

Private HealthCare

Systems of Care

Organized RecoveryCommunity

DoD &Veterans Affairs

Indian Health Service

Addictions

Tribes/Tribal Organizations

Bureau of Indian Affairs

Child Care

Housing/Transportation

Financial

LegalCase Mgt

Peer Support

Health Care

Mental Health

Alcohol/Drug

VocationalEducation

SpiritualCivic Organizations

Mutual Aid

Services & Supports

Community Individual

Family

The Faith Community is an Essential Part of An Integrated Response to Behavioral Health

Community Coalitions

Business Community

Faith Community

Child Welfare

31

Federally Qualified Health Centers

Many of the newly insured will utilize Federally Qualified Health Centers (FQHC).

In 2007, 1080 Community Health Centers (CHC) reported seeing 17 million patients.

Mental health services were provided to 677,213, and substance abuse services to 92,406 – approximately 4% of total patients receiving services.

2.8% of CHC staff are mental health personnel; 0.7% are substance abuse treatment professionals.

A few CHC’s also engage in medication-assisted treatment.

32

Health Homes

The Affordable Care Act has authorized a health home provision [Sec. 2703 & Sec. 19459(e)] that provides the opportunity for States to build a person-centered care system that results in improved outcomes for beneficiaries and better services and value for State Medicaid and other programs, including mental health and substance abuse agencies.

33

What this Means for Community and Faith-Based Providers

Many of the traditionally underserved populations that will gain more access to health care through the ACA will use community health centers and health homes.

More individuals may be presenting earlier for treatment, through screening and increased access, when recovery support services offered by community and faith-based providers can be most effective.

34

Recruit, Enroll, Implement

Increasing access for traditionally underserved and at-risk populations does not mean that those individuals will present for treatment.• Recruit: Faith-based providers should reach out to their

vulnerable populations to ensure that they understand what services are available to them through health reform & how to access them.

• Enroll: Faith-based providers need to help their populations meet the requirements needed to receive new and expanded services.

• Implement: Faith-based providers need to ensure they are a part of an integrated approach to treatment & recovery

35

Evaluating Your Position: What Do You Have to Offer?

Faith-Based providers can help overcome barriers and help increase access by providing services that meet the spiritual as well as physical needs of the client.

To clients for whom faith is an integral part of their culture and community, faith-based providers can offer culturally sensitive services and materials that contribute to client trust and comfort – increasing the chances for sustained treatment and recovery.

In order to be a part of the integrated care system under health reform, now is the time to ask yourselves:

Are you communicating the importance of community and faith-based provider services within integrated care?

36

Workforce Challenges of Health Care Reform

Health care reform offers many potential benefits, but relies on the ability of the health care field to meet the challenges resulting from its implementation:• Influx of millions of new clients into the behavioral health

care system.• Need to implement Health IT• Greater emphasis on evidence-based practices and

outcomes• Increased emphasis on credentials and education for

behavioral health workforce• Emphasis on early intervention and integrated care

(primary and behavioral health)

37

Training and Research Increased patient-centered health research Training grants for behavioral health workforce Training on MH/SUD for primary care extender

Support for Workforce Development Funding for residencies for behavioral health included with other

disciplines (HRSA) Loan repayment programs Push towards more national certification standards and re-

licensure/re-certification Primary care/behavioral health integration -- bidirectional

ACA Focus on Workforce Development

38

The Role of Health IT

The effective integration of Health Information Technology is an important part of linking between programs, services, and providers.

Health IT can help the criminal justice system:• Communicate and collaborate between providers and

other programs• Track the progress of those for whom substance abuse

and/or mental health treatment is part of probation.• Reduce redundancy between programs and providers

39

Challenges for Behavioral Health Care

Clarifying how 42 CFR Part 2 is impacted by Health IT.• Without a guarantee of confidentiality, many individuals with

substance abuse problems would be reluctant to participate fully in treatment programs.

Establishing trust between providers and patients.• Electronic exchange efforts must establish trust relationships

with all participants, including patients. Acquiring and Training Adequate Resources:

• Most mental health providers and the majority of substance use treatment providers are not Eligible Providers or Meaningful Users under the HITECH Act and are thus not eligible for financial incentives to modernize either the acquisition or use of EHR.

Sources: STATE of Florida v CENTER FOR DRUG-FREE LIVING, INC, 842 So.2d 177 (2003) at 181. Melissa M. Goldstein, JD et al, 2010

40

SAMHSA Office of Behavioral Healthy Equity

Along with the National Institutes of Health (NIH) SAMHSA’s Office of Behavioral Health Equity supports the National Network to Eliminate Disparities in Behavioral Health (NNED).

The NNED supports information sharing, training and technical assistance among organizations and communities dedicated to the behavioral health and well-being of diverse communities.

The NNED identifies and links "pockets of excellence" in reducing disparities and promoting behavioral health equity. It will reduce the tendency to “reinvent the wheel.”

Website: www.nned.net

41

NNED – Faith Based Learning Cluster (FBLC)

NNED Faith Based Learning Cluster (FBLC) is a partnership between faith-based and health care organizations.

The goal is to provide a means for organizations to connect and share guidance about engaging and collaborating to better address health disparities.

Curriculum for laity has been finalized that will improve their ability to identify and access the mental health and substance abuse needs of their peers.

Curriculum will be pilot-tested in fall/winter 2011. The skills gained through the curriculum will help faith-based

organizations connect with their communities regarding how health reform affects them.

42

Summary

Health reform can have a great impact on improving the behavioral health of the populations served by faith-based providers.

Now is the time for providers to connect with their communities and vulnerable populations to help them take advantage of the new services available to them under health reform, and

Now is the time for providers to reach out to community health centers, health homes, and other entities to ensure that faith-based services are included, where appropriate, in treatment and recovery programs.

43

THANK YOU.