Healthcare Reform The “Affordable Care Act”

1. Healthcare Reform The “Affordable Care Act” How Will It Affect Substance Abuse Care?

2. Population Prevalence In Treatment ~ 2,300,000 LOTS Addiction ~ 25,000,000 Diabetes ~24,000,000 “Harmful – 60,000,000 Use” Little or No Use LITTLE

3. President’s 2012 Budget Defense 19% Poverty Assist. 17% Healthcare 23% Social Secur. 21%

4. The Presentation 1 - The Basic Elements 2 – Changes Expected 3 – The Implications

5. 2010 Healthcare Reform The “Affordable Care Act” • Transformative for MH/SA • SA care is “Essential Service” • Funds full continuum of care • Prevent, BI, Meds, Spec Care • Focus on Primary Care • Part of “Medical Home” • Information management

6. Insure ~45 million uninsured Reduce Costs of Healthcare Correct Insurance Problems Improve Care Quality Purposes: ~32 million newly insured Admin Costs, Prevention, Tech. Pre-exist cond, dropping, portability Ev Based Pract., Technology

7. Expanded Insurance Health Exchanges “Medical Home” Electronic Health Record Prevention Emphasis Key Features

8. Training Emphasis Significant grants for provider training On-line Medicaid billing requirement Federal/State funding “match” “Essential services” 100% federal Most prevention is 100% federal Other Issues

9. The Presentation 1 - The Basic Elements 2 – Changes Expected 3 – The Implications

10. Addiction XXXXXXXX “Substance Use Disorders”

11. 1 Conceptual Approach to Addiction A “Bad Habit” not an Illness Leads to a Special Approach

12. A Nice Simple Rehab Model Substance Abusing Patient Treatment NTOMS Sample of 250 Programs Non- Substance Abusing Patient

13. ASSUMPTIONS • Some fixed amount or duration of treatment will resolve the problem • Clinical efforts put toward correctly placing patients and getting them to complete treatment • Evaluation of effectiveness should occur following completion • Poor outcome means failure

14. Addiction Treatment Very Frequent Use In Specialty Treat. ~ 2,300,000 Very Rare Use

15. Detoxification – 100% Ambulatory – 85% Opioid Substitution Therapy – 50% Urine Drug Screen – 100% 7 per year Note – Great variability state to state Current Benefit in Addiction

16. Virtually all these are hospital benefits Very few are “visit” benefits – almost all are program benefits Very few care options, little variety within options Comparatively little acknowledgement of patients’ rights, little help with access Addiction Benefits

17. Treatments For Other Illnesses Why it matters

18. A Continuing Care Model Primary Care Specialty Care Primary Continuing Care

19. In Chronic Illnesses…. 1 –There is no Cure - the effects of treatment do not last very long after care stops 2 – Patients who are out of contact are at elevated risk for relapse: Retention is essential

20. In Chronic Illnesses…. 3 – Early, intensive stages prepare patients for less intensive care: – ultimately Self-Management 4 -Evaluation is a clinical duty: Good function = continue care Poor function = change care

21. Physician Visits – 100% Clinic Visits – 100% Home Health Visits – 100% Glucose Tests, Monitors, Supplies – 100% Insulin and 4 other Meds – 100% HgA1C, eye, foot exams 4x/yr – 100% Smoking Cessation – 100% Personal Care Visits – 100% Language Interpreter - Negotiated Medicaid Benefit in Diabetes

22. Virtually all these are in primary care Most are “visit benefits” not packaged The term “dual disorder” originated here as diabetes and hypertension Note patients have rights and benefits designed to help them access care and to benefit from it Diabetes Benefits

23. Physician Visits – 100% Clinic Visits – 100% Home Health Visits – 100% Glucose Tests, Monitors, Supplies – 100% Insulin and 4 other Meds – 100% HgA1C, eye, foot exams 4x/yr – 100% Smoking Cessation – 100% Personal Care Visits – 100% Language Interpreter - Negotiated Medicaid Benefit in Diabetes

24. Virtually all these are in primary care Most are “visit benefits” not packaged The term “dual disorder” originated here as diabetes and hypertension Note patients have rights and benefits designed to help them access care and to benefit from it Diabetes Benefits

25. Physician Visits – 100% Screening, Brief Intervention, Assessment Evaluation and medication – Tele monitoring Clinic Visits – 100% Home Health Visits – 100% Family Counseling Alcohol and Drug Testing – 100% 4 Maintenance and Anti-Craving Meds – 100% Smoking Cessation – 100% Future Benefit for Substance Use Disorders

26. ~ 500,000Primary Care Physicians + CNPs Prevention Services Screening and Brief Intervention - UPHS Early Intervention Brief Counseling / Treatment Office-Based Treatment Medications, Monitoring, Management Referral to Specialty Care Referral Back for Continuing Care Care Continuum

27. The Presentation 1 - The Basic Elements 2 – Changes Expected 3 – The Implications

28. New market for prevention research Very significant funding in ACA new initiatives to drive down cost and improve personal responsibility Challenge– What is prevention – just vaccines or community focus – wellness Prevention

29. Need “intervention research” with PCPs Adherence assistance Tele-health and Tele monitoring New market for medications 500,000 PCPs – other “prescribers” Research on counseling in primary care “Behavioral Health” focus? Family focus? Primary Care

30. Adaptation of Health Homes to SUD 90% Federal funding for Health Home services Emphasis on care integration and transition Addition of case management services Information exchange and decision support research New information will be in EMR Need standard “performance measures” Primary Care

31. Most “treatment” funding will come from Medicaid and private health insurance New populations – medical referrals New billing requirements – reporting requirements Emphasis upon Outpatient care integrated into “Medical Home” Emphasis on “Evidence Based” Practices What is a profitable outpatient model? Specialty Care

32. Emphasis/expansion home health services – Will “specialty care” fill this role? Role of Block Grant could change Recovery-Oriented services NOT covered in healthcare Specialty Care

33. Budget negotiations may change someof this State variability will continue but ultimately reduce Warning!

34. Thank You