Access: The TAC Blog
There are fundamental reasons that patients with opioid use disorder (OUD) should be offered access to medications approved to treat their condition. For one, the evidence base is compelling: Medication-assisted treatment (MAT) improves patients’ quality of life; reduces substance misuse; and lowers emergency department and hospitalization costs, hepatitis B and HIV rates, and overdose death rates. National organizations dedicated to health care quality have endorsed quality measures assessing the use of pharmacotherapy for OUD, and propose adding them to widely used performance measurement sets. The U.S. Department of Justice has signaled that refusing to permit access to MAT and discriminating against persons receiving MAT are violations of the Americans with Disabilities Act. For policymakers and providers seeking to promote patient-centered care, information about medications available to treat a condition should be shared freely and objectively so that patients and their family members can make informed decisions based on the best scientific information available.
Opportunities for Alignment
Medication-assisted treatment and other practice approaches that embody the principles of patient-centered care are considered by many to be incompatible with abstinence-based addiction treatment models rooted in 12-step programs. The tension that sometimes forms between providers who include medication in the treatment of OUD and those who do not threatens to jeopardize recent investments in prevention, treatment, and recovery, and to fracture a community of stakeholders who need to work together. It is important that addiction care stakeholders recognize and build on the overlap between treatment approaches that involve MAT and harm reduction considerations, and interventions based on 12-step programs. Too often these models are presented as “either/or.” In this post, we’d like to highlight the opportunities for “both.”
Considerable progress has been made in recent years towards improving the availability of medications and services used to manage OUD. Commercial payers, sometimes in collaboration with state leadership, are trending towards removing prior authorization requirements for buprenorphine. At least 51 Medicaid programs have assigned preferred status to buprenorphine, and lifetime treatment limits have all but disappeared. Training resources abound, offering vital supports to primary care clinicians adopting MAT as a new therapy and OUD as a new condition to treat. Support has burgeoned for harm reduction approaches such as syringe service programs, safe injection facilities, and naloxone distribution initiatives, saving lives through overdose reversals and reduced incidence of viral and bacterial infections.
And yet, only 27 percent of specialty addiction treatment centers offer MAT. This unfortunate discrepancy is the result of many factors, including a shortage of medical practitioners who have received a waiver from SAMHSA to prescribe buprenorphine for opioid dependence treatment; obstacles to billing for sufficient reimbursement; and, often, a philosophical orientation informed by a particular interpretation of 12-step programs. Proponents of MAT and harm reduction modalities supporting patient-centered care often face opposition from some segments of the 12-step recovery community. Understanding the positions of 12-step organizations on the role of MAT and harm reduction is a key step to crossing this quality chasm.
A Closer Look at 12-Step Literature
The official literature of Alcoholics Anonymous (i.e., approved by the AA General Service Conference) shows significant alignment with harm reduction and MAT approaches. One AA pamphlet, The AA Member—Medications and Other Drugs, leads with the suggestion that “No AA member should ‘play doctor’; all medical advice and treatment should come from a qualified physician.” The pamphlet continues, “Because of the difficulties that many alcoholics have with drugs, some members have taken the position that no one in A.A. should take any medication. While this position has undoubtedly prevented relapses for some, it has meant disaster for others… they feel guilty because they are convinced that ‘A.A. is against pills.’”
The foundational text Alcoholics Anonymous explicitly supports the use of medications for withdrawal management, as in the chapter Working With Others: “Sometimes you will have to call a doctor and administer sedatives under his direction.” Further, the book notes the important role of clinicians, explaining in the chapter The Family Afterward that “We are convinced that a spiritual mode of living is a most powerful health restorative… But this does not mean that we disregard human health measures. God has abundantly supplied this world with fine doctors, psychologists, and practitioners of various kinds. Do not hesitate to take your health problems to such persons. Try to remember that though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward.”
The traditions of AA mirror central tenets of harm reduction. For example, Tradition 3 is: “The only requirement for AA membership is a desire to stop drinking.” AA members recognize that relapse can be part of recovery, and encourage even chronic relapsers to “keep coming back.” Indeed, many people begin attending meetings while still actively drinking alcohol or using substances. The fellowship’s response is to welcome these individuals with open arms. The refrain “We are glad you are here, especially the newcomer” is commonly used in preambles at the beginning of meetings. The underlying premise of Tradition 3 — in text and in practice — is meeting people where they are in their recovery, which is consistent with the core principles of harm reduction.
Nationwide, a patient-centered orientation of care within a framework of harm reduction is beginning to emerge in clinical practice. Guided with evidence amassed over the past few years, clinicians are revisiting restrictive protocols originally issued for buprenorphine care. Recent literature in an influential academic journal offers new clinical recommendations with respect to the incidence of relapse, patients’ use of other substances and benzodiazepines, and the expected duration of treatment. These evolving approaches both embody the model of harm reduction and are consistent with AA’s Tradition 3.
Another major 12-step organization, Narcotics Anonymous (NA), issued a pamphlet titled “Narcotics Anonymous and Persons Receiving Medication-Assisted Treatment” that notes, “Narcotics Anonymous does not express opinions — either pro or con — on civil, social, medical (including medically assisted treatment), legal, or religious issues.” Echoing AA, NA’s Tradition 3 states that the only requirement for membership is a desire to stop using. NA delegates to individual groups the question of whether members receiving MAT should be allowed to share their experience during meetings: “Each group is free to make its own decision on recovery meeting participation and involvement in group services for those receiving medication assistance for drug addiction.” The pamphlet encourages members receiving medications to find different meetings if they encounter strong opinions about MAT from other members.
Building Common Ground
There are promising examples in the addiction treatment community of providers beginning to weave MAT and harm reduction principles together with 12-step-based models. The Hazelden Betty Ford Foundation developed a clinical protocol and training materials to intentionally integrate MAT with 12-step concepts and therapies. Social Model Recovery Systems has served as a ‘provider champion,’ educating other 12-step-based providers that MAT is — as the organization’s medical director Donald Kurth asserts — “well worth including in our armamentarium.” Such initiatives can play an instrumental role in state, payer, and stakeholder efforts to promote dialogue about MAT and harm reduction.
Nationwide, treatment providers are revising discharge policies to better achieve the patient-centered goal of keeping patients engaged in care despite lapses in complete abstinence or in strict adherence to program rules. Too often, patients are administratively discharged — kicked out of treatment — for continued use of alcohol or substances, i.e., their presenting symptom. Encouragingly, providers are trending towards harm reduction in this respect. Administrative discharges have recently declined by half, from 16 percent of all discharges in 2002 to 7 percent of all discharges in 2010.
There are opportunities for policymakers as well. Regulators, accreditors, and payers managing provider networks may benefit from understanding the inclusive positions of 12-step organizations in their efforts to incorporate MAT and harm reduction models into policy requirements. Those seeking to mitigate ambivalence toward MAT and harm reduction must have a grasp of 12-step literature sufficient to address the concerns emanating from the recovery community. Yet to suggest that pharmacotherapy should replace the value offered by 12-step-based providers is a blind spot. There are historical reasons why 12-step-based providers staffed by individuals with lived experience are so common, including stigma and longstanding financial neglect of addiction research and services. The focus of the 12-step framework on addressing the spiritual dimensions of recovery can be a valuable part of OUD disease management; The American Society of Addiction Medicine acknowledges the spiritual manifestations of addiction in both its definition of addiction and its clinical assessment criteria. Rather than discount the abstinence-based provider network, stakeholders should seek opportunities to support 12-step-based providers and staff in integrating medication-based therapies and patient-centered harm reduction principles into their treatment paradigm.
Much of this work is unfolding. California, Massachusetts, and other states have issued guidance clarifying that residential providers are expected to admit patients treated by clinicians with MAT. Missouri requires all SUD treatment providers to offer or arrange for all forms of MAT. Virginia requires residential treatment organizations to demonstrate access to MAT through specified methods, and has issued policy guidance to establish harm reduction principles within its buprenorphine provider network. State Medicaid agencies implementing section 1115 SUD demonstrations must ensure that residential treatment facilities either offer MAT on-site to residents or facilitate off-site access, and are revising licensure, certification, policy, and contracting to promulgate and operationalize these new requirements.
In general, states are setting expectations and developing policies to promote access to MAT to better align with the established scientific consensus, the interest of national quality measurement organizations, recognition of potential legal liabilities, and, perhaps above all, the goal of providing patient-centered care to individuals who want to reclaim their lives. These objectives are achievable within the context of a 12-step framework for recovery, which is a prominent and longstanding feature of the specialty treatment field.
Disclaimer: The views expressed in this post are those of the authors and are not intended to represent the views of Alcoholics Anonymous or Narcotics Anonymous.
A Nevada Community Mobilizes to End Youth Homelessness
In 2017, Southern Nevada tallied the third highest rate of unaccompanied youth homelessness in the nation. Recognizing the urgent need for a dedicated response to this crisis, the community, which includes the city of Las Vegas, issued a national request for technical assistance proposals. Through this competitive process, TAC was selected to facilitate a robust and inclusive planning effort, and ultimately to draft the first-ever Southern Nevada Plan to End Youth Homelessness.
From April to October 2018, TAC consultants Lauren Knott, Ellen Fitzpatrick, and Ashley Mann-McLellan worked with the community to create decision-making groups, analyze data to identify areas of need, articulate goals and strategies, and strengthen the active involvement of "Young Adults in Charge" (the Southern Nevada Homeless Continuum of Care's official Youth Action Board) in guiding the development of the Plan.
This engagement culminated in a Summit to End Youth Homelessness, a packed and lively event at which the Plan was officially launched. Rounding out presentations by members of the planning group, TAC consultants facilitated brainstorming sessions for Summit participants on implementation of the Plan, focusing on next steps with identified strategies. Service providers, educators, law enforcement, policymakers, funders, faith groups, and business leaders were all in attendance, demonstrating this community's broad commitment to the shared goal of ending youth homelessness in Southern Nevada.
Meeting the Challenge of Expanding Access to Integrated Physical Health and Addiction Care
With support from the Melville Charitable Trust, TAC Senior Consultant John O'Brien assembled teams of experts to produce two new papers exploring the ways care integration is being practiced - and paid for - in a rapidly changing U.S. health care environment.
Rather than searching for a uniform set of requisite elements in the integration of substance use disorder (SUD) treatment and mainstream medical care, the authors of "Integrating Substance Use Disorder Treatment & Mainstream Medical Care: Four Ground-Level Experiences" decided to showcase a few very different groups of providers that have each moved in this direction. In each case, they asked the same key questions, including "What is the context in which your integrated care effort occurred?" "Why and how did the shift to integrated care come about?" and "What more should we know about integrated care?" A condensed version of this paper was published on the AcademyHealth Blog.
From 2000 to 2014, the rate of deaths in the U.S. from drug overdoses increased by 137 percent, yet access to treatment services for people with SUDs continues to lag. Expanding the capacity of primary care providers to assess and treat addiction is critical to filling this gap, especially given the stigma associated with seeking treatment in specialty settings. "Exploring Value-Based Payment to Encourage Substance Use Disorder Treatment in Primary Care," a joint publication project with the Center for Health Care Strategies, describes how several states and health plans are exploring value-based payment to promote SUD treatment in primary care, and offers considerations for others who might want to implement these models.
TAC Staff in Action
Executive Director Kevin Martone moderated a plenary panel on "The Health of Housing: State and Community-Based Approaches" at the National Association of Medicaid Directors' fall conference (to see the panel, start at about 31:00), delivered the keynote address at the 20th anniversary gathering of the Supportive Housing Association of New Jersey, and led a workshop on Mainstream Housing Choice Vouchers at the National Association of Housing and Redevelopment Officials (NAHRO) conference; Senior Consultant John O'Brien has been named a distinguished adviser at the Pew Charitable Trusts and was recently interviewed by Pew on "How Health Care Payers Can Help Stem the Opioid Crisis"; Subcontractor Naomi Sweitzer led a well-attended event to promote the homeless preference in multifamily housing, held at Austin (TX) City Hall and hosted by Mayor Steve Adler; Associate Ashley Mann-McLellan facilitated workshops and leadership conversations with the Suburban Cook County (IL) CoC on maximizing the impact of rapid re-housing to end homelessness; Ashley also volunteered at Boston's annual Surge to End Chronic Homelessness event; Senior Consultant Jim Yates, Associate Phil Allen, and other partners from the Rural Supportive Housing Initiative traveled to Fairbanks, AK to help the community establish new permanent supportive housing units and house more families and individuals through a robust rapid re-housing program.
Last week, I had the pleasure of delivering the keynote address at the annual conference of the Supportive Housing Association of New Jersey. This gathering marked the association’s 20th anniversary, an opportunity to reflect on two decades of work to make permanent supportive housing — i.e., lease-based housing paired with voluntary, flexible services — a primary intervention for people with a wide range of disabilities and for people experiencing or at risk of homelessness. Many other states, too, have invested time and resources in the successful expansion of this approach for their homeless and disabled populations.
In an interesting fluke of timing, the New York Times had published an article the day before the conference, highlighting negative stories about permanent supportive housing (PSH) in New York and painting a picture of a model that had too often failed persons with serious mental illness. The tone of the article was keenly felt by this group of PSH practitioners, and several leaders from other states and policy groups have since contacted me to discuss the article’s potential impact. How could PSH — an approach that leaders in many states are working to expand in order to support the community integration needs of those who are homeless or disabled — be represented as a failure? What are the article’s implications for those seeking to invest in or expand PSH, for providers, and for people determined to live independently?
While the Times article was alarming, strong evidence nevertheless suggests that people with serious mental illness can succeed in PSH, and that use of the model should indeed be expanded. But there are considerations that must be addressed to ensure that PSH meets the needs of the people it is intended to serve.
Supportive Housing Works
People with serious mental illness have historically lived in institutional settings whether they actually needed to or not. Over time, however, understanding has grown that the policy of housing people in state psychiatric hospitals, for example, is both cost-ineffective and inhumane, and that it fails to demonstrate positive outcomes. Deinstitutionalization efforts from the 1970s to the 1990s meant that many more people with mental illness began living in the community. We all know the story of the resulting growth in homelessness and trans-institutionalization to correctional settings, as public systems failed to develop their community-based services capacity and affordable housing resources to meet the increase in demand. Some people had access to services and residential supports, but many did not, and many still do not today.
When I was a case manager over 20 years ago, "supportive housing" meant doing everything possible to get people with mental illness into housing and helping them stay there. Over time, anecdotal stories of success across the country evolved into an evidence base for what we now know as permanent supportive housing.
There is plenty of evidence to demonstrate the effectiveness of PSH for people with mental illness and for people transitioning from homelessness. Many PSH programs have shown increased housing stability, decreased emergency department and inpatient use, reduced jail days, and significant cost savings compared to homelessness, inpatient care, and other institutional or supervised settings.
Even the statistics noted by the Times suggest that a large majority of people have succeeded in supportive housing. It is important to regard this in light of evidence showing safety and quality of care concerns in New York's adult homes, the housing situation from which many people with mental illness move into supportive housing.
Services Must Be Well-Designed and Adequately Funded
Does supportive housing work for everyone? No. Some people need supervised treatment settings, or prefer group residential programs. However, contrary to the assumptions that used to govern our mental health care systems, supportive housing in the community has been shown to work for a variety of people, including those with the most significant needs who are transitioning from state psychiatric hospitals, nursing facilities, jails, or homelessness. Even people with the most complex conditions need a place to call home that is not contingent on being a "compliant" patient or a "good" client; in fact, providing a choice of housing together with voluntary services has been shown to strengthen retention in housing and services.
In order for PSH to be successful, particularly for persons with complex needs, services must be voluntary, flexible, responsive, robust, and comprehensive. Furthermore, they must be delivered by well-trained staff who are able to provide the right types of services, in the right locations (i.e., where people live), and at the right times, adapting what is offered to meet individuals’ evolving needs. Providers that struggle to adequately support people in PSH are often those with inadequate staffing, which makes them unable to respond quickly and appropriately.
To underfund services is to undermine the ability of providers to meet the needs of PSH tenants. In my experience, the services covered by Medicaid are not, on their own, enough to meet the needs of many people who could otherwise succeed in PSH. If systems will be expected to serve an increasingly complex population, state and county funding agencies and Medicaid managed care organizations must have adequate resources available to pay for a full range of services; successful permanent supportive housing programs are those that braid or blend Medicaid with other resources.
Building On the Evidence
As a former state mental health commissioner, a behavioral health provider, and the family member of someone with a mental illness, it boggles my mind that we would rather pay several hundred thousand dollars per year to house a person in an institutional setting than commit a fraction of that amount to support them in an integrated, community-based setting with demonstrated positive outcomes. Too often, the response to challenges that arise in PSH is an assumption that a person is "not ready," or "needs supervision," instead of a person-centered mindset that tailors and continually adapts services to each individual’s needs and choices.
Yes, people with mental illness and other disabilities may need inpatient treatment, at times. They may need round-the-clock support, at times. They may need assistance with their medications, at times. They may need transportation to medical appointments, at times. People with mental illness and other disabilities may need lots of things — but that doesn’t mean we should return to institutionalization at a cost that is much greater than the sum required to meet all of those needs. With sufficient resources to pay for both rental assistance and robust, flexible services, permanent supportive housing can be a primary intervention for individuals with complex needs.
Systems should move forward on bringing well-designed, fully funded permanent supportive housing to scale, so that all who can benefit from living in safe, independent, community-integrated housing have the opportunity to do so.
June 2018: Using Value-Based Payment to Encourage Integrated Substance Use Disorder Care — The First Steps
DRUG OVERDOSE IS NOW THE LEADING CAUSE of accidental death in the United States, with staggering numbers of additional deaths occurring every year due to tobacco use, alcohol addiction, and other substance use disorders (SUDs). It is essential to expand access to treatment, and there is growing recognition that integrated care — in which SUD services are incorporated into existing primary care settings — must be a key component of this effort.
Knowing that value-based payment (VBP) systems are one tool used by health care payers to promote system-wide changes, TAC partnered with the Center for Health Care Strategies to find out how states and health plans are beginning move toward VBP as a way to encourage SUD treatment in primary care. To learn more about the definitions and framework that we relied on, and to find greater detail about the practices highlighted here and considerations for the future of this promising trend, read our full paper: "Exploring Value-Based Payment to Encourage Substance Use Disorder Treatment in Primary Care."
Health Plan Innovations
For SUD treatment in primary care to succeed, providers must be prepared to administer medication-assisted treatment (MAT). To overcome provider hesitation to take this step, two of the community-based Medicaid plans we interviewed, the Central California Alliance for Health (CCAH) and Partnership HealthPlan of California, award primary care providers (PCPs) a cash bonus when they become “waivered” — i.e., licensed to prescribe buprenorphine. In recognition that patients being treated with SUD medications often require more services and management than others, CCAH also allows waivered PCPs, along with the nurse practitioners and physician assistants in their practices, to bill for consultative services related to SUD care.
To encourage more sophisticated payment methods for SUD services, the federal Medicaid Innovation Accelerator Program has created clinical pathways and rate tools for MAT. Similarly, the American Society of Addiction Medicine and the American Medical Association recently released a concept paper on patient-centered opioid addiction treatment (P-COAT), a new alternative payment model that supports office-based treatment using buprenorphine or naltrexone. The P-COAT model includes a one-time payment for the initiation of MAT for opioid use disorders, as well as an ongoing monthly payment to help providers coordinate outpatient, psychological, and social services for patients who have successfully initiated treatment.
States Taking Action
There are state-level examples of such approaches, too. Pennsylvania’s Centers of Excellence for Opioid Use Disorder receive $500,000 annually for two years from state funds to meet specific requirements in coordinating physical and behavioral health services, such as having defined referral standards, tracking and reporting quality outcomes, and participating in a learning network. The State of Virginia has actively redesigned its system of care for individuals with SUDs through its Addiction and Recovery Treatment Services program, expanding Medicaid beneficiaries’ access to evidence-based addiction services — including in primary care settings. Virginia makes enhanced payments to select providers who work with patients receiving medication-assisted treatment for an opioid use disorder.
Paying for Performance
States and managed care organizations are using pay-for-performance arrangements to encourage providers to incorporate SUD screenings and services into primary care. UPMC for You, a Medicaid managed care organization in Pennsylvania, evaluates providers both on screening for and documenting co-occurring medical conditions and secondary symptoms, and on ensuring that a high percentage of patients with SUDs who are new to treatment receive a behavioral health assessment by a licensed drug and alcohol counselor. The health plan also tracks how often providers successfully coordinate care with patients’ behavioral health providers. Partnership HealthPlan of California, too, has implemented process measures focused on providers conducting thorough screenings — in this case, to track important indicators in patients taking medication for chronic pain. The Oregon Health Authority uses incentive and challenge pools to financially reward those of the state’s Coordinated Care Organizations that meet key target measures, including alcohol and drug misuse screenings.
The First Steps
Interest is growing in integrating SUD services with primary care, fueled by the determination to improve treatment access for individuals with unmet needs. Many payers are using financial incentives to increase capacity in the primary care network to provide screenings and treatment, as well as referrals to more advanced care as appropriate. States and health plans are still in the early stages of developing more sophisticated VBP arrangements for substance use disorders in primary care, but there are valuable lessons to be learned from those that have already taken preliminary steps.
Our thanks to the Melville Charitable Trust, whose support made this exploration possible.
Improving Addiction Treatment with Consumer Report Cards
"Consumer report cards are a well-established approach to improving the accountability and quality of health care providers." And, as a team of expert authors including TAC Senior Consultant John O'Brien further observe in a recently published Health Affairs blog post, such accountability is sorely needed in the burgeoning field of addiction treatment. People facing a decision about how best to tackle an opioid use disorder should have some way to determine whether a given treatment option will successfully reduce their key symptoms, improve their health and functioning, and prepare them to manage the risk of future relapses. Drawing on several new reports and tools, the authors recommend specific metrics to identify providers using evidence-based principles in their substance use disorder treatment programs.
TAC Staff in Action
Senior Policy Advisor Francine Arienti and Associate Amy Horton conducted site visits in Pawtucket, RI, Northampton, MA, and Albany, NY as part of SAMHSA's national evaluation of the Cooperative Agreements to Benefit Homeless Individuals (CABHI) grant program; Managing Director Marie Herb and Senior Associate Gina Schaak met with Fall River (MA)'s Mayor's Task Force to End Homelessness to help produce a strategic plan; Associate Jennifer Ingle led a training for housing support and management staff in Malden, MA on de-escalation and crisis prevention; Associate Lauren Knott presented on "Unstably Housed Youth: Different Needs, Different Services" at the Homes Within Reach conference in December; Associate Ashley Mann-McLellan is serving as the subject matter expert for a monthly webinar series on developing non-time-limited supportive housing for youth experiencing homelessness, produced in partnership with Collaborative Solutions; Ashley also facilitated a recent session with Long Island, NY's Veteran Leadership Team to plan for sustaining its successful work to end veteran homelessness; Executive Director Kevin Martone and Associate Phillip Allen traveled to Alaska for the Fairbanks Symposium on Homelessness, where Kevin gave the plenary address and led a workshop on "Permanent Supportive Housing and Rapid Re-Housing Services," and Phil gave a workshop on "Rapid Re-Housing: A Systematic Approach to Ending Homelessness"; Kevin also traveled to Phoenix, AZ to work with several states on behavioral health care integration at an event sponsored by the National Governors Association.
Congratulations to Associate Amanda Tobey and her family on the birth of Parker Collins-Tobey — and welcome to the world, Parker!
THE NUMBER OF STATE INSTITUTIONAL PSYCHIATRIC BEDS, which were once the primary setting for psychiatric treatment, has gone down dramatically nationwide. Community psychiatric hospitals, private hospitals, and nursing facilities filled the gap in the 1980s and '90s, but inpatient capacity in these settings, too, has recently been on the decline. There is widespread concern — given ample voice by the media — that we need to restore our nation’s psychiatric bed capacity, both to reduce the risk of violence perpetrated by people with untreated mental illness, and for their own safety and health.
In reality, however, inpatient treatment should form only one part of a robust system of mental health care. For comparison, note that treatment for even the most serious medical conditions now frequently occurs in outpatient and in-home settings. However, recent findings from the Healthcare Cost and Utilization Project reveal a widening gap between our country’s approaches to hospitalization for mental and for physical health conditions: Between 2005 and 2014, the rate of inpatient stays per 100,000 people for all causes decreased across all age groups, while the number of hospital stays for mental health/substance use actually increased by 12.2 percent.
To examine these trends and their implications, the National Association of State Mental Health Program Directors recently commissioned a series of working papers on the question: “What is the real need for inpatient psychiatric beds in the context of a best practice continuum of care?” In this series, researchers and policy leaders describe ways to improve mental health and substance use disorder treatment at many different points in a community’s system of care so as to necessitate fewer psychiatric hospitalizations, of shorter duration, with better and more equitable outcomes.
Increasing the number of psychiatric inpatient beds is not the solution in most communities. As my colleague Kevin Martone and I argue in our contributions to the series, investments in care and services can create alternatives to inpatient beds that are both more effective and less costly. “Beyond Beds: The Vital Role of a Full Continuum of Psychiatric Care” lays out specific public policy recommendations to minimize the human and economic costs associated with severe mental illness by building and invigorating a robust, interconnected, and evidence-based system of care. And as “The Role of Permanent Supportive Housing in Determining Psychiatric Inpatient Bed Capacity” shows, stable and affordable housing combined with voluntary services can contribute to improved outcomes in both physical and behavioral health, while reducing incarceration and homelessness. Furthermore, the cost of serving a person in supportive housing is half that of a shelter, a quarter that of incarceration, and one-tenth the cost of a state psychiatric hospital bed.
Advances in medical research and technology, chronic disease management programs, and alternative treatment settings such as walk-in urgent care centers — along with payment approaches that support medical care in outpatient settings — have all helped reduce hospitalizations for physical health conditions. Evidence-based mental health care options, especially when provided in the communities where people live, offer the potential to bring down psychiatric hospitalizations as well. Private insurers rarely cover these services, however, and state and federal mental health funding are drastically insufficient to meet demand. Medicare and Medicaid together fund approximately 60 percent of inpatient care in the United States. Unfortunately, Medicare funds very few evidence-based mental health practices, and Medicaid funding for housing transition and tenancy-sustaining programs — a critical component of permanent supportive housing for people with mental health disabilities — is not yet fully incorporated into services.
We don’t need to re-create massive numbers of psychiatric inpatient beds. Rather, policymakers must prioritize funding for the evidence-based preventive treatment and services that people with mental illness need and desire. With these effective and cost-saving resources available and truly accessible in every community, hospitalization will play an appropriate role in a balanced system.
Access: The TAC Blog is Launched!
With the addition of Access to TAC’s website, our senior consultants are now able to contribute their unique perspectives from the intersection of affordable housing, health care, and human services policy. Posts so far have included John O’Brien on “The Next Frontier: Care and Service Integration for People with Substance Use Disorders” and Kevin Martone asking “Can States Take On the Fiscal Responsibility that Federal Policymakers Are About to Hand Them?” Watch your email for monthly post alerts.
A New “Practice Profile” on In-Home Therapy
In the fall of 2015, the Children’s Behavioral Health Initiative (CBHI) Knowledge Center, in collaboration with MassHealth, began an extensive effort to develop a “practice profile” for providers of in-home therapy to Massachusetts children and youth receiving publicly funded behavioral health services. After conducting a literature review and a series of workshops with stakeholders, CBHI drafted the new resource and engaged TAC to help produce the final version. Publicly available, the In-Home Therapy Practice Profile offers in-home therapy providers easy-to-use guidance on best practices in cultural relevance, risk assessment and safety planning, engaging natural supports, and other key areas.
TAC Staff in Action
Senior Associate Liz Stewart participated in the inaugural Winter Walk across Boston to end homelessness; Liz and Associate Lauren Knott joined a panel on “Improving Systems in Balance of State and Regional CoCs” at the National Alliance to End Homelessness’ Annual Conference on Ending Family & Youth Homelessness.
We’re happy to welcome Phillip Allen as a new Associate on the TAC housing team. Phil is helping Supportive Services for Veteran Families (SSVF) grantees and communities to develop and implement effective programs.
March 2017: Two Olmstead Settlement Agreements Resolved, but the Future of Community Integration is Unclear
DEPENDING ON WHOM YOU ASK, an Olmstead settlement agreement can be a blessing or a curse. While the parties typically agree on the principle affirmed by the U.S. Supreme Court — that people with disabilities should live in the most integrated setting possible — costly housing markets and complex service delivery systems are formidable barriers to this goal. More than 15 years after the Supreme Court's landmark Olmstead decision, states still struggle to serve people with disabilities in integrated settings.
Delaware and New Jersey are two states that have recently resolved their Olmstead settlements, achieving significant reforms though years of dedicated effort — Delaware's settlement was originally signed in 2011 with the U.S. Department of Justice, while New Jersey's was signed in 2009 with Disability Rights New Jersey and the Bazelon Center for Mental Health Law.
Thanks to the successes of these states in substantially attaining the outcomes required by their agreements, thousands of people with serious mental illness now have the opportunity to live in integrated community settings. What is perhaps most impressive is that a substantial part of the system reform accomplished by New Jersey and Delaware occurred during the great recession (2007 to 2009) and the following period of slow economic recovery.
Delaware and New Jersey both offer good examples of what is possible when states focus on community integration for people with mental illness and other disabilities.
A U.S. Department of Justice press release describes some of Delaware’s most significant gains. The state reduced the number of bed days in the Delaware Psychiatric Center by 47.2 percent. The number of Medicaid-eligible Delawareans receiving community-based services has increased by 92 percent since the United States began its investigation. The state has seen the growth of a strong peer and self-advocacy movement that is now incorporated into its entire service system. Two statewide mobile crisis teams and a crisis walk-in center divert 70 to 90 percent of the individuals they engage away from hospitalization and criminal justice interaction and toward community-based services.
As a press release from Bazelon details, New Jersey’s settlement also brought about important changes. Between 2005 and 2016, New Jersey invested nearly $104 million in services and rental assistance for Olmstead-related activities. The state also established a $200 million special needs housing trust fund, and created nearly 1,500 new permanent supportive housing units through capital and rental assistance. New Jersey’s state psychiatric hospital census was reduced by a third, patients’ average length of stay went down, and one state hospital was closed — changes that allowed state hospital operating funds to be reinvested in community supports. New Jersey created a Medicaid benefit to fund community support services for residents of supportive housing, and leveraged additional Medicaid money with investments in community-based services.
Both Delaware and New Jersey used their Olmstead settlement agreements as a driver for change, embracing a community integration platform to guide them toward significant behavioral health system reform. These states recognized that without sustainable system reform and new resources, counting numbers to achieve settlement targets wouldn’t bring about the changes needed to serve people with serious mental illness effectively.
Commitment to Olmstead in a Changing Landscape
Across the country, Olmstead stakeholders are raising questions about the future of community integration for people with serious mental illness and other disabilities. Doubt surrounds the capacity and motivation of states to tackle Olmstead in the years ahead; the commitment of the Department of Justice to focus on Olmstead as strongly as it has in the past; and the ability of protection and advocacy organizations to hold states accountable.
Changes to the Medicaid landscape at the federal level could put at risk the types of benefits coverage that makes community integration work for people with disabilities. Looming cuts to non-mandatory discretionary budgets, such as HUD housing assistance programs, may further jeopardize the ability of states to support community integration.
The Department of Justice has been instrumental in the movement toward community integration, enforcing Olmstead by leading investigations, entering into settlement agreements in several states, and intervening in support of class actions. If the Department shifts its attention to other priorities established by the Trump administration, individuals with serious mental illness and other disabilities will be left without civil rights enforcement at the very time when loss of benefits could place them at greater risk of institutionalization. Many state protection and advocacy agencies, as well as legal services organizations, have the authority to bring class action lawsuits on behalf of people with disabilities, and these groups may be called upon to step up their efforts.
Complying with Olmstead will become increasingly difficult if federal policy and budgetary changes reduce support to states in the near future. Federal cuts currently under consideration would put people with mental illness and other disabilities at greater risk of institutionalization and homelessness due to thinner benefits and services and reductions to the rental assistance that can make housing affordable. Our February blog post on budget impacts explained the challenges states will face in making resources available to meet federal requirements. Nevertheless, it is states that are on the hook to ensure that individuals are served in integrated settings.
Community integration mandates in the Olmstead decision, Title II of the Americans with Disabilities Act, and Section 504 of the Rehabilitation Act are still the law, regardless of fluctuations in federal enforcement and support. Furthermore, serving individuals with disabilities in integrated, community-based settings is good, cost-effective policy. With these facts in mind, states should continue to design and implement Olmstead plans that build sustainable, system-wide improvements. The benefits — to individuals, communities, and all who recognize the value of true integration — are well worth the challenges.
February 2017: Can States Take On the Fiscal Responsibility that Federal Policymakers Are About to Hand Them?
A FEW WEEKS AGO, I had the opportunity to explain to a roomful of congressional staffers the profound impact that a repeal of Medicaid expansion would have on individuals with substance use disorders - and on the systems that serve them. In the questions that followed, an underlying theme was evident: Would lost Medicaid revenue and other federal resources be replaced by state funds to pay for such services? This issue has far-reaching implications for all of our nation's safety net programs. Both my current work with state systems across the country and my experience as a former state commissioner of behavioral health make clear to me that states are in no position to absorb the transfer of fiscal responsibility they are about to receive from federal policymakers.
Systems Work Better Together
In every state, there are vulnerable populations whose complex challenges require coordinated solutions that use federal and state funding. In recent years, awareness has grown in both the health care and affordable housing communities of the positive outcomes to be attained by leveraging these resources together. State Medicaid directors have become educated on the costs to their programs of individuals with chronic health conditions who are homeless, at risk of homelessness, or living in substandard housing. Likewise, affordable housing leaders have learned that lack of access to health insurance, and especially to integrated behavioral and primary health care services, jeopardizes housing stability. States are becoming sophisticated in their use of interventions that build on this new understanding, such as supportive housing - an approach that combines affordable housing assistance with wraparound supportive services. Such states have increasingly demonstrated cost savings in their systems.
The availability of federal funding has afforded states the opportunity to improve the lives of millions of children and adults. The option to expand Medicaid through the Affordable Care Act (ACA) allowed states to increase access to care for populations with many health needs, create better health care delivery systems, and save taxpayer dollars. Federal funding was the incentive needed for 31 states and the District of Columbia to expand coverage, while states that did not expand Medicaid still rely on significant federal support to operate their traditional Medicaid programs. Federal housing assistance programs have been a critical resource for millions of seniors, people with disabilities, and people living on very little income - though a significant gap remains between available assistance and need.
Shifting the Burden to States
The imminent repeal of Medicaid expansion and the ACA, and proposals to convert Medicaid to a block grant or per capita program, threaten millions of people's access to health care, with disproportionate consequences for vulnerable populations. While these changes will create significant savings for the federal government, states will in turn experience both immediate and long-term pressures to fill the void - allegedly in exchange for more control and "flexibility." Under a block grant plan previously proposed by former House Budget Chair and Health and Human Services Secretary nominee Tom Price, the Medicaid and Children's Health Insurance Program would receive 34 percent less funding in 2025 than under the current federal law.
Decreases in affordable housing assistance resulting from cuts to non-defense discretionary (NDD) programs like those at HUD will disproportionately affect the same populations impacted by cuts in Medicaid. We don't have to look too far back to see how this plays out: the March 2013 sequestration cuts forced state and local housing agencies to decrease the number of households using tenant-based vouchers by more than 80,000. About half of all voucher recipients are seniors or people with disabilities, most of whom live on fixed incomes such as Social Security or Supplemental Security Income (SSI) and rely on Medicaid. In not a single rental housing market in the country can a person with a disability who is living on SSI afford housing at the "fair market rent" determined by HUD. According to the National Low Income Housing Coalition, the United States has a shortage of 7.2 million rental units affordable to extremely low-income renter households. Yet President Trump has proposed a one-percent reduction to NDD each year for the next ten years. Even a simple freeze, suggested by several members of Congress, would result in the defunding of housing vouchers currently used by more than 100,000 families in 2017 alone.
Faced with such a significant loss of federal support, Democratic and Republican governors, legislators, and mayors will have to make some very difficult budgetary decisions. Will these leaders, as many have suggested, find ways to sustain access to health benefits, affordable housing assistance, and social services once federal policymakers shift the financial burden onto states?
Recent history shows that as resources are squeezed, many states are unable or unwilling to prioritize vulnerable populations. Most Medicaid expansion states were in a position to increase coverage only because of significant federal matching. Without such support, states have generally opted to provide only limited benefits to people who are traditionally ineligible for Medicaid, and several states have established highly restrictive eligibility criteria. Economic downturns can create added challenges for states as tax revenues decrease while unemployment and enrollment in Medicaid increase. According to the U.S. Government Accountability Office (GAO), during the nation’s last recession, Medicaid enrollment grew by 14.2 percent from October 2007 through February 2010. During the same period, total Medicaid expenditures grew nearly 21 percent, from $332.2 billion in 2007 to $401.5 billion in 2010.
To reduce program spending, the GAO noted, states generally make certain changes to their Medicaid programs, such as altering payments to providers, limiting eligibility, eliminating optional services, or reducing the amount, duration, or scope of services covered. Even as need rose, states cut funding for a range of services by 4.2 percent in fiscal year 2009 and an additional 6.8 percent in 2010, according to estimates by the National Association of State Budget Officers (NASBO). In 2011, two-thirds of states cut provider payments, and 18 states reduced Medicaid benefits. The recession of 2009–2012 resulted in losses of over $4 billion from public behavioral health systems across the country, losses from which they have still not fully recovered.
Most states have allocated resources to support housing assistance for low-income populations. A report prepared by the Technical Assistance Collaborative in 2014 indicated that 34 states offer some type of rental assistance or homelessness prevention funds (e.g. security deposits). However, there is wide variation in the number of individuals such programs can support, and program funding tends to fluctuate annually due to state budget pressures. Indeed, a NASBO survey conducted in the fall of 2016 indicated that in 24 states, general fund revenues for 2017 are coming in below projections, the greatest number of states expecting revenue shortfalls at this time in the fiscal year since 2010. Nineteen states reported net mid-year budget reductions in fiscal 2016, a historically high number outside of a recession period.
There is indisputable evidence that the availability of health insurance and access to health care and affordable housing improve people's lives. As lawmakers contemplate dramatic reductions that will hurt people and economically burden states, we find ourselves at a pivotal point. There is little evidence to suggest that state governments can or will assume the financial responsibility offloaded by the federal government under current proposals. Yet, it is state and local budgets that must absorb the preventable economic consequences when individuals engage costly, crisis-oriented health care, correctional, and homelessness systems. Federal policymakers must understand that a cost shift to states under the guise of flexibility and efficiency will have dramatic and unfortunate consequences for vulnerable individuals and their families.
February 2017: Care and Service Integration for People with Substance Use Disorders - by John O'Brien
THIS MONTH, states are submitting proposals to the Substance Abuse and Mental Health Services Administration (SAMHSA), outlining their plans to address the opioid crisis. While the strategies proposed will vary, SAMHSA’s message is clear: the funds it provides must be used to connect individuals to needed services in communities that have been hit hardest by opioids. Time is of the essence, and states have only a few months — lightning speed for most state bureaucracies — to increase access to substance use disorder (SUD) services.
Many states will no doubt use their awards to expand prevention and treatment programs. That’s terrific — enhancing the services that directly address addiction should be paramount. However, it is of great importance that federal and state agencies also ensure the availability of physical health care and long-term services, such as in-home supports, for individuals dealing with addiction. States should take steps to integrate these forms of care into the continuum of SUD services, rather than relegating them to separate systems.
Awareness has never been stronger of the importance of an integrated approach to treating diabetes, asthma, HIV/AIDS, and behavioral health conditions. Data has helped show the impact these health challenges have on people’s morbidity, quality of life, and health care costs, while also revealing that people who have any one of these conditions often have others on the list as well — or are at significant risk for acquiring them.
The good news is that insurers and health care providers recognize the need to coordinate medical, behavioral health, and long-term services. Over the past ten years, Medicare and Medicaid have laid the foundation for developing integrated care models to help tens of millions of Americans — and private sector insurance companies have followed suit. These insurers have learned from the pioneering work of health care providers in integrated care, and are bringing their efforts to scale.
A Good Use of Resources
Much of the energy powering integration efforts in behavioral health has so far been directed specifically toward mental health. As the opioid crisis intensifies, however, private and public insurers are paying increased attention to the impact of substance use disorders on morbidity. Meanwhile, prompted by federal requirements that many insurance plans cover SUDs, insurers have found plenty of data that offers compelling reasons to integrate physical health care, SUD services, and long-term supports.
Individuals with untreated SUDs and co-morbid medical conditions often incur high medical costs. For instance, $3.3 billion was expended in one year on behalf of 575,000 Medicaid beneficiaries with a secondary diagnosis of an SUD — triple the cost for those without an SUD. Two of the top ten reasons Medicaid patients are readmitted to a hospital within 30 days of discharge are SUD-related. Conditions that occur more frequently among individuals with SUDs than in the general population include respiratory issues, skin infections, and suicide.
Other problems related to SUDs are opioid-exposed pregnancies, drugged driving, and increases in Hepatitis C and in some circumstances HIV. Opiate use during pregnancy increased from 1.19 to 5.63 per 1000 hospital births from 2003 to 2009; seventy-eight percent of these births were to women covered by Medicaid. For newborns with Neonatal Abstinence Syndrome (NAS) and their mothers, the post-delivery costs are seismic — $43,000 per child versus $900 per child who does not have NAS.
To succeed fully, integration efforts must also factor in the social determinants of health. Many individuals with SUDs are homeless or have unstable living arrangements, challenges that often render health care needs secondary to the search for affordable and safe housing.
Meeting the Need
For insurers who are ready to introduce or enhance integrated care, the first task is encouraging recognition of the need. This may also be the easiest task, as insurers already have the data to make a strong clinical and business case for integration. The next step is to use the data to be more precise regarding who, what, and where should be the focus of insurers’ attention.
First, who? While some individuals are at elevated risk of acquiring a substance use disorder, others have struggled with addiction for decades. Insurers can’t assume that a one-size-fits-all integration program is sufficient. Using data analytics, we can identify the specific health care, treatment, and recovery service needs of different populations. These results can be used in turn to develop data-informed integration strategies.
Which leads to the question of what models an insurer might implement as part of an integration strategy. Some approaches are well-researched and proven to be effective. For instance, the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model has proven invaluable in assessing an individual’s SUD risk and providing immediate and short-term interventions. Screening and brief intervention should occur in a doctor’s office; if patients have more extensive treatment needs, the doctor can make a referral to an SUD treatment provider who is either part of the same practice or a member of a network of practitioners and organizations specializing in SUD treatment.
For individuals with more intensive SUD treatment needs, models for integration are still developing. Several states have created partnerships between physical health care providers and SUD care providers to increase access to evidence-based treatment, such as medications coupled with counseling. Other insurers have assembled teams of physicians, nurses, licensed SUD practitioners, and recovery coaches to coordinate the health, behavioral health, long-term supports, and social services needed by people with significant health and SUD challenges. Evaluations are underway to measure the effectiveness of these strategies.
And finally, the where. Where does it make sense for insurers to invest in new and existing models of integrated care for individuals with an SUD or at risk of an SUD? Again, the answer is not immediately clear. The models highlighted above are being tested in primary care settings, emergency departments, and the specialty SUD system. Some insurers have been working with health clinics to increase access to SUD medications (which generally must be prescribed by a physician or other health practitioner). Other insurers have invested in placing physicians, nurses, and physician assistants in SUD specialty agencies, creating teams to help the high need/high cost individuals who often engage with this system.
In these times of uncertainty, it makes sense to prioritize the protection of individuals’ access to insurance coverage and treatment services — but this can’t be our only focus. Excellent progress has been made over the past eight years to introduce and sustain integrated care for people with substance use disorders, and to test models that will improve their quality of care while reducing costs. Let’s keep going.