Access: The TAC Blog
The destructive nature of substance use disorders and the influence of active addiction on people’s behavior can often lead to homelessness. In fact, The Substance Abuse and Mental Health Administration (SAMHSA) estimates that 38 percent of individuals experiencing homelessness are dependent on alcohol, while 26 percent abuse other drugs, including opioids. With growing recognition of housing as a critical determinant of health and recovery, we must thoughtfully consider what kinds of housing can best help people with addictions optimize their potential for recovery and re-stabilize their lives.
Two recognized housing approaches intended to help people with substance use disorders (SUDs) transition from homelessness are “recovery housing” and Housing First. These approaches operate differently and have unique histories — yet rather than advocate for one over the other, I suggest that fully supporting both approaches should be our priority.
Alcohol and drug-free (recovery) housing is a critically important and currently under-resourced intervention. It can be operated with tiered levels of supports that are matched with the needs of residents, including more intensive supportive services for those exiting homelessness to self-governed Oxford Houses or Recovery Homes. Many residents of recovery housing attest to their need for this safe and supportive living environment in order to promote their long-term recovery from addiction, their health and wellness, and their ability to stay stably housed.
In the Housing First model, the top priority for service providers is to help individuals and families secure permanent housing. Often the term “low-barrier” is applied in this model, indicating that there are no conditions on tenancy, such as sobriety or participation in treatment. Housing First is based on evidence that stable, lease-based housing plus voluntary acceptance of services can help people make progress on addressing their mental health and addiction disorders.
My advocacy for both models is rooted in 17 years of work on programs designed to help this population. Indeed, my work starting Housing First programs at Central City Concern (CCC) in Portland, Oregon and at Colorado Coalition for the Homeless in Denver was inspired in part by wanting to make sure we were "throwing everything that worked” at ending chronic homelessness and addiction. At CCC, the idea of adding Housing First programming was initially met with some resistance, especially by colleagues who were themselves in long-term recovery. Over time, however, people began to see the value and successful outcomes of offering housing that was paired with individuals’ choices.
Recovery housing can be very effective for clients who are self-initiating detox and treatment. When evidence-based supported employment services, peer recovery mentors, and coordinated outpatient treatment were incorporated into CCC’s recovery housing, we found that high percentages of individuals with primary SUDs who had been homeless completed treatment and remained housed and employed one year post-exit.
With evidence supporting both approaches to housing for people with SUDs, providers and policymakers must be open to a range of approaches to address the diverse preferences and needs of the individuals they hope to serve. For this reason, when I shared the effectiveness of CCC’s recovery housing programs with federal agencies and stakeholders around the country, I also spoke (and still do) about the importance of ensuring housing choice for homeless people with SUDs.
Likewise, the Department of Housing and Urban Development (HUD) discussed in its 2015 Recovery Housing Policy Brief the value of promoting individual choice among housing options for homeless individuals. The brief encouraged expanding the supply of permanent supportive housing and other models that use a low-barrier, Housing First approach, so as not to exclude a large number of people who are unprepared to meet sobriety or abstinence requirements. But HUD also affirmed the importance of providing recovery housing options for people who want and need a sober-living environment. HUD’s Policy Brief outlines the characteristics, practices, and outcomes it expects from recovery housing funded with its homeless dollars.
The expansion of recovery housing received broader federal support in the 2016 Surgeon General’s Facing Addiction in America report, and in another report issued in 2017 by the President’s Commission on Combating Drug Addiction and the Opioid Crisis. Earlier this year, the National Council for Behavioral Health (NCBH) issued a Recovery Housing Guide to help states include high-quality recovery housing among the options offered by their behavioral health systems. NCBH followed this guide with a letter to every Single State Agency, alerting them to SAMHSA’s unprecedented decision to allow State Opioid Response Grants ($930 million) to fund supportive services for individuals with opioid use disorders in recovery housing.
Research is needed on the long-term effectiveness of both recovery housing and Housing First programs for people with primary SUDs. For now, states and local jurisdictions can use the practices described in the HUD and NCBH policy briefs to expand the capacity of recovery housing and improve the practices of existing programs. Recovery housing can promote housing tenure, long-term recovery, reunification with families and children, economic and educational advancement, improved health and wellness, and community involvement. Many of my colleagues whose experience of recovery housing helped cultivate my understanding of the model also report perhaps the most significant outcome of all: They say they owe their lives to it.
Current legislation in Congress addressing the nation’s opioid crisis has wide bipartisan support and includes several provisions to provide housing-related assistance for people in recovery from SUDs. As the final bill becomes law, states and communities working to combat both addiction and homelessness will become better able to offer housing choice that includes robust recovery housing programs.
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 Trump administration’s interest in addressing the opioid epidemic is heartening, and last week's proclamation is a welcome acknowledgment that opioid addiction and overdoses do indeed constitute a major public health crisis in our nation. While there is no immediate prospect of a significant cash infusion (millions are touted, versus the badly needed billions) to address the crisis, there has at least been the promise of statutory and regulatory relief — with a particular focus on allowing states to waive the Institutions for Mental Diseases exclusion. This 52-year-old statute bars Medicaid payments for mental health and addiction treatment provided to individuals in large treatment facilities, and some advocates assert that waiving it will allow Medicaid funds to flow for thousands of substance use disorder (SUD) treatment beds that currently lie empty.
All efforts to expand access to treatment are important, but the push to open up large facilities for SUD care as the first priority should be kept in perspective. Empty beds in such institutions may be the result of many causes. For instance, a community with a strong array of community-based treatment options may not need additional beds. In some cases, beds go unused if private payers don't refer patients to a facility because it lacks a modern, evidence-based approach to treating addiction (for instance, if no-one on staff is qualified to provide medication-assisted treatment). And finally, some facilities have never participated in either Medicaid or commercial insurance programs simply because they don’t have to, as their private fee structure allows them to maintain empty beds; these providers may have neither the financial motivation nor the business operations know-how to bill insurers, or to train their staff to meet the quality standards of states and commercial payers.
So, states — before you rush off to the Centers for Medicare and Medicaid Services asking for IMD waivers, make sure your request is going to make a true difference in getting people high-quality care. We won’t turn this crisis around by assuming that any treatment is better than no treatment.
February 2017: Can States Take On the Fiscal Responsibility that Federal Policymakers Are About to Hand Them? - by Kevin Martone
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.