Transcript Addiction Treatment Programs in the 21st Century

Addiction Treatment Programs in the 21st
Century—The Habits of Successful Programs
Thriving in the age of Parity and ACA
Phil Herschman, PhD
CCO CRC Health Group
WCSAD
May 29,2014
Two Major Federal Activities Impacting our Field:
The Parity Act (MHPEA)
Federal Healthcare Reform (ACA)
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What is “Parity” anyway?
Insurance plans offering mental health and
substance abuse treatment can no longer
offer coverage that differs in dose,
frequency, or quantity from coverage for
physical health services such as diabetes
or cancer.
But…
Notice the wording – “insurance plans
offering mental health and substance abuse
treatment..”
The Parity Act doesn’t require that plans cover
Substance Abuse and Mental Health
treatment
That’s OK Because…..
Healthcare Reform mandates the inclusion
of substance use disorder treatment as
one of the TEN Essential Benefits.
It must be included by all companies
offering health insurance (along with
the 9 other Essential Benefits:
Emergency Services, outpatient and inpatient
services, pediatric and lab services…)
Estimates on Healthcare Reform
Unprecedented increase in the potential market for
mental health and addition treatment services
In total, the CBO (Congressional Budget Office)
estimates that the ACA will cover
27 million previously uninsured individuals
12 million more in Medicaid
and
15 million in marketplace insurance plans
Estimates on Healthcare Reform
Unprecedented increase in the potential market for
mental health and addition treatment services
MHPAEA and the ACA expected to expand behavioral
health coverage for 62.5 million people
30.4 million individuals will have expanded
behavioral health coverage and benefits.
32.1 million individuals could access substance abuse
benefits for the first time
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Implications of ACA and Parity—Lot’s of
unintended consequences
.
.
.
Implications of the Parity Act
The Final/Final rule was promulgated in November—it
contained new language that supported the
“intermediate levels of care” in behavioral healthcare
(not implemented until July 2014)
However, the potential repercussions of the Final Parity
Bill have not been fully vetted in the marketplace
- What does intermediate care mean?
- How will Payers (Public and Private) interpret this?
Parity will dictate what is covered as an essential benefit
in the exchanges; however--Medicaid was “exempted”
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from Parity
Implications of ACA and Parity—Lot’s of
unintended consequences
.
.
Implications of ACA
The ACA will offer new markets for treatment services.
New populations previously not served will have access to
services but not necessary in the inpatient setting
As exchanges evolve, manage costs and adopt outcome
driven models- more patients will likely be directed into
lower levels of care, shorter lengths of stay and new
forms of contracted reimbursement—this is a trend
evolving now
There will be impacts on Medication Assisted
Treatment—parity assures that these services will be
covered for the expanded Medicaid populations, however
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exchanges will decide the scope
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The Treatment Market Today
Neither
Parity nor
ACA create
demand
In treatment: ~ 2,300,000
Abuse/Dependent
?
~ 23,000,000
Harmful Users
Low Level Use
Little or No Use
40,000,000
Most People in Need of Addiction Treatment
Do Not Receive It
Penetration Rate (% with Disorder who receive
Treatment)
77%
80%
73%
71%
60%
40%
20%
10%
0%
Substance
Hypertension
Use Disorders
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Diabetes
Major
Depression
More detail on the scale of the current market
23,000,000 --met criteria for substance
abuse dependence…
2,300,000 --received treatment…
20,700,000 -- needed treatment but did not
receive treatment
800,000 -- who say they tried to get
treatment and could not. (Will ACA help?)
19,900,000 Didn’t try to get treatment
(Do we understand why? And will ACA help?)
So what’s the state of the field and why are
we not reaching more people in need?
..
.
..
..
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Highly fragmented and dominated by treatment techniques developed in the 1950s
Many providers do not deliver Evidence-Based Treatment
Many staff in the treatment field overall have few credentials and little education and no
consistent credential for Counselors or Managers
Limited use of technology
Poor coordination of service with the medical community
Little use of data and research
Limited consumer knowledge of treatment—patient admission decisions based on
perceptions not fact
Patients are marginalized, stigmatized and lack advocacy and currency with payers
Despite this, we are dealing with the single most important public
health problem in our nation
We now have the potential for significant growth in the long run and
the opportunity to fully leverage favorable law and regulation
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Payer Response
What do Payers Want in this new market?
Cost Effective
Quality Service
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Utilize recognized best practices
Focus on Patient safety
Documentation (EHR)
Credential and licensed staff
• Cost
Improving
Outcomes
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Reward Provider
Performance
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Readmission Rates
Retention Rates
Participate in the Continuum
Use of Medication
Ranked on patient experience
Quality of Documentation
Patient Safety
Outcome Measures
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Provider Response
Who do we Treat?
From Here:
Acute Problems
Notable
Problems
Little or No Use
Treating only
the most
acutely
impaired
clients
Who could we Treat?
To Here:
Acute Problems
Notable
Problems
Little or No Use
Continue with
our current
clients
Add treatment
options for
less severe
clients
Six Habits of the Highly Effective Treatment
Program
Or…Who’s going to thrive in the New World……
Six Critical things for Treatment Programs going
forward:
1. Programs must be “fleet of foot”
2. Develop financial sophistication
3. Establish a “Continuum”
4. Data Driven
5. Compliance is important
6. Evolve out of the “Residential” moniker
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Six Critical areas for Treatment Programs going
forward
1. Programs must be “Fleet of foot”:
· Program rigidity, resistance to change and failure to
adopt evidence based treatment will limit a
programs involvement in the new market
· Deliver effective (Evidence-Based) Practices
· New services to meet the new demand
· Organizations must have an ability to change critical
components of their clinical and operational
structure
· Clinical and financial flexibility
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Implications for Treatment Programs
2. Programs must be financially sophisticated
· Financial Manger will be key member of the Program Team
· Billing and collecting is a given provided- additional
·
requirements for documentation and processes
· Understand “risk”
· New levels of analysis and data management
· Cost management
· Contract evaluation
Programs will need to document and bill like all other
healthcare providers
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Six Habits of the Highly Effective Treatment
Programs
3. Establish a Continuum:
• Integrate the concept of Chronic Care
• Disease management – Continuing Care critical
• Ability to transition to lower and higher levels of
behavioral healthcare within the community
• Ability to transition data and records to the broader
medical community and the payer
• Develop a portable EHR for patients
• Not necessary to be a one stop shop—but an
integral part of the care system in a community
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Partner with Other Healthcare Providers
From Here:
Bricks
And
Mortar
WHERE DO WE WANT TO PROVIDE SERVICES?
Partner with Other Healthcare Providers
To Here:
Mental
ACOs
Health
Providers
Bricks
and
Mortar
Community
Providers
Home and
School
Based
Programs
Hospitals
Six Habits of the Highly Effective Treatment
Programs
4. Programs Must be Data Driven:
- Three Key areas of data :
•Management Data
- Operational and management performance reports (financials and critical
operating metrics, KPI’s)
- Internal and external benchmarks
- Dashboards
- Operational Analytics—the deep dives
•Outcomes/Performance Data
- Measure our performance/show value
- Patient satisfaction
- Educated, credentialed staff
- Clinical interactions and measurements
- Failure rates
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- Participation in the continuum
Six Habits of the Highly Effective Treatment
Programs
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Market Data
- Is your organization a market out organization?
•Demand data
•Competitor data
•Payers (Public and Private) market penetrations
•Rates and Pricing
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Six Habits of the Highly Effective Treatment
Programs
5. Rigorous Compliance Program:
- Playing in the public markets and new commercial insurance
markets will demand a higher degree of compliance and
consistency of documentation
- Private Insurers are demanding more documentation and
support of claims and compliance with standards
- Utilize the concept of medical necessity and supporting criteria in
support documentation
- Programs will need to support a robust compliance program
•EHR will be a critical component of a compliance program
- Rigor of Compliance will be a factor supporting the of the quality
of a program the eyes of third party payers
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Six Habits of the Highly Effective Treatment
Programs
6. Evolve out of the “Residential” Moniker:
Part of the issue resides in the definition for “residential care”
- Widely perceived as social model or therapeutic community
- Limited understanding of services provided in the residential level of care
- Insurance contracting practices often shift contracted services to residential
from inpatient despite significant overlapping services:
The “residential model”
Detox
Inpatient
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Partial
Detox is medically supervised
Physician services
24 Hour Nursing coverage
Credentialed and licensed staff
Residential Care evolved as a licensing artifact and does not reflect actual scope
of service: detox, rehabilitation/inpatient, and partial services
Healthcare Reform & SA Treatment
It is estimated that 20-40% of
substance abuse treatment
programs will not be ready for
healthcare reform.
Don’t be one of those programs!
Questions
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