Transcript 062012 SAAS Plenary FINAL

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CHANGE, CHALLENGE & OPPORTUNITY
– SUBSTANCE ABUSE AND ADDICTION
IN A CHANGING HEALTH CARE
ENVIRONMENT
Pamela S. Hyde, J.D.
SAMHSA Administrator
2012 SAAS Conference / NAITx Summit
Federal Leadership Panel
New Orleans, LA • June 20, 2012
TODAY’S DISCUSSION
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SUBSTANCE ABUSE & ADDICTION IN AMERICA
SAMHSA PRIORITIES
HEALTH REFORM
PROVIDER READINESS AND WORKFORCE
NATIONALLY – SUBSTANCE ABUSE
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~ 22.1 million persons aged 12 + were
classified with substance dependence or
abuse in the past year (8.7 percent)
• 4.2 million illicit drugs
• 15.0 million alcohol
• 2.9 million classified with dependence or
abuse of both
UPTICKS IN SUBSTANCE ABUSE
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Use of illicit drugs ↑ between 2008 and 2010
• 2010: 22.6 million (8.9 percent of those 12+) current illicit
drug users
• 2009: Rate of 8.7 percent
• 2008: Rate of 8.0 percent
Use of marijuana ↑ from 2007 to 2010
• 2010: 6.9 percent (17.4 million)
• 2007: 5.8 percent (14.4 million)
Continuing ↑ in rate of current illicit drug use among
young adults aged 18 to 25
• 2010: 21.5 percent
• 2009: 21.2 percent
• 2008: 19.6 percent
AREAS OF IMPROVEMENT
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Current methamphetamine users ↓ by ~ half
• 731,000 people (0.3 percent) in 2006 to 353,000
(0.1 percent) in 2010
Current Cocaine users ↓ (2006 to 2010)
• 2.4 million current users in 2006 to 1.5 million in
2010
AREAS OF IMPROVEMENT – ALCOHOL
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Alcohol Use Among Underage Persons (12-20) ↓ (2002
to 2010)
• Current alcohol ↓ 28.8 to 26.3 percent
• Binge drinking ↓ 19.3 to 17.0 percent
• Heavy drinking ↓ 6.2 to 5.1 percent
Current Use Varies by Age
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18-20 year olds ↓ 51.0 to 48.9 percent
16-17 year olds ↓ 32.6 to 24.6 percent
14-15 year olds ↓ 16.6 to 12.4 percent
12-13 year olds ↓ 4.3 to 3.1 percent
Binge Drinking Varies by College Enrollment
• In college more likely to drink, drink heavily and binge drink
FULL OF CHALLENGES…FULL OF OPPORTUNITIES
A Day in the Life of American Adolescents
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On an average day in the U.S., adolescents (12-17)
• 508,000 drink alcohol
• 641,000 use illicit drugs
• > than 1 million smoke cigarettes
Adolescents who used substances for the first time on an average
day:
● Approximately 7,500 alcohol
● Approximately 4,360 used an illicit drug
● Around 3,900 smoked cigarettes
● Nearly 3,700 used marijuana
● Approximately 2,500 abused pain relievers
UNDERAGE DRINKING ↓, BUT…
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~5,000 young people die each year from injuries caused by
underage drinking – stagnant
> 67 percent of young people who start drinking before age 15
will try an illicit drug
> 4 in 10 who begin drinking before age 15 eventually become
dependent on alcohol
Six million children (9 percent) live with at least one parent
who abuses alcohol or other drugs
Young people with a major depressive episode are twice as
likely to take a 1st drink or use drugs for the 1st time as those
who do not experience such an episode
ON COLLEGE CAMPUSES
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Adults who begin drinking alcohol before age 21 are more likely
to have an alcohol dependence or abuse disorder than those
who had their first drink after age 21
Nearly 6,000 students (ages 18 - 24) injured under the influence
of alcohol
 >1,800 students die from alcohol-related causes
More than 150,000 students develop an alcohol-related health
problem
As many as 1.5 percent of students report a suicide attempt due
to drinking or drug use
SUICIDE, ALCOHOL, AND DRUGS
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~30 % of deaths by suicide involved alcohol
intoxication – BAC at or above legal limit
4 other substances were identified in ~10%
of tested victims – amphetamines, cocaine,
opiates (prescription & heroin), marijuana
TREATMENT EPISODES DATA (TEDS)
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In 2010: 1,820,737 SA Treatment Admissions
Five Substance Groups Accounted for 96 Percent of
Primary Substances Reported
• Alcohol: 41 percent
• Opiates: 23 percent
• Marijuana: 18 percent
• Cocaine: 8 percent
• Methamphetamine/Amphetamines: 6 percent
TREND DATA:
TREATMENT ADMISSIONS
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2000 – 2010 Treatment Admission Rates (per 100,000
population) for Persons 12 and Older
• Overall admissions ↑ 4 percent
• 400 percent ↑ for abuse of prescription pain relievers
• Rates for opiates (other than heroin) were between
272 and 774 percent ↑ in 9 of 9 Census divisions
• 27 percent ↑ methamphetamine/amphetamines
• 21 percent ↑ primarily related to marijuana disorders
PRESCRIPTION DRUG ABUSE CHALLENGES
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Increasing rates of prescription drug misuse – all ages,
genders, and communities
Emergency room visits involving pharmaceutical drugs
misuse or abuse have doubled over the past five years;
and, for the third year in a row, exceed the number of
visits involving illicit drugs
25 percent of controlled substance prescriptions come
from emergency departments
Over half (55.9 percent) of youth and adults who use
prescription pain relievers non-medically got them from
a friend or relative for free
SAMHSA PRIORITIES
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Prevention
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SA Prevention & Emotional Health Development
Suicide
Underage Drinking
Prescription Drug Abuse
Health Reform
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Essential Health Benefits/QHPs/Parity
Enrollment/Eligibility
Provider Capacity
Workforce
RFA - STRATEGIC PREVENTION FRAMEWORK
PARTNERSHIPS FOR SUCCESS II
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Grants to States, to Build on Strategic
Prevention Framework and Epidemiology Efforts
Prioritize Underage Drinking, Prescription Drug
Abuse and/or a Third Issue Based on State’s Own
Data
Focus on High Need Communities for Issues
Addressed
FOCUS: UNDERAGE DRINKING
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2012 STOP Act RFA – Asked for Evidence of or Barriers to
State/Community Collaboration, to Meet Goals of Act
HHS Behavioral Health Coordinating Council (BHCC) –
Campus Presidents’ Collaboration
Interagency Coordinating Committee on the Prevention
of Underage Drinking (ICCPUD)
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Surgeon General’s Call to Action – Updating
Evidence-Base of Policy/Environmental Approaches
Webinar Series from Participating Departments
Common Messages for Public Education
ICCPUD COMMON MESSAGES
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Alcohol is the drug of choice among our Nation’s young
people; while they drink less frequently than adults,
youth consume more when they drink
Drinking often starts at young ages, and alcohol use and
binge drinking increase dramatically during adolescence
Youth who report drinking prior to the age of 15 are
more likely to experience problems related to alcohol
later in life
Many young people drink in extreme ways
ICCPUD COMMON MESSAGES (cont’d)
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Underage drinking has profound negative consequences
Underage drinkers not only negatively affect themselves,
they harm others
For some, underage drinking & drug use occur together;
this combination increases the risk of negative
consequences from both
Underage alcohol use is not inevitable – there are policies
and programs that have been proven to prevent and
reduce underage drinking
FOCUS: PRESCRIPTION DRUG ABUSE
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Work w/ ONDCP’s 2011 Prescription Drug Abuse
Prevention Plan
BHCC Subcommittee
• Information & Strategies for Office of the Secretary
• Data re Sources and Prescribing Patterns (w/ ASPE)
RFA re PDMP Electronic Health Record (EHR)
Integration and Cross-State Interoperability Expansion
Funding PDMP Pilots (IN & OH) to Test Interoperability
with Other HIT/EHR Systems (w/ ONC)
PRESCRIPTION DRUG ABUSE (cont’d)
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Medical Education for Current Prescribers
• CMEs for Prescribers for Chronic Pain
• Training in Opioid Treatment Programs
• Physician Clinical Support System – Opioids
Prevention of Prescription Drug Abuse in the
Workplace (PAW) Technical Assistance
Webinar and Issue Brief on Prescription Drug Abuse
and Misuse for Older Americans (w/ AoA)
*PRESCRIPTION DRUG ABUSE (cont’d)
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Public Education – “not work the risk, even if it’s
legal”
Opioid Overdose Prevention Toolkit in Process
WHO World Health Assembly – First Opioid Overdose
Mortality Prevention Panel (May 2012, Geneva)
DEA/HHS Prescription Drug Take Back Days
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HEALTH REFORM
THE CHANGING HEALTH CARE
ENVIRONMENT
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Quality rather than quantity
Integration rather than silo’d care – parity
Prevention and wellness rather than illness
Access to coverage and care rather than
significant parts of America uninsured – parity
Recovery rather than chronicity or disability
Cost controls through better care
SAMHSA’S FOCUS – 2012 & 2013
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Uniform Block Grant Application 2014-2015
Essential Benefits & Qualified Health Plans
Enrollment
Provider capacity development
Quality and Data (including HIT)
Parity – Implementation & Communication
Workforce
Continuing Work with Medicaid (health homes,
rules/regs, good & modern services, screening,
prevention), and PBHCI
IN 2014: MILLIONS MORE AMERICANS
WILL HAVE HEALTH CARE COVERAGE
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 Currently, 37.9 million are uninsured <400%
FPL*
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18.0 M – Medicaid expansion eligible
• 19.9 M – ACA exchange eligible**
• 11.019 M (29%) – Have BH condition(s)
* Source: 2010 NSDUH
**Eligible for premium tax credits and not eligible for Medicaid
Prevalence of Behavioral Conditions
Among Medicaid Expansion Pop
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Uninsured Adults Ages 18-64 with Incomes < 138% FPL (18 Million)
18.0%
Percent with Condition
16.0%
14.9%
14.0%
14.2%
12.0%
10.0%
8.0%
7.0%
6.0%
4.0%
Percent with a Serious
Mental Illness (1,283,000)
CI: 6.3%-7.7%
Percent with Serious
Psychological Distress
(2,731,742)
CI: 14.0%-15.9%
CI = Confidence Interval
Sources: 2008 – 2010 National Survey of Drug Use and Health
2010 American Community Survey
Percent with a Substance
Use Disorder (2,603,405)
CI: 13.2%-15.2%
Prevalence of Behavioral Conditions
Among Exchange Population
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UNINSURED WITH SUD –
MEDICAID EXPANSION POPULATION (<138% FPL)
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Male
Age 18-34
Race/Ethnicity
Non-Hispanic White
Non-Hispanic Black
Non-Hispanic Other
Hispanic
73%
63%
Typical person with SUD in Medicaid
expansion population is:
51%
18%
3%
28%
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Male
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18-34 years old
43%
32%
25%
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White or Hispanic
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HS education or less
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Living in a metropolitan area
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Rating his health as good/very
EDUCATION
< High School
High School Graduate
College
Population Density
CBSA: 1 Million +
CBSA: < 1 Million
Non-CBSA
Overall Health
Excellent
Very Good
Good
Fair/Poor
CBSA: Core Based Statistical Area
47%
32%
20%
13%
28%
36%
23%
good
UNINSURED WITH SUD –
AFFORDABLE EXCHANGE POPULATION (139-400% FPL)
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Male
Age 18-34
Race/Ethnicity
Non-Hispanic White
Non-Hispanic Black
Non-Hispanic Other
Hispanic
EDUCATION
< High School
High School Graduate
College
Population Density
CBSA: 1 Million +
CBSA: < 1 Million
Non-CBSA
Overall Health
Excellent
Very Good
Good
Fair/Poor
CBSA: Core Based Statistical Area
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73%
71%
Typical person with SUD in exchange
population is:
60%
12%
4%
23%
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Male
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18-34 years old (more)
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White (more White) or Hispanic
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HS education or less (more
24%
40%
36%
56%
28%
15%
15%
40%
31%
13%
educated)
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Living in a metropolitan area (more)
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Rating his health as good/very good
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(More 18-34, white, educated,
urban, better health)
ESSENTIAL BENEFITS – 10 SERVICE AREAS
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1. Ambulatory patient
services
2. Emergency services
3. Hospitalization
4. Maternity and newborn
care
5. Mental health and
substance use disorder
services, including
behavioral health
treatment
6. Prescription drugs
7. Rehabilitative and
habilitative services and
devices
8. Laboratory services
9. Preventive and wellness
services and chronic
disease management
10. Pediatric services,
including oral and vision
care
DEFINING ESSENTIAL HEALTH BENEFITS
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• Encompass 10 Categories of Services & Reflect Balance Among Categories
• Reflect Typical Employer Health Benefit Plans
• Account For Diverse Health Needs Across Many Populations
• Ensure No Incentives for Coverage Decisions, Cost Sharing or Reimbursement
Rates To Discriminate by Age, Disability, or Expected Length of Life
• Ensure Compliance with Mental Health Parity and Addiction Equity Act of
2008 (MHPAEA) and the Parity Requirements of Affordable Care Act (ACA)
• Provide States a Role in Defining Essential Health Benefits (Good for BH)
• Balance Comprehensiveness and Affordability
• Assure Evidence-Based Quality Services
BENCHMARK APPROACH
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- Serves as a Reference Plan – Reflecting Scope of
Services and Limits Offered by a “Typical Employer
Plan” in that State
- States Will Be Allowed to Select a Single Benchmark:
• 1 of the 3 largest small group market plans
• 1 of the 3 largest state employee plans
• 1 of the 3 largest federal employee plans, or
• The largest HMO plan in a state
BENCHMARK APPROACH (cont’d)
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- Plans must include all 10 benefit categories regardless
of what the benchmark plan covers or excludes
- May supplement from other plans if category is not
sufficiently covered
- Regarding mental health and substance abuse
services, parity applies
- If a State does not select a benchmark, HHS will
default to the largest plan by enrollment in the largest
product in the small group market
*BENCHMARK APPROACH (cont’d)
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- HHS intends to assess the benchmark process for 2016
- Periodically review and update essential health benefits:
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Difficulties with access due to coverage or cost
Changes in medical evidence or scientific advancement
Market changes
Affordability of coverage
QUALIFIED HEALTH PLANS –
NETWORK ADEQUACY
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Qualified Health Plans (QHPs) Offered through Affordable
Health Exchanges (or Marketplaces)
QHPs Must Maintain a Network of Providers Sufficient in
Number & Types to Assure Services Will Be Accessible
Without Unreasonable Delay
• Highlights MH/SUD providers
• Encourages QHPs to provide sufficient access to a broad
range of MH/SUD services, particularly in low-income
and underserved communities
• Must be sufficient providers to deliver!
CONSUMER ENROLLMENT ASSISTANCE
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Navigator Functions
• Include at least one consumer-focused non-profit
• Maintain expertise in eligibility and enrollment and
facilitate enrollment in QHPs
• Conduct public education activities to raise
awareness about the state’s exchange
• Provide referrals to any applicable office of health
insurance consumer assistance or health insurance
ombudsman
SAMHSA ENROLLMENT ACTIVITIES
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Consumer Enrollment Assistance Subcontracts (BRSS
TACS)
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Outreach/public education
Enrollment/re-determination assistance
Plan comparison and selection
Grievance procedures
Eligibility/enrollment communication materials
Enrollment Assistance Best Practices TA – Toolkits
Communication Strategy – Message Testing, Outreach
to Stakeholder Groups, Webinars/Training Opportunities
Data Work with ASPE and CMS
PROVIDERS ACCEPTING HEALTH
INSURANCE PAYMENTS*
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Primary MH plus some SA – 85 percent
Primary SA – 56 percent
Other (homeless shelters and social services)
– 37 percent
Residential SA – 54 percent
Inpatient – 95 percent
Outpatient – 68 percent
*Source: NSATSS
SOURCE OF FUNDS FOR CMHCs*
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State/County Indigent Funds – 43 percent
Medicaid – 37 percent
Private health insurance – 6 percent
Self-pay – 6 percent
*Source: 2011 National Council Survey
SAMHSA FOCUS: PROVIDERS
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SAMHSA Provider Training and Technical Assistance
Topics for 2013
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Business strategy under health reform
Third-party contract negotiation
Third-party billing and compliance
Eligibility determinations and enrollment assistance
HIT adoption to meaningful use standards
Targeting high-risk providers
Provider Infrastructure RFP
• Training and technical assistance
• Learning collaborative
WORKFORCE DEVELOPMENT CHALLENGES
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Worker shortages
More than one-half of BH workforce is over age 50
Between 70 to 90 percent of BH workforce is white
Inadequately and inconsistently trained workers
Education/training programs not reflecting current research base
Inadequate compensation
High levels of turnover
Poorly defined career pathways
Difficulties recruiting people to field – esp., from minority
communities
SAMHSA’S WORKFORCE ACTIVITIES
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Reports and Plans (to Congress in
process)
Training and Technical Assistance,
especially on technology transfer and
evidence-based practices
Manuals, publications and media
resources
National Network to Eliminate
Disparities in Behavioral Health (NNED)
Integrating Primary and Behavioral
Health Care
Workforce efforts within each of
Strategic Initiatives
EXAMPLES OF SAMHSA’S
WORKFORCE EFFORTS
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Regional Leadership Institutes
Minority Fellowship Program
Knowledge Application Programs
Center for Adoption of Prevention Technology
Addiction Technology Transfer Centers
Medical Residency Programs
TIPs, TAPs, Webinar Series, Media Materials
SBIRT Medical Residency Programs
Various TA Centers, Trainings
HRSA BH WORKFORCE ACTIVITIES
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 2/3 of Community Health
Centers (CHCs) provide MH and 1/3
provide SA services
• SBIRT encouraged through training and in
data reporting
 National Health Service Corps –
2,426 BH providers in National
Health Service Corps (May 2012)
Graduate Psychology Education
Program – 710 trainees in 20102011, ½ in underserved areas
 Mental and BH Education and
Training Grants FOA – 280
psychologists and social workers
HRSA/SAMHSA
COLLABORATIVE EFFORTS
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Center for Integrated Health Solutions (PBHCI)
• Focus on bi-directional integrated care
• Psychiatrist training and competency-based MSW curricula
National Database – thru HRSA National Center for
Workforce Analysis w/ BH professional organizations
Education/Training Opportunities in Historically Black
Colleges & Universities w/ Morehouse School of Medicine
Same Day Billing Initiative – w/ BHCC and CMS Medicare
Military Culture Training for Health/BH Providers w/
AHECs
HRSA/SAMHSA EFFORTS
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June 5 Listening Session to Identify BH
Workforce Needs and Possible Approaches
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Data
Capacity
Training
Non-Traditional Workforce – Peers, Recovery
Coaches, Case Managers, etc.
• Partnerships – Professional Orgs, Peer/Recovery
Orgs, Community Colleges, etc.
SAMHSA HEALTH REFORM WEBINARS
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Archived webinars at
http://www.samhsa.gov/HealthReform/
SSA/SMHA series on EHB (archived)
SSA/SMHA series on eligibility/enrollment (July 12th,
August 2nd ; State staff only)
Learning collaborative series on EHB (archived and
forthcoming)
• Live limited to MD, VT, ME, CA, NY, NM, AZ, MO
• To register, email: [email protected]