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Health Care Reform National Perspective: Implications for Managing Chronic Addiction and Mental Health Conditions

Health Care Reform National Perspective: Implications for Managing Chronic Addiction and Mental Health Conditions. Michael L. Dennis, Ph.D . Chestnut Health Systems Normal, IL

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Health Care Reform National Perspective: Implications for Managing Chronic Addiction and Mental Health Conditions

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  1. Health Care Reform National Perspective: Implications for Managing Chronic Addiction and Mental Health Conditions Michael L. Dennis, Ph.D. Chestnut Health Systems Normal, IL Presentation at the Mental Health, Chemical Abuse and Dependency Services Division 1st Annual All Providers’ Meeting, January 27, 2012. This presentation was supported by funds from the King County Mental Health, Chemical Abuse and Dependency Services Division usingdata from NIDA grants no. R01 DA15523, R37-DA11323, R01 DA021174,, CSAT contract no. 270-07-0191 and several public data sets.. It is available electronically at www.chestnut.org/li/postersor http://www.kingcounty.gov/healthservices/MHSA/EventsTrainings/2012%201st%20Annual%20All%20Provider%20Meeting.aspx. The author thanks We would like to thank Christy Scott, Belinda Willlis, Rodney Funk,, Brook Hunter and Lilia Hristova, Lisa Nicholson, for their assistance in preparing this presentation. Please address comments or questions to the author at mdennis@chestnut.org or 309-451-7801. .p

  2. The Goals of this Presentation are to: • Overview macro trends driving health care reform • Advances in understanding and improving “identification” and access • Why evidenced based assessment and treatment are useful • Demonstrating how well we do in analyses looking at benefit-costs • Examples of how Addiction is a Chronic condition and studies of how to best manage it.

  3. Rise in the Cost of Health Care Spending Per Capita By Time & Country Health care spending in the US has risen faster than inflation and is not twice what you see in other countries Source: Kaiser Family Foundation

  4. The “rate of increase” in both national health expenditures and gross domesstic product has been slowing. Amount of growth dropping over time Source: Center for Medicare and Medicaid Services

  5. Estimated Contributions of Selected Factors to Growth in Real Health Care Spending Per Capita More use of new technology and medicine largest factor

  6. Impact of 2008-2012 Recession:Effect of a 1% Point Increase in Unemployment

  7. Average Annual Growth in Selected Factors Accounting for Growth in Personal Health Care Source: Center for Medicare and Medicaid Services

  8. Physician and Clinical Services in Particular has Slowed Down to Less Than the Rate of Inflation Source: Center for Medicare and Medicaid Services

  9. In the coming years Personal Health Care Expenditures are Expected to Grow at or above the Rate of Gross Domestic Product Spike due to full Implementation of Affordable Care Act (ACA) Source: Center for Medicare and Medicaid Services

  10. Prevalence of Lifetime Disorders and Past Year Remission in the 2002 US adult pop (209.1 million) Past Year Remission Yet many are in Remission (no systems in the past year) Almost half of all adults have been touched by substance, internalizing or externalizing disorders 100% 90% Lifetime Disorder 80% 70% 47% 60% 37% 50% 31% 40% 25% 20% 19% 30% 15% 13% 13% 12% 10% 10% 8% 8% 8% 8% 20% 7% 7% 5% 4% 2% 2% 10% 0% ADHD Dysthymia Agoraphobia Any Disorder Drug Disorder Social Phobia Bi-Polar I or II Panic Disorder Alcohol Disorder Conduct Disorder Oppositional Defiant Any Mood Disorder: Intermittent Explosive Internalizing Disorder Other Specific Phobia Major Depressive Epi. Externalizing Disorder Any Anxiety Disorder: Any Substance Disorder Generalized Anxiety Dis. Posttraumatic Stress Dis. Adult Separation Anxiety Source: Dennis, Scott, Funk & Chan forthcoming; National Co morbidity Study Replication (n=9282)

  11. Past Year Recovery “Rates” (Remission/Lifetime) by Disorders in the US 89% 89% Past Year Recovery Rate 100% 83% 90% 77% 71% 66% 80% 57% 58% 56% 70% 50% 45% 48% 48% 43% 44% 41% 42% 60% 44% 41% 39% 30% 50% 31% 40% 30% 20% 10% 0% ADHD Dysthymia Agoraphobia Any Disorder Drug Disorder Social Phobia Bi-Polar I or II Panic Disorder Alcohol Disorder Conduct Disorder Oppositional Defiant Any Mood Disorder: Intermittent Explosive Internalizing Disorder Other Specific Phobia Major Depressive Epi. Externalizing Disorder Any Anxiety Disorder: Any Substance Disorder Generalized Anxiety Dis. Posttraumatic Stress Dis. Adult Separation Anxiety Source: Dennis, Scott, Funk & Chanforthcoming; National Co morbidity Study Replication

  12. Multimorbidity is Common Pattern of Disorders (n=3,179 age 18-44) Number of Disorders (n=9,282) Source: Dennis, Scott, Funk & Chanforthcoming; National Co morbidity Study Replication

  13. Remission is Related to Number of Disorders and Pattern of Multimorbidity Pattern of Disorders Number of Disorders Source: Dennis, Scott, Funk & Chan forthcoming; National Co morbidity Study Replication

  14. Recovery Rate is related to the to Number of Disorders and Pattern of Multimorbidity 100% 90% Past Year Recovery Rate 80% 68% 65% 64% 70% 51% 50% 60% 41% 50% 40% 26% 24% 19% 30% 16% 20% 10% 0% None None 1 Disorder 2 Disorders Substance Only 3 to 16 Disorders Internalizing Only Sub. + Ext. + Int. Externalizing Only Substance+Internalizing Substance+Externalizing Externalizing+Internalizing Pattern of Disorders Number of Disorders Source: Dennis, Scott, Funk & Chan forthcoming; National Co morbidity Study Replication

  15. Treatment Participation is related to the to Number of Dis. and Pattern of Multimorbidity SUD Tx Generally Less common Pattern of Disorders Number of Disorders Source: Dennis, Scott, Funk & Chan forthcoming; National Co morbidity Study Replication

  16. Substance Use Disorders are Common, US Treatment Participation Rates Are Low Few Get Treatment: 1 in 20 adolescents, 1 in 18 young adults, 1 in 11 adults Over 88% of adolescent and young adult treatment and over 50% of adult treatment is publicly funded Much of the private funding is limited to 30 days or less and authorized day by day or week by week Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]

  17. Potential AOD Screening & Intervention SitesAdolescents (age 12-17) Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]

  18. Potential AOD Screening & Intervention SitesAdults (age 18+) Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]

  19. Adolescent Rates of High (2+) Scores on Mental Health (MH) or Substance Abuse (SA) Screener by Setting in Washington State Problems could be easily identified Comorbidity is common Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

  20. Adult rates of High (2+) Scores on Mental Health (MH) or Substance Abuse (SA) Screener by Setting in Washington State Lower than expected rates of SA in mental health & children’s admin Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

  21. Adolescent Client Validation of High Co-Occurring from GAIN Short Screener vs. Clinical Records by Setting in Washington State Two-page measure closely approximated all found in the clinical record after the next 2 years Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

  22. Higher rate in clinical record in mental health and children’s administration (But that was past on “any use” vs. “abuse/dependence” and 2 years vs. past year) Adult Client Validation of High Co-Occurring from GAIN Short Screener vs. Clinical Records by Setting in Washington State Source: Lucenko et al. (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

  23. Where in the System are the Adolescents with Mental Health, Substance Abuse and Co-occurring? School Assistance Programs (SAP) largest part of BH/MH system; 2nd largest of SA & Co-occurring systems SAP+ SA Treatment Over half of system Source: Lucenko et al (2009). Report to the Legislature: Co-Occurring Disorders Among DSHS Clients. Olympia, WA: Department of Social and Health Services. Retrieved from http://publications.rda.dshs.wa.gov/1392/

  24. Length of Stay Less that the 90 days Recommended by Research Source: Office of Applied Studies 2007Discharge – Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm

  25. Less than Half are Positively Discharged Source: Office of Applied Studies 2007 Discharge – Treatment Episode Data Set (TEDS) http://www.samhsa.gov/oas/dasis.htm

  26. Programs often LACK Evidenced Based Assessment to Identify and Practices to Treat: • Substance use disorders (e.g., abuse, dependence, withdrawal), readiness for change, relapse potential and recovery environment • Common mental health disorders (e.g., conduct, attention deficit-hyperactivity, depression, anxiety, trauma, self-mutilation and suicidal thoughts) • Crime and violence (e.g., inter-personal violence, drug related crime, property crime, violent crime) • HIV risk behaviors (needle use, sexual risk, victimization) • Child maltreatment (physical, sexual, emotional) • Recovery environment and peer risk

  27. Other Structural Challenges to Delivery of Quality Care in Behavioral Health Systems High turnover workforce with variable educationbackground related to diagnosis, placement, treatment planning and referral to other services Heterogeneous needs and severitycharacterized by multiple problems, chronic relapse, and multiple episodes of care over several years Lack of access to or use of data at the program levelto guide immediate clinical decisions, billing and program planning Missing, bad or misrepresented datathat needs to be minimized and incorporated into interpretations Lack of Infrastructure that is needed to support implementation and fidelity

  28. Some Common Record Based Performance Measures * NQF: National Quality Forum; WCG: Washington Circle Group; CSAT: Center for Substance Abuse Treatment evaluations; NOMS: National Outcome Monitoring System; NIATX: Network for the Improvement of Addiction Treatment; PFP: Pay for Performance evaluations

  29. Evaluation of Existing Measures Strengths: Easy to collect/ calculate in electronic health records Give broad overview of where problems Useful for program evaluation and pay for performance Weaknesses: Doesn’t lead to specific changes or intervention with individuals Doesn’t address case mix or context issues Doesn’t easily lead to specific improvement at the program level Doesn’t address relationships with other gaps in the macro system Linkage to other behavioral health record systems is efficient, but limited by the coverage, content and quality of those systems

  30. Additional NQF Standards of Care Annual screening for tobacco, alcohol and other drugs using systematic methods Referral for further multidimensional assessment to guide patient-centered treatment planning Brief intervention, referral to treatment and supportive services where needed Pharmacotherapy to help manage withdrawal, tobacco, alcohol and opioid dependence Provision of empirically validated psychosocial interventions Monitoring and the provision of continuing care Source: www.tresearch.org/centers/nqf_docs/NQF_Crosswalk.pdf

  31. In practice we need a Continuum of Measurement(Common Measures) More Extensive / Longer/ Expensive Screener Quick Comprehensive Special • Screening to Identify Who Needs to be “Assessed” (5-10 min) • Focus on brevity, simplicity for administration & scoring • Needs to be adequate for triage and referral • GAIN Short Screener for SUD, MH & Crime • ASSIST, AUDIT, CAGE, CRAFT, DAST, MAST for SUD • SCL, HSCL, BSI, CANS for Mental Health • LSI, MAYSI, YLS for Crime • Quick Assessment for Targeted Referral (20-30 min) • Assessment of who needs a feedback, brief intervention or referral for more specialized assessment or treatment • Needs to be adequate for brief intervention • GAIN Quick • ADI, ASI, SASSI, T-ASI, MINI • Comprehensive Biopsychosocial (1-2 hours) • Used to identify common problems and how they are interrelated • Needs to be adequate for diagnosis, treatment planning and placement of common problems • GAIN Initial (Clinical Core and Full) • CASI, A-CASI, MATE • Specialized Assessment (additional time per area) • Additional assessment by a specialist (e.g., psychiatrist, MD, nurse, spec ed) may be needed to rule out a diagnosis or develop a treatment plan or individual education plan • CIDI, DISC, KSADS, PDI, SCAN

  32. Longer Measures Assess and Identify More Problems Source: CSAT 2010 AT Summary Analytic Data Set(n = 17,356)

  33. Count of Major Clinical Problems at Intake Source: CSAT 2010 AT Summary Analytic Data Set (n=17,978)

  34. Count of Major Clinical Problems* at Intake by Level of Care Source: CSAT 2010 AT Summary Analytic Data Set (n=17,681)

  35. Count of Major Clinical Problems* at Intake by Severity of Victimization Source: CSAT 2010 AT Summary Analytic Data Set (n=18,120)

  36. Change (post-pre) Effect Size for Core Treatment Outcomes by Type of Treatment Four best on treatment outcomes include A-CRA, MST, MDFT, & FSN

  37. Change in Abstinence by level of Support: Adolescent Community Reinforcement Approach (A-CRA) Effects associated with Coaching, Certification and Monitoring (OR=7.6) Source: CSAT 2008 SA Dataset subset to 6 Month Follow up (n=1,961) 37

  38. But better than the average for OP in ATM (200 days of abstinence) Similarity of Clinical Outcomes : Cannabis Youth Treatment (CYT) Not significantly different by condition. Trial 2 Trial 1 300 50% . 280 40% . 260 30% over 12 months at Month 12 Total days abstinent Percent in Recovery 240 20% 220 10% 200 0% MET/ CBT5 MET/ FSN MET/ CBT5 ACRA MDFT (n=102) CBT12 (n=102) (n=99) (n=100) (n=99) 269 256 260 251 265 257 Total Days Abstinent* 0.28 0.17 0.22 0.23 0.34 0.19 Percent in Recovery** * n.s.d., effect size f=0.06 * n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.12 ** n.s.d., effect size f=0.16 Source: Dennis et al., 2004

  39. ACRA did better than MET/CBT5, and both did better than MDFT MET/CBT5 and 12 did better than FSN Moderate to large differences in Cost-Effectiveness by Condition Trial 2 Trial 1 $20 $20,000 $16 $16,000 $12 $12,000 Cost per person in recovery at month 12 over 12 months Cost per day of abstinence $8 $8,000 $4 $4,000 $0 $0 MET/ MET/ CBT5 MET/ CBT5 FSN ACRA MDFT CBT12 $4.91 $6.15 $15.13 $9.00 $6.62 $10.38 CPDA* $3,958 $7,377 $15,116 $6,611 $4,460 $11,775 CPPR** * p<.05 effect size f=0.48 * p<.05 effect size f=0.22 ** p<.05, effect size f=0.72 ** p<.05, effect size f=0.78 Suggest the need to consider cost-effectiveness of treatment approaches Source: Dennis et al., 2004

  40. The Cost of Substance Abuse Treatment is Trivial Relative to the Costs Treatment Reduces SBIRT models popular due to ease of implementation and low cost • $750 per night in Medical Detox • $1,115 per night in hospital • $13,000 per week in intensive • care for premature baby • $27,000 per robbery • $67,000 per assault $70,000/year to keep a child in detention $22,000 / year to incarcerate an adult $30,000/ child-year in foster care Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004 in 2009 dollars

  41. Investing in Substance Abuse Treatment Results in a Positive Return on Investment (ROI) • Substance abuse treatment has an ROI of between $1.28 to $7.26 per dollar invested. • Consequently, for every treatment dollar cut in the proposed budget, the actual costs to taxpayers will increase between $1.28 and $7.26. • How will this happen? Individuals needing substance abuse treatment will not disappear but instead interface with much more expensive systems such as emergency rooms and prisons. • Bottom line = The proposed $55 million dollar cut will cost Illinois taxpayers between $70 and $400 million within the next 1 to 2 years. Source: Bhati et al., (2008); Ettner et al., (2006)

  42. Examples using Unit Costs *Quarterly cost to society 2009 dollars

  43. Example #1: Haymarket Clients • Under a NIDA grant, a cohort of 436 adults admitted to Haymarket Center in Chicago were interviewed at intake between February to March, 2004 and quarterly for 4 years (with over 95% completion). • In 2009, dollars these clients averaged $3,698 in costs to society in the 90 days before accessing treatment ($15,383 in the year before intake). • Before entering outpatient treatment, clients incurred lower quarterly costs when compared to clients entering long-term residential ($2,191 vs. $4,749). More intensive treatment serves clients that cost taxpayers more. • During the year prior to treatment, this cohort of 436 adults cost taxpayers $6,707,103. Without treatment, these costs would have continued. • It only took an average of 18 months before the cost of treating these people at Haymarket was off set by reductions in other costs to society and at the end of 4 years, there was an average net savings of $14,589 per client.

  44. Investing in Treatment has a Positive Annual Return on Investment (ROI) • Substance abuse treatment has been shown to have a ROI of between $1.28 to $7.26 per dollar invested • Even the long term and more intensive Treatment Drug Courts programs have an average ROI of $2.14 to $2.71 per dollar invested This also means that for every dollar treatment is cut, we lose more money than we saved. Source: Bhati et al., (2008); Ettner et al., (2006)

  45. Example #1: Haymarket Clients • Under a NIDA grant, a cohort of 436 adults admitted to Haymarket Center in Chicago were interviewed at intake between February to March, 2004 and quarterly for 4 years (with over 95% completion). • In 2009, dollars these clients averaged $3,698 in costs to society in the 90 days before accessing treatment ($15,383 in the year before intake). • Before entering outpatient treatment, clients incurred lower quarterly costs when compared to clients entering long-term residential ($2,191 vs. $4,749). More intensive treatment serves clients that cost taxpayers more. • During the year prior to treatment, this cohort of 436 adults cost taxpayers $6,707,103. Without treatment, these costs would have continued. • It only took an average of 18 months before the cost of treating these people at Haymarket was off set by reductions in other costs to society and at the end of 4 years, there was an average net savings of $14,589 per client.

  46. Change in Quarterly Costs To Society: Haymarket Center Adult Cohort Treatment costs initially increase costs Followed by a sustained period of reduced quarterly costs Source: Dennis & Scott NIDA Grant no. R37 DA011323

  47. Over 4 years, cumulative saving of $14,589 per person ($6,360,804 for 436 person admission cohort) Cumulative Actual Costs Minus ExpectedCosts To Society Additional Cost of Treatment offset by Savings in other costs within 18 months Source: Dennis & Scott NIDA Grant no. R37 DA011323

  48. Cumulative Actual Minus Expected Costs To Society: Haymarket by Level of Care All Levels of Care Produced Net Savings Similarly, IOP produced greater savings than OP Though the most expensive initially, long term treatment also produced the most long term savings Source: Dennis & Scott NIDA Grant no. R37 DA011323

  49. Example #2: Chestnut Health Systems • As part of a NIAAA grant, a cohort of 355 adolescents were recruited at discharge between 2004 and 2008 from Chestnut’s residential treatment programs in central and southern Illinois and interviewed quarterly for 1 year (with over 90% completion). • In 2009 dollars, they averaged $6,554 in costs to society in the 90 days before intake ($26,217 in the year before intake). • This 4 year cohort of 355 adolescents cost society $9,307,163 in the year before they were admitted to treatment – costs they would have continued to incur if they were not treated. • Usual continuing care produces a net benefit of $4,816 per adolescent within 12 months post discharge. Three more intensive types of continuing care produced greater net benefits of between $7,876 to $11,559 within 12 months post discharge.

  50. Change in Quarterly Costs To Society: Chestnut Adolescent Cohort Outpatient Continuing Care plus other Costs Consistently Below Baseline Costs Source: Godley NIAAA Grant no. R01 AA 10368

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