Pamela S. Hyde, J.D. SAMHSA Administrator

2. Pamela S. Hyde, J.D. SAMHSA Administrator CHANGE, CHALLENGE & OPPORTUNITY – SUBSTANCE ABUSE AND ADDICTION IN A CHANGING HEALTH CARE ENVIRONMENT 2012 SAAS Conference / NAITx Summit Federal Leadership Panel New Orleans, LA • June 20, 2012

3. TODAY’S DISCUSSION

4. NATIONALLY – SUBSTANCE ABUSE • ~ 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

5. UPTICKS IN SUBSTANCE ABUSE • 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

6. AREAS OF IMPROVEMENT 6 • 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

7. AREAS OF IMPROVEMENT – ALCOHOL • 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 • 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

8. FULL OF CHALLENGES…FULL OF OPPORTUNITIESA Day in the Life of American Adolescents 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 Adolescentswho 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

9. UNDERAGE DRINKING ↓, BUT… ~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

10. ON COLLEGE CAMPUSES 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

11. SUICIDE, ALCOHOL, AND DRUGS 11 ~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

12. TREATMENT EPISODES DATA (TEDS) • 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

13. TREND DATA:TREATMENT ADMISSIONS • 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

14. PRESCRIPTION DRUG ABUSE CHALLENGES 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

15. SAMHSA PRIORITIES • Prevention • SA Prevention & Emotional Health Development • Suicide • Underage Drinking • Prescription Drug Abuse • Health Reform • Essential Health Benefits/QHPs/Parity • Enrollment/Eligibility • Provider Capacity • Workforce

16. RFA - STRATEGIC PREVENTION FRAMEWORK PARTNERSHIPS FOR SUCCESS II 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

17. FOCUS: UNDERAGE DRINKING • 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) • Surgeon General’s Call to Action – Updating • Evidence-Base of Policy/Environmental Approaches • Webinar Series from Participating Departments • Common Messages for Public Education

18. ICCPUD COMMON MESSAGES 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

19. ICCPUD COMMON MESSAGES (cont’d) 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

20. FOCUS: PRESCRIPTION DRUG ABUSE • 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)

21. PRESCRIPTION DRUG ABUSE (cont’d) • 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)

22. *PRESCRIPTION DRUG ABUSE (cont’d) 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

23. HEALTH REFORM

24. THE CHANGING HEALTH CARE ENVIRONMENT 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

25. SAMHSA’S FOCUS – 2012 & 2013 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

26. IN 2014: MILLIONs MORE AMERICANS WILL have health care coverage • Currently, 37.9 million are uninsured <400% FPL* • 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

27. Prevalence of Behavioral Conditions Among Medicaid Expansion Pop CI = Confidence Interval Sources: 2008 – 2010 National Survey of Drug Use and Health 2010 American Community Survey

28. Prevalence of Behavioral Conditions Among Exchange Population

29. UNINSURED WITH SUD – MEDICAID EXPANSION POPULATION (<138% FPL) Typical person with SUD in Medicaid expansion population is: Male 18-34 years old White or Hispanic HS education or less Living in a metropolitan area Rating his health as good/very good Male 73% Age 18-34 63% Race/Ethnicity Non-Hispanic White 51% Non-Hispanic Black 18% Non-Hispanic Other 3% Hispanic 28% EDUCATION < High School 43% High School Graduate 32% College 25% Population Density CBSA: 1 Million + 47% CBSA: < 1 Million 32% Non-CBSA 20% Overall Health Excellent 13% Very Good 28% Good 36% Fair/Poor 23% CBSA: Core Based Statistical Area

30. UNINSURED WITH SUD – AFFORDABLE EXCHANGE POPULATION (139-400% FPL) Male 73% Age 18-34 71% Race/Ethnicity Non-Hispanic White 60% Non-Hispanic Black 12% Non-Hispanic Other 4% Hispanic 23% EDUCATION < High School 24% High School Graduate 40% College 36% Population Density CBSA: 1 Million + 56% CBSA: < 1 Million 28% Non-CBSA 15% Overall Health Excellent 15% Very Good 40% Good 31% Fair/Poor 13% CBSA: Core Based Statistical Area Typical person with SUD in exchange population is: • Male • 18-34 years old (more) • White (more White) or Hispanic • HS education or less (more educated) • Living in a metropolitan area (more) • Rating his health as good/very good • (More 18-34, white, educated, urban, better health)

31. ESSENTIAL BENEFITS – 10 SERVICE AREAS • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services, including behavioral health treatment • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services, including oral and vision care

32. DEFINING ESSENTIAL HEALTH BENEFITS • 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

33. BENCHMARK APPROACH • 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

34. BENCHMARK APPROACH (cont’d) • 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

35. *BENCHMARK APPROACH (cont’d) • HHS intends to assess the benchmark process for 2016 - Periodically review and update essential health benefits: • Difficulties with access due to coverage or cost • Changes in medical evidence or scientific advancement • Market changes • Affordability of coverage

36. QUALIFIED HEALTH PLANS – NETWORK ADEQUACY • 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!

37. CONSUMER ENROLLMENT ASSISTANCE • 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

38. SAMHSA ENROLLMENT ACTIVITIES • Consumer Enrollment Assistance Subcontracts (BRSS TACS) • 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

39. PROVIDERS ACCEPTING HEALTH INSURANCE PAYMENTS* 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

40. SOURCE OF FUNDS FOR CMHCs* State/County Indigent Funds – 43 percent Medicaid – 37 percent Private health insurance – 6 percent Self-pay – 6 percent *Source: 2011 National Council Survey

41. SAMHSA FOCUS: PROVIDERS • SAMHSA Provider Training and Technical Assistance Topics for 2013 • 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

42. WORKFORCE DEVELOPMENT CHALLENGES 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

43. SAMHSA’S WORKFORCE ACTIVITIES 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

44. EXAMPLES OF SAMHSA’SWORKFORCE EFFORTS 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

45. HRSA BH WORKFORCE ACTIVITIES 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 2010-2011, ½ in underserved areas Mental and BH Education and Training Grants FOA – 280 psychologists and social workers

46. HRSA/SAMHSA COLLABORATIVE EFFORTS • 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

47. HRSA/SAMHSA EFFORTS • June 5 Listening Session to Identify BH Workforce Needs and Possible Approaches • Data • Capacity • Training • Non-Traditional Workforce – Peers, Recovery Coaches, Case Managers, etc. • Partnerships – Professional Orgs, Peer/Recovery Orgs, Community Colleges, etc.

48. SAMHSA HEALTH REFORM WEBINARS • 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: CFRI.info.samhsa@samhsa.hhs.gov