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Recovery, Opportunities under Health Care Reform
Behavioral Health & Addiction Treatment Opportunities under Health Care Reform
Los Angeles, CA September 30, 2011
H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director
Center for Substance Abuse TreatmentSubstance Abuse Mental Health Services Administration
U.S. Department of Health & Human Services
3
Without effective treatment, abuse of alcohol, illicit drugs, or prescription medications can devastate the mind and
body. With treatment, substance use disorders can
be managed, giving individuals the effective tools
necessary to address their addiction.
President Barack ObamaAugust 31, 2009
4
Kathleen SebeliusSecretary
U.S. Department of Health & Human Services
“Faith leaders are trusted partners in local communities. You have a unique ability to reach people, especially the most vulnerable, with
the tools and information they need
to get healthy, stay well, and thrive.”
March 2010
5
“In 2011, and beyond, SAMHSA will work to improve
understanding about mental and substance use disorders, promote
emotional health and the prevention of substance abuse
and mental illness, increase access to effective treatment,
and support recovery.”
SAMHSA
Pamela S. Hyde, J.D.Administrator, SAMHSA
Excerpt from Leading Change: A Plan for SAMHSA’s Roles and Actions 2011-2014
6
SAMHSA’s Role in Improving the Nation’s Health
Behavioral health services improve health status and reduce health care and other costs to society.
SAMHSA is charged with effectively targeting substance abuse and mental health services to the people most in need and to translate research in these areas more effectively and more rapidly into the general health care system.
Continued improvement in the delivery and financing of prevention, treatment and recovery support services provides a cost effective opportunity to advance and protect the Nation’s health.
7
SAMHSA’s Strategic Initiatives
Prevention of Substance Abuse and Mental Illness Trauma and Justice Military Families Recovery Support Health Reform Health Information Technology Data, Outcomes, and Quality Public Awareness and Support
8
SAMHSA’s Health Care Reform Strategic Initiative
Purpose:• Increase access to appropriate high quality
prevention, treatment, and recovery services;• Reduce disparities that currently exist between the
availability of services for mental and substance use disorders compared with the availability of services for other medical conditions; and
• Support integrated, coordinated care, especially for people with behavioral health and co-occurring health conditions, such as HIV/AIDs.
9
SAMHSA’s Health Care Reform Strategic Initiative - Goals
Strategic Initiative Goals: • Ensure that behavioral health is included in all aspects of
health reform.• Support Federal, State, Territorial, and Tribal efforts to
develop and implement new provisions under Medicaid and Medicare.
• Finalize and implement the parity provisions in the Mental Health Parity and Addiction Equity Act and the Affordable Care Act.
• Develop changes in SAMHSA Block Grants to support recovery and resilience.
• Foster the integration of primary and behavioral health care.
10
Challenges Remain
In 2010, an estimated 22.1 million persons were classified with substance abuse or dependence.
• 2.9 million of them were dependent upon or abused both alcohol and illicit drugs.
And, during 2009, there were an estimated 11 million adults (18 or older) in the U.S. – 4.8% of adults -- with serious mental illness in the past year.
Source: 2009 & 2010 NSDUH
11
Past Month Alcohol Use - 2010
Any Use: 51.8% (131 million)
Binge Use: 23.1% (59 million)
Heavy Use: 6.7% (17 million)
Source: NSDUH 2010
(Current, Binge, and Heavy Use estimates are similar to those in 2009)
12
Past Month Use of Selected Illicit Drugs among Persons Aged 12 or Older: 2002-2010
8.9%
6.9%
2.7%
8.7%8.0%8.3%8.1%7.9%8.2%8.3% 8.0%
6.6%5.8%6.0%6.0%6.1%6.2%6.2% 6.1%
2.8%2.8%2.9%2.7%2.5%2.7%2.7% 2.5%
0.6%0.7%0.8%1.0%1.0%0.8%1.0%0.9%0.7%
0.5%0.5%0.4%0.4%0.4%0.4%0.4%0.5% 0.4%0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
2002 2003 2004 2005 2006 2007 2008 2009 2010
Perc
ent U
sing
in P
ast M
onth
Illicit Drugs Marijuana Psychotherapeutics Cocaine Hallucinogens
Source: NSDUH, 2010
13
Concurrent Illicit Drug and Alcohol Use
Illicit Drug Use concurrent with Last Alcohol use among Past Month Alcohol Users aged 12+
31.8%
17.7%
6.8%
4.0%
0% 5% 10% 15% 20% 25% 30% 35%
Heavy Alcohol Use
Binge Alcohol Use (butnot heavy)
Current Alcohol Use (butnot heavy or binge)
No Alcohol in PastMonth
Source: NSDUH 2010
Percentage of Illicit Drug use Concurrent with Past Month Alcohol Use
Perc
ent o
f Alc
ohol
use
rs w
ho a
lso
used
Ill
icit
Dru
gs –
pas
t m
onth
14
Past Month Nonmedical Use of Prescription Drugs (Psychotherapeutics) among Persons 12+:2002-2009
Source: NSDUH 2009
2.1%
0.8%
0.5%
0.1%
1.9%2.1%2.1%
1.9%1.8%
2.0%1.9%
0.7%0.7%0.7%0.7%0.7%0.8%0.8%
0.4%0.4%0.6%0.5%0.5%0.6%0.6%
0.1%0.1%0.2%
0.1%0.1%0.1%0.2%
0%
1%
1%
2%
2%
3%
2002 2003 2004 2005 2006 2007 2008 2009
Perc
ent U
sing
in P
ast M
onth
Pain Relievers Tranquilizers Stimulants Sedatives
15
California State Indicators vs. National Average
Source: NSDUH, 2008-2009 average
Percent of clients reporting… California National Average
Binge Alcohol Use in Past Month 16.74% 23.46%
Any Illicit Drug Use in the Past Month
10.0% 8.34%
Alcohol or Drug Dependence or Abuse in Past Year
9.48% 8.92%
Needing, but not receiving treatment for illicit drug use
2.76% 2.53%
Needing, but not receiving treatment for alcohol use
7.50% 6.98%
16
Past Year Initiates for Specific Illicit Drugs among Persons Aged 12 or older: 2010
45
140
252
377
624
637
937
1,238
2,004 2,426
793
0 500 1,000 1,500 2,000 2,500
PCP
Heroin
Sedatives
LSD
Stimulants
Cocaine
Inhalants
Ecstasy
Tranquilizers
Pain Relievers
Marijuana
Numbers in ThousandsSource: NSDUH 2010
Number of Individuals nationally reporting first use of substance in past year
1717
22.4%
8.2% 8.6%
2.2%
18.3%
7.0%
0%
5%
10%
15%
20%
25%
30%
% D
epen
dent
on
or A
busi
ng S
ubst
ance
Drug or AlcoholDependence or Abuse
Drug Dependence orAbuse
Alcohol Dependence orAbuse
Had Major Depressive Episode in Past Year Did NOT Have Major Depressive Episode in Past Year
Source: SAMHSA NSDUH 2009
Substance Dependence or Abuse among Adults Aged 18 or Older, by Major Depressive Episode in the Past Year: 2009
18
Where Past Year Substance Use Treatment Was Received among Persons 12+: 2010
Numbers in Thousands
1,689 2,334
342
467
653
731
986
999
0 500 1000 1500 2000 2500
Prison or Jail
Emergency Room
Private Doctor's Office
Hospital Inpatient
Inpatient Rehabilitation
Outpatient MH Center
Outpatient Rehabilitation
Self-Help Group
Source: NSDUH 2010
19
20.5 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use
3.3%
Felt They Needed Treatment and Did
Make an Effort
Did Not Feel They Needed
Treatment
Felt They Needed Treatment and Did Not
Make an Effort
1.7%95.0%
Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving
Treatment for Illicit Drug or Alcohol Use: 2010
(683,000)
(341,000)
( 19.5 Million)
Source: NSDUH 2010
20
Reasons for Not Receiving Substance Use Treatment: Persons Aged 12+
Percent Reporting Reason
Not Ready to Stop Using
No Health Coverage and Could Not Afford Cost
No Transportation/Inconvenient
Might Cause Neighbors/Community to Have Negative Opinion
Able to Handle Problem without Treatment
7.1%
6.5%
38.1%
30.3%
9.0%
8.4%
7.9%
7.4%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
Those who Needed & Made the Effort to Get Treatment But Did Not Receive Specialty Treatment
Source: NSDUH, 2006-2010 combined
Might Have Negative Effect on Job
Did Not Feel the Need for Treatment at the Time
Had Health Coverage but Did Not Cover Treatment or Did Not Cover Cost
21
Payment for Substance Abuse Treatment – U.S.
In 2009, persons who received their most recent substance use treatment at a specialty facility in the past year reported the following method of payment.
Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1992 to 2009
27.0%
7.8%
1.0%14.1%
28.8%
12.3%
8.9%Self-pay
Blue Cross/Blue Shield, Other Health Insurance
Medicare, Worker's Compensation
Medicaid
Other Government Payments
No Charge
Other
22
The Uninsured – U.S.
More than 18.4 million full-time employees (18-64) had no health insurance coverage -- 54.5% of the Nation’s uninsured adults.
24.4%
15.5%
6.9%
19.2%
11.2%
6.9%
14.4%12.1%10.5%
0%
5%
10%
15%
20%
25%
30%
Aged 18-25 Aged 26-49 Aged 50-64* Male Female
Full-time Employees, Uninsured
Perc
ent
Need for SA Treatment Receipt of SA Treatment
*Receipt of treatment data for the 50-64 age group were suppressed because of low precision.Source: 2007 & 2008 SAMHSA NSDUHs
23
Patient Protection and Affordable Care Act (ACA)
38.1% of those needing substance abuse treatment did not receive it because they did not have health insurance coverage or couldn’t afford the cost.
Another 7.4% had health insurance, but it didn’t cover the cost of treatment.
The Affordable Care Act (ACA) Does Several Things:• Expands Insurance Coverage• Institutes Insurance Reforms• Builds Infrastructure To Provide Improved Health
Outcomes• Puts In Motion Structural Changes To How Healthcare
Delivery Is Structured & Financed
24
Expanded Health Insurance Coverage - 2014
Insurance Coverage Expands From 83% to 94%• 21% of non-elderly Californians (or 6.9 million) are
currently uninsured. (Kaiser Family Foundation)
Individual Mandate Applies Subsidies For Those Under 400% FPL Medicaid Eligibility Set At 133% FPL
• For California, this means approximately 3 million new residents will be eligible for Medicaid (Kaiser Family Foundation)
25 Million nationally get insurance through state exchanges
25
What Do We Know About the Newly Covered?
In 2014 —16 million will become newly eligible under the expansion in Medicaid.
An estimated 1.8 million uninsured have a serious addiction and 3.3 million uninsured have a mental illness
Individuals Near the Federal Poverty Level—More diverse group than we think: 40% under the age of 29, 56% are employed or living with their families, conditions are more acute when they present, and care is more costly
>100% FPL >100 – 200% FPL >200% FPL
Poor or fair physical health
25% 18% 11%
Poor or fair mental health
16% 11% 6%
Source: Center on Budget and Policy Priorities
26
The Social Determinants of Health*
* Adapted from the World Health Organization
INTERMEDIARY DETERMINANTS OF HEALTH
SOCIOECONOMICPOLITICAL
CONTEXT
Governance
Macroeconomic Policies
Social PoliciesLabor Market,Housing, Land.
Public Policies,Education, Health,Social protection, Drug Laws*, Immigration laws*
Culture and Societal Value
Socioeconomic Position
Social ClassGenderEthnicity (racism)Sexual Orientation*Age*Legal Status*
Education
Occupation
IncomeHealth System
IMPACT ON EQUITY IN HEALTH AND WELL-BEING
Material Circumstances(Living and Working Conditions, Food & Water Availability, etc)
Behaviors and Biological Factors(including alcohol and drug use)*
Behaviors and Biological Factors(including alcohol and drug use)*
Psychological FactorsPsychological Factors
STRUCTURAL DETERMINANTS OF HEALTH INEQUITIES
Social cohesion & Social Capital
We must remember that mental illness and substance abuse are determinants of health
We must remember that mental illness and substance abuse are determinants of health
27
Upstream vs. Downstream
Traditionally, individuals presenting with co-occurring disorders were “downstream.”– Providers could expect that symptoms reflected more acute
conditions. Increased access to health care, as well as an
emphasis on early screening will result in more individuals entering treatment “upstream.”– Providers need to be flexible and not assume that these
individuals have co-occurring conditions.– At the same time, working with individuals upstream means
providers can proactively meet other needs, such as recovery support services,
28
Recovery Support & Health Reform
Assess &Link to Service Recovery HousingPrevention & Screening EmploymentStress Management Drug Free RecreationFamily/Relationship Groups Drop In Centers orRole Modeling & Mentoring Cyber CafeRecovery Coaching Peer Council
Spiritual Support
Medical Model Social Services
Instead of Disease Model, Need Health/Wellness Model
29
ACA and Integrated Care
ACA programs focus on coordination between primary care and specialty care through:Significant enhancements to primary care
• Workforce enhancements• Mental illness and substance abuse treatment in primary care
through Federally-Qualified Health Centers (FQHCs)• Primary care in MH/SUD settings through community mental
health centers & other agencies• Services and technical assistance
Health Homes and Accountable Care Organizations
30
ReducedCriminalInvolvement
Stability inHousing
Cost Effectiveness
PerceptionOf Care
Retention Abstinence
Employment/Education
Evidence-Based Practice
Social ConnectednessAccess/Capacity
Ongoing Systems Improvement
Recovery
Health
Wellness
Outcomes
Mental Health
Primary Care
Housing
Human Services
Educational
Criminal Justice
Employment
Private HealthCare
Systems of Care
Organized RecoveryCommunity
DoD &Veterans Affairs
Indian Health Service
Addictions
Tribes/Tribal Organizations
Bureau of Indian Affairs
Child Care
Housing/Transportation
Financial
LegalCase Mgt
Peer Support
Health Care
Mental Health
Alcohol/Drug
VocationalEducation
SpiritualCivic Organizations
Mutual Aid
Services & Supports
Community Individual
Family
The Faith Community is an Essential Part of An Integrated Response to Behavioral Health
Community Coalitions
Business Community
Faith Community
Child Welfare
31
Federally Qualified Health Centers
Many of the newly insured will utilize Federally Qualified Health Centers (FQHC).
In 2007, 1080 Community Health Centers (CHC) reported seeing 17 million patients.
Mental health services were provided to 677,213, and substance abuse services to 92,406 – approximately 4% of total patients receiving services.
2.8% of CHC staff are mental health personnel; 0.7% are substance abuse treatment professionals.
A few CHC’s also engage in medication-assisted treatment.
32
Health Homes
The Affordable Care Act has authorized a health home provision [Sec. 2703 & Sec. 19459(e)] that provides the opportunity for States to build a person-centered care system that results in improved outcomes for beneficiaries and better services and value for State Medicaid and other programs, including mental health and substance abuse agencies.
33
What this Means for Community and Faith-Based Providers
Many of the traditionally underserved populations that will gain more access to health care through the ACA will use community health centers and health homes.
More individuals may be presenting earlier for treatment, through screening and increased access, when recovery support services offered by community and faith-based providers can be most effective.
34
Recruit, Enroll, Implement
Increasing access for traditionally underserved and at-risk populations does not mean that those individuals will present for treatment.• Recruit: Faith-based providers should reach out to their
vulnerable populations to ensure that they understand what services are available to them through health reform & how to access them.
• Enroll: Faith-based providers need to help their populations meet the requirements needed to receive new and expanded services.
• Implement: Faith-based providers need to ensure they are a part of an integrated approach to treatment & recovery
35
Evaluating Your Position: What Do You Have to Offer?
Faith-Based providers can help overcome barriers and help increase access by providing services that meet the spiritual as well as physical needs of the client.
To clients for whom faith is an integral part of their culture and community, faith-based providers can offer culturally sensitive services and materials that contribute to client trust and comfort – increasing the chances for sustained treatment and recovery.
In order to be a part of the integrated care system under health reform, now is the time to ask yourselves:
Are you communicating the importance of community and faith-based provider services within integrated care?
36
Workforce Challenges of Health Care Reform
Health care reform offers many potential benefits, but relies on the ability of the health care field to meet the challenges resulting from its implementation:• Influx of millions of new clients into the behavioral health
care system.• Need to implement Health IT• Greater emphasis on evidence-based practices and
outcomes• Increased emphasis on credentials and education for
behavioral health workforce• Emphasis on early intervention and integrated care
(primary and behavioral health)
37
Training and Research Increased patient-centered health research Training grants for behavioral health workforce Training on MH/SUD for primary care extender
Support for Workforce Development Funding for residencies for behavioral health included with other
disciplines (HRSA) Loan repayment programs Push towards more national certification standards and re-
licensure/re-certification Primary care/behavioral health integration -- bidirectional
ACA Focus on Workforce Development
38
The Role of Health IT
The effective integration of Health Information Technology is an important part of linking between programs, services, and providers.
Health IT can help the criminal justice system:• Communicate and collaborate between providers and
other programs• Track the progress of those for whom substance abuse
and/or mental health treatment is part of probation.• Reduce redundancy between programs and providers
39
Challenges for Behavioral Health Care
Clarifying how 42 CFR Part 2 is impacted by Health IT.• Without a guarantee of confidentiality, many individuals with
substance abuse problems would be reluctant to participate fully in treatment programs.
Establishing trust between providers and patients.• Electronic exchange efforts must establish trust relationships
with all participants, including patients. Acquiring and Training Adequate Resources:
• Most mental health providers and the majority of substance use treatment providers are not Eligible Providers or Meaningful Users under the HITECH Act and are thus not eligible for financial incentives to modernize either the acquisition or use of EHR.
Sources: STATE of Florida v CENTER FOR DRUG-FREE LIVING, INC, 842 So.2d 177 (2003) at 181. Melissa M. Goldstein, JD et al, 2010
40
SAMHSA Office of Behavioral Healthy Equity
Along with the National Institutes of Health (NIH) SAMHSA’s Office of Behavioral Health Equity supports the National Network to Eliminate Disparities in Behavioral Health (NNED).
The NNED supports information sharing, training and technical assistance among organizations and communities dedicated to the behavioral health and well-being of diverse communities.
The NNED identifies and links "pockets of excellence" in reducing disparities and promoting behavioral health equity. It will reduce the tendency to “reinvent the wheel.”
Website: www.nned.net
41
NNED – Faith Based Learning Cluster (FBLC)
NNED Faith Based Learning Cluster (FBLC) is a partnership between faith-based and health care organizations.
The goal is to provide a means for organizations to connect and share guidance about engaging and collaborating to better address health disparities.
Curriculum for laity has been finalized that will improve their ability to identify and access the mental health and substance abuse needs of their peers.
Curriculum will be pilot-tested in fall/winter 2011. The skills gained through the curriculum will help faith-based
organizations connect with their communities regarding how health reform affects them.
42
Summary
Health reform can have a great impact on improving the behavioral health of the populations served by faith-based providers.
Now is the time for providers to connect with their communities and vulnerable populations to help them take advantage of the new services available to them under health reform, and
Now is the time for providers to reach out to community health centers, health homes, and other entities to ensure that faith-based services are included, where appropriate, in treatment and recovery programs.
43
THANK YOU.