Let’s Get Serious about Substance Abuse Treatment – Starting with Payment Reform
New Year’s resolutions are about fresh starts and new beginnings, and for many Americans that includes the decision to finally give up heavy drug and alcohol use. Unfortunately, when it comes to encouraging individuals to enter treatment, providing counseling, and supporting long-term recovery, our health care system is showing up late to the party.
There are 21 million adults and adolescents with a diagnosable substance abuse problem in the United States, but fewer than one in five receive treatment in a given year. The reasons why people do not get treated are complicated. Many are not ready to give up using substances or don’t recognize they have a problem, but many others are discouraged from seeking treatment because of the cost or the perceived lack of treatment options. Opportunities to raise awareness about treatment are often missed, as primary care doctors infrequently screen for substance abuse during routine visits, and are often unaware of where to refer patients for specialized addiction treatment.
Even more troubling, when individuals do enter treatment, they often receive treatments that are inadequate, not based in evidence, and fragmented. This is unfortunate, because substantial research shows that, when delivered effectively, substance abuse treatment can dramatically improve people’s quality of life and create massive societal benefit through increased workplace productivity and reduced taxpayer spending on criminal justice and health care.
We can do better. Experts on substance abuse treatment have rightly emphasized the need to provide patients with “a medical home”– a model of care that would integrate primary care with different levels of specialized care and create linkages with other supportive services such as housing and vocational training. One important step is to ensure that the entire care team is using complementary treatment approaches and communicating frequently.
“Advancing Recovery” (sponsored by the Robert Wood Johnson Foundation) is one promising model for fostering the adoption of evidence-based addiction treatment methods such as medication-assisted treatment within networks of providers. Under this model, many treatment providers are able to double the number of patients continuing to outpatient treatment after an initial course of residential care. While no single approach to substance abuse treatment will work in every setting, evidence-based practices are much more likely to flourish in settings where substance abuse treatment providers are encouraged – either financially or through a cultural change – to maintain regular dialogue and to track patient outcomes.
Moving addiction treatment to a fully integrated model will not happen overnight, but there are some obvious places to start. I recommend focusing on financing and reimbursement. There are two sides to this coin. More money is desperately needed to support addiction treatment, but the payment models also need to change. For too long, substance abuse treatment has existed within its own parochial realm, separate from primary care and mental health treatment. Under this model, addiction treatment providers are paid by local or state authorities on a per-case basis, regardless of treatment outcomes. Services such as case management, monitoring of treatment outcomes, and relapse prevention are under-provided.
To tackle these problems of sub-standard coordination, quality, and follow-up, there are several critical investments that need to happen: more spending on case management resources to ensure that people receive needed services in a timely manner, greater accountability at the provider level for treatment outcomes, and greater incentives for physicians and substance abuse treatment providers to adopt evidence-based treatments, including medications that help to manage withdrawal from alcohol and opiates.
The Affordable Care Act provides an important platform for adopting payment reforms. For example, the new law will provide Medicaid coverage to millions of poor, uninsured adults – the population that is most reliant on our public substance abuse system. Within a single insurance plan, there may be greater scope to adopt payment models that reward coordinated care. For example, Medicaid programs will be able to restructure payments for populations with chronic conditions through the use of “health homes,” designated networks of providers that meet standards related to integrated care through case management, preventive care, and the use of electronic medical records. These innovations could help to pull substance abuse treatment back into mainstream health care provision. But, there is an urgent need to ensure that planning for health homes involves the substance abuse treatment community as full partners in the care of vulnerable populations.
There is more work to be done. The coming year will be critical, as legislators in Washington, D.C. and in every statehouse debate strategies to cut health care spending. As this conversation unfolds, it is important to remind lawmakers that first, investing in substance abuse treatment now will save taxpayers millions of dollars in the future, and second, that there are many opportunities within the framework of the Affordable Care Act to streamline and integrate the delivery of substance abuse treatment.
Like most New Year’s resolutions, there are no real shortcuts here. Fixing our substance abuse treatment system will take dedication from providers and up-front investments from state and federal government. “Quick fixes,” such as shifting responsibilities for treatment to outside contractors without oversight and monitoring, will prove to be as useless as a symbolic week of diet and exercise in January. Instead, we need to stick with substance abuse treatment for as long as people continue to need help and to tailor treatment to the specific needs of people looking to make a fresh start.