Study: Looking for the uninsured in Massachusetts? Check opioid dependent persons seeking detoxification

An interesting study from Drug and Alcohol Dependence cites the rate of uninsurance at a large Massachusetts detox program as 23% in the 2013 sample they observed (five years after the insurance mandate). That's nearly five times higher than the state average of 4.8%. The authors highlight correlates of being uninsured (table below), which include being young and being male (expected), but also having a higher level of education (unexpected). Finally, more than half of the uninsured participants in the study had been so for more than one year, highlighting the ongoing need for outreach and education about public programs.

Here is the abstract via ScienceDirect:

Abstract

Background

We examined the rate of uninsurance among persons seeking detoxification at a large drug treatment program in Massachusetts in 2013, five years after insurance mandates.

Methods

We interviewed three hundred and forty opioid dependent persons admitted for inpatient detoxification in Fall River, Massachusetts. Potential predictors of self-reported insurance status included age, gender, ethnicity, employment, homelessness, years of education, current legal status, and self-perceived health status.

Results

Participants mean age was 32 years, 71% were male, and 87% were non-Hispanic Caucasian. Twenty-three percent were uninsured. In the multivariate model, the odds of being uninsured was positively associated with years of education (OR = 1.22, 95%CI 1.03; 1.46, p < .05), higher among males than females (OR = 2.63, 95%CI 1.33; 5.20, p < .01), and inversely associated with age (OR = 0.94, 95%CI 0.90; 0.98, p < .01).

Conclusion

Opioid dependent persons recruited from a detoxification program in Massachusetts are uninsured at rates far above the state average. With the arrival of the Affordable Care Act, drug treatment programs in Massachusetts and nationally will be important sites to target to expand health coverage.

And here's a table from the report:

Correlates of Being Uninsured (n = 340).

Correlate	Unadjusted OR (95%CI)	Adjusted OR (95%CI)
Age	0.95** (0.91; 0.98)	0.94** (0.90; 0.98)
Gender (Male)	1.98* (1.07; 3.69)	2.63** (1.33; 5.20)
Non-Hispanic Caucasian (Yes)	2.48 (0.94; 6.54)	2.30 (0.83; 6.41)
Homeless (Yes)	0.38 (0.11; 1.29)	0.33 (0.09; 1.21)
Employed Part- or Full-Time (Yes)	1.09 (0.49; 2.42)	0.77 (0.32; 1.89)
Education (Years)	1.16* (1.01; 1.33)	1.22* (1.03; 1.46)
Pending criminal charges (Yes)	1.03 (0.58; 1.82)	0.92 (0.51; 1.65)
Perceived Health	0.71* (0.54; 0.93)	0.78 (0.58; 1.05)

* p < .05, **p < .01

http://www.sciencedirect.com/science/article/pii/S0376871613005322

I Challenge You to Find a Better Deal in Integrated Addiction & Psychiatric Treatment

First, my apologies for the drought in blogs lately. The last few weeks have been among the busiest in my life. Feels like internship all over again! Ian McLoone has been helping me with blog writing, and I haven't even had time to quickly look them over before publishing.

Busy is good to an extent, of course. The good news is that Alltyr is catching on, with very little marketing. Granted, being mentioned (with a very appreciated link) in Jane Brody's column, and the publication of Inside Rehab have propelled things along rather quickly, and to some extent it caught us off guard. But the new office in the 1st National Bank Bldg in St. Paul, MN is great. I love the building! Built in 1931, with lots of wonderful marble, and marvelous metalwork around the elevators. And, get this, planters with orchids all over the main level. In St. Paul, "the main level" is confusing. If you drive through downtown St. Paul, it looks like a kind of abandoned city on the street level. There's not much there except bus stops and the new light rail stops. Thing is, all the action occurs one story up, on the Skyway Level. Most buildings in downtown St. Paul and Minneapolis are connected to skyways. Skyways are connections between buildings 1 floor up from the street. So when I go to work there, I park in the heated garage in the building, leave my coat in the car, take the elevator to the skyway level. Here is where there are restaurants and delis, dry cleaning places, hair stylists, food courts, etc.

In addition to the office space, there are great amenities, including conference and training facilities at no extra charge and a modern workout facility, all included in the rent. And, we are in front of one of the new light rail stops, so it will be very easy to get here.

There are several suites on our current floor, which we are looking at for clinic expansion. My goal is to open a full -service SUD clinic in the fall of 2013. We are also talking to providers of sober housing. The idea is to create a comprehensive, state-of-the-art system of care that is based on 21st Century science, compassion and common sense.

We are also in discussions with local health plans, who are very interested in what we are doing. Remember, they are paying a lot for repeated useless residential and IOP rehabs. For example, a local nationally known provider charges about $30,000 for a 28-day residential rehab. I don't know what kind of discount the health plans get, but let's say they are paying $20,000 for it. Another prominent provider in the area charges $10,000 cash up front for a very pedestrian IOP with no housing. Alltyr's intensive services package, which includes a comprehensive evaluation by a physician (not a counselor), 10 1-hour psychotherapy and medication management visits, plus 25 30-minute therapy and medication visits over the course of a year, is only $4800, discounted from $5400 if purchased separately. Sober housing I'm going to estimate high at $1200 per month. So, for under $7,000, Alltyr Clinic will provide treatment services for a year plus 1 month supervised sober housing.  And with results that are guaranteed to be superior, because Alltyr's program includes completely integrated psychiatric treatment and uses all available treatment modalities.

I challenge you to find a better deal anywhere.

Health Care Changes Important to Addiction Treatment

Among the various things I do, I work about half time for a large health care organization (HCO) in Minnesota called Allina Health. Currently Allina is the largest HCO in Minnesota, but it is likely to become the second largest due to continuing consolidation in HCOs. HealthPartners and Park Nicollet, two other HCOs in Minnesota desire to merge, and it does not appear that there will be any barriers from either the MN Attorney General or federal agencies. So it is likely to proceed, which would produce a larger HCO than Allina. Consolidation in health care is almost a torrent right now. It's happening very rapidly. In the Twin Cities area in Minnesota, there are almost no independent primary care practices; they've all been purchased by large HCOs. The health plans like Blue Cross/Blue Shield and HealthPartners are working very closely with the large HCOs to create products that maximize value to the consumer. So the future of health care is one dominated by a few large HCOs that dominate a market. Unfortunately, this is all to familier. Witness the consolidation in airlines and in cable television, internet and wireless services.

But there are important changes in perspective that will drive a much more pronounced and determined effort to deal with behavioral health issues, including both mental health and addiction. The most important of these is the movement from fee for service to capitated approaches. In fee for service, a clinician is paid a specific amount for providing a service, such as a primary care visit or an addiction counseling session. This rewards providing more services for fewer people, and it drives up costs without regard to quality or outcomes. Increasingly, health plans are moving towards a different model where the HCO is accountable for outcomes, not just whether the service was delivered. In a capitation model, a HCO is given a single fee for treating someone with a given diagnosis. It is up to the HCO to figure out how to do this efficiently and effectively.

This is a good thing. Here's an example. Someone with an addiction goes to a time-limited, intensive rehab program, which is the current standard of care. Let's say that this intensive outpatient program costs $2400. Someone else who was able to produce equivalent outcomes for $1800 would be attractive to a health plan, not to mention someone paying out of pocket. Similarly, a $15,000 or $20,000 residential treatment program would go out of business if it could not produce substantially better outcomes than someone providing office-based treatment for a third of that amount. I think this is quite possible to do, since there is no demonstrated benefit to residential treatment. There is room here for innovation, for modernizing our approach to addiction treatment. It's time for addiction treatment providers to take responsibility for the outcomes of their treatment. It's time to end the idea that treatment failures are the patient's fault. In the future, this isn't going to fly. One of my goals is to make sure this happens. We can generate better outcomes at much less cost.

What if, instead of being paid $30,000 for a residential treatment lasting 28 days regardless of whether that actually produced a good outcome, HCOs were only paid for treatment that worked? What if payment was based on outcomes rather than the treatment provided? I can tell you, that would change the addiction treatment world in a heartbeat. Give patients that same treatment over and over even though it's already proved ineffective? No way! Give everybody the same treatment whether they need it or whether it's been shown to improve outcomes? Forget about it? Changes in how payment is made for services will force change in the treatment delivered. And it's about time.

What's the silver lining? We can lead the way. Many of the very high utilizers of health care have addiction and mental health problems. We have to figure out ways to improve their care and outcomes. That's our challenge and our opportunity.

MW

Program Thinking: The Bane of Addiction Treatment

I appreciate the two comments on my last blog, and they prompt a couple of responses from me. (If you didn't read them, click on the "Comments" link at the bottom of the blog.)

First, I'd like to clarify something in response to Dr. Dawson's comments. I was not arguing that people who are living in a sober structured environment do not need programming, or do not benefit from it. What I am saying is that there is no such thing as "residential or inpatient treatment." That is, studies have shown that staying overnight in the same place while receiving treatment has no outcome advantages over going home or to some other place, like a sober residence. So, there is treatment, and there is housing structure. Just like addiction psychotherapy, addiction pharmacotherapy, vocational counseling, psychiatric treatment, treatment for conditions below the neck (CBTN) (often but erroneously called "physical or medical" as opposed to "psychiatric," as if psychiatric conditions were somehow not organ-based or medical), transportation, family or marital therapy, and so on, addiction psychotherapy and housing structure are two very important, but essentially independent components of an interdisciplinary approach to comprehensive modern addiction treatment.

Marrying addiction psychotherapy to a residential treatment bed leads to "program thinking." Program thinking promotes a number of undesirable behaviors or characteristics. First, there is constant pressure to "keep the beds full." Thus, inclusion/exclusion criteria become flexible depending on bed occupancy, and people who could be treated quite well as outpatients are instead admitted to a residential program. This constant push leads to excessive costs without adding to outcome. Second, program thinking leads to cookie-cutter programming, because it's like running a factory, churning out patients and it is too difficult to have completely individualized lengths of stay or treatment plans. For example, the old joke in rehab is that we conduct a comprehensive individualized assessment and then send the client to group. It works much better to have the same groups for everyone, the same treatment for everyone, every time. Third, it leads to inappropriate levels of housing and of treatment services. Some people who need longer-term housing are pushed out at the end of the "program," while others who don't need sober housing are forced into it (and to pay for it.) Some patients need more intensive and comprehensive treatment services for a long time, but their treatment is interrupted arbitrarily, often with devastating consequences such as recurrent addiction along the way to connecting with some (different) outpatient follow up (inappropriately called "aftercare" rather than "care"). When treatment services are provided independently, then there is no disruption of services when a patient moves from one level of housing structure to another. Lack of continuity is compounded when the residential facility is geographically distant from the patient's home, which is often the case. It is always tempting to "send the patient away" to a distant facility so we don't have to worry about whether they are safe, but if we did that with every condition, we'd be sending out of control diabetics, not to mention almost all adolescents, to residential treatment too. We used to hospital people for long periods for psychiatric disorders such as depression and anxiety too, but when it became clear that that was actually harmful and expensive, it was stopped. It is long past time to stop it for addiction treatment too.

I'll respond to the other comment later.

Keep the comments and dialogue coming!

MW

Families' Health Costs Reduced After Addiction Treatment

This is a the second blog about healthcare costs and substance use disorders (SUD). The first one (6 Sept 2012) dealt with healthcare costs among patients who presented for treatment for SUD. This one is from the same great health services research group founded and anchored by Connie Weisner at UCSF, and addresses a novel topic: the healthcare costs of family members of patients with SUD, and the effect of SUD outcomes (abstinence vs. non-abstinence) in the index patient on family members’ healthcare costs (Weisner, Parthasarathy et al. 2010).

In this study, a group of patients who presented for treatment for SUD (and who were thus likely to have chronic or recurrent, and more severe, SUD, compared to people not presenting for treatment) were followed for 5 years. One year following treatment entry, they were asked questions pertaining to their current (past 30 day) use of a wide variety of intoxicants. Those who had used none in the previous 30 days were considered abstinent for study purposes, while those who had used anything were considered non-abstinent. (Note that in other studies as well as this one, 30-day abstinence at the 12 month time point is strongly related to longest continuous period of abstinence over the entire five years.) Also over this 5 year period, healthcare costs of family members were also tracked, and family members whose index patient were abstinent at 1 year were compared to those who were not. Just to avoid confusion, I’ll state that differently: healthcare costs for families over a 5 year period were compared between those whose family member was either abstinent or not for the past 30 days 1 year after treatment entry.

The results were both surprising and encouraging. First, the authors point out that in the first year following treatment entry, healthcare costs for family members may well go up, as they attend to medical, SUD and psychiatric problems they neglected due to the crisis associated with escalating use and problems in the SUD patients. Thus, it is important to long past the one-year point. Thus, a major strength of the study is that they studied costs over five years. Another strength is that they compared both groups to matched controls without SUD.

And sure enough, in the first two years, healthcare costs were higher among both groups of family members of SUD patients compared to non-SUD control families but were not different between abstinent and non-abstinent groups. However, beginning in the third year the abstinent began to diverge from the non-abstinent families. By year 5, the abstinent family members’ costs were not different from the non-SUD controls, while the non-abstinent family members’ were significantly higher. Average cost for abstinent family members at year five was $3 per member per month, while average cost for non-abstinent family members was $36 per member per month, a 12-fold difference!

In summary, 30-day abstinence one year after treatment for SUD strongly predicted the costs for their family members over the ensuing four years. Healthcare costs of family members of SUD patients abstinent at one year began to go down three years following treatment and by year five, did not differ from control families without SUD. However, costs for family members of SUD patients not abstinent at one year were 12 times higher than for either abstinent SUD families or for control families! Thus, SUD outcomes are strongly related not only to healthcare costs of the SUD patients themselves but to their families as well!

A lot of money could be saved (not to mention the misery that could be avoided) by improving rates of abstinence following SUD treatment. Other studies, by this and other groups, have found that providing ongoing continuing care over long periods is associated with improved rates of abstinence and reduced healthcare costs among SUD patients (see previous blog.)

To me, these findings have two implications:

1)    Current, evidence-based treatment needs to be more widely available to people and, to encourage them to come, they need to include a lot more consumer choice about path to recovery, as well as form and place of treatment, and

2)    We need more research on how to improve rates of abstinence, which are far too low to be acceptable. This will require more money. The only way to get more money for addiction research is advocacy by the people affected: people with SUD, recovering from SUD, and their friends and families. We need to advocate not just for more treatment, but for more money for research. More on this later.

Weisner, C., S. Parthasarathy, et al. (2010). "Individuals receiving addiction treatment: are medical costs of their family members reduced?" Addiction 105(7): 1226-1234.

Continuing Care Produces Reduces Costs for Substance Use Patients

Persuasive Research for a Chronic Care Model for Some People with SUD

There are two fascinating research reports that recently came out of the group anchored and founded by Connie Weisner, a very productive and insightful scientist conducting health services research at Kaiser-Permanente in San Francisco. In addition to being a first-class scientist, Dr. Weisner is a genuinely good person and a great mentor who has built an extremely productive group. Jennifer Mertens is one of her protégés who has emerged as a first-class scientist in her own right.

The first of these two articles examined the healthcare costs of a group of people who presented for substance use disorder (SUD) treatment at a Kaiser facility. First-authored by Sujaya Parthasarathy, another up-and-coming health services researcher, this study followed SUD patients and compared their health care costs over the ensuing 9 years, compared to a matched group of non-SUD patients (Parthasarathy, Chi et al. 2012). The aim of the study was to examine the association between elements of continuing care over that period and health care costs. Continuing care was defined as ideally having three components: an annual primary care visit plus the availability and use of either SUD or psychiatric services as needed. They hypothesized that people with more components of continuing care would have lower healthcare costs. They had previously shown that having more elements of continuing care was associated with greater rates of abstinence.

What did they find? Having all three elements of continuing care available and used was associated with lower health care costs over a 9 year period, compared with those receiving fewer components. The SUD patients who did not receive continuing care had inpatients costs of $66 per member per month (that’s a lot), while those receiving continuing care did not differ from non-SUD controls.

This study is observational. That is, it followed people over time and then examined correlations, or associations among different variables. There is a principle in research, which is, “Correlation does not imply causation.” That is, one cannot determine what causes what, merely that two variables, such as receiving continuing care and abstinence, tend to occur together more than would be expected by chance. So, it cannot be concluded, for example, that providing continuing care caused improved outcomes and reduced healthcare costs. Or whether patients who were already doing well (for whatever reason) caused more continuing care by making better use of appropriate healthcare services.

Nevertheless, I believe that, combined with other studies, there is a powerful argument to be made that SUD services should include all three components when appropriate: primary care, SUD treatment services and mental health treatment, and that these services should be available on a continuing basis for as long as needed. This is, after all, how we treat virtually every other disease, from asthma to depression to arthritis. It also makes sense to make every effort to make them available in as seamless and integrated a fashion as possible.

Parthasarathy, S., F. W. Chi, et al. (2012). "The role of continuing care in 9-year cost trajectories of patients with intakes into an outpatient alcohol and drug treatment program."  6. Retrieved 0230027, lsm, 50, from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=22584889.

Update on operating in the trenches of health care

This is from an email I recently sent to a colleague. It also relates to the comment on my last blog by Dr. Dawson, and the new assembly line psychiatry. I can't begin to count the number of patients of mine who complain that they've been to other psychiatrists who never talked to them, spent 10 mins and prescribed drugs. This, in my view, results in gross overtreatment with medications, poor decision-making regarding medication management, poor patient outcomes, lack of patient participation in treatment decision-making, as well as patient and family dissatisfaction. I don't think it's possible to properly evaluate a patient in that amount of time. If the patient is so stable they don't really need an evaluation, just a prescription, then they don't need a psychiatrist, their primary care doctor can do that.

There is now a terrible shortage of psychiatrists, and it will reach truly crisis proportions in the next 10 years as the aging workforce retires or dies. This could be changed by reforming practice to make it more gratifying (and effective), increasing compensation (psychiatry is the third-lowest paid specialty, after pediatrics and primary care (family practice and general internal medicine), and involving patients and families more in decision-making. Unfortunately, the mistakes made in the past, such as separating psychotherapy (now provided by therapists and counselors from a wide variety of backgrounds and competencies)  from medication management (by psychiatrists), with another: replacing psychiatrists with "mid-level" providers, such as nurse practitioners and physicians assistants. The result is simply an ongoing degradation of psychiatric practice and care and outcomes, and an increasing shortage of competent and well-trained staff.

But I digress. Here's the email, responding to a question about how things were going in my post-NIH world.

All is good here, working my butt off in practice and still working to establish a new model of scientifically based treatment in the next year. As with most things, it turned out to be more complex and difficult than initially imagined, but there is tremendous enthusiasm among health care professionals and even more so among patients and their families, who are very very frustrated with the current state of affairs. So the time is still ripe, if not riper than ever. Toughest parts are going to be staffing, especially with docs, and financing and the business model, especially with the continuing near-depression we are still in. 

I have to say, working where I do, in downtown St. Paul, I treat a lot of people who have lost everything, when they had everything in 2007. Their jobs, homes, families, self-esteem, health. Everything. Experiencing the human face of this terrible economic crime gives a whole different perspective. And Minnesota is in better shape than most places, and has arguably the best safety net in the country. So I can't imagine what it's like in Arizona, Texas or Florida. At any rate, I'm fortunate to work (part-time) for a company that essentially subsidizes psychiatric care for the poor. Again, that is not the norm around the country. Minnesota has a law requiring health care organizations to be non-profit, which makes all the difference in the world. 

The other part of the health care world I've had the pleasure of experiencing is the horrible nature of the health insurance industry, and the games they play to deny payment for care they are obligated to, by putting up lots of bureaucratic barriers, knowing that many patients or doctors will give up. Yesterday, for example, I was trying to induct Suboxone treatment for a patient in the clinic (who was in withdrawal) and the insurance company wouldn't pay for the Suboxone without a prior authorization (one of the most common and frustrating barriers.) So the patient had to go to the pharmacy, get the coverage denied before we could initiate the PA request, then the nurse went through the hoops, spending 30 mins, but the company wouldn't even give an answer for 24 hours. So the pt had to leave without the Suboxone, use more illicit opioids until we got the approval, then return to the clinic again in withdrawal, or start at home. And you can't get a PA in advance, it has to be denied first. So the patient spent an entire afternoon waiting around for the PA, the nurse spent 30 mins on the phone, and I spent about 30 mins of my time trying to make this work (none of which we got paid for). And people wonder why our system costs so much. And this didn't make any sense at all anyway, all they needed to know was that the indication was opioid dependence. 

MW