Care integration bogged down
by regs, SH law school study finds
Seton Hall University School of Law has issued a new report strengthening the case that integrating primary and behavioral care produces better health outcomes at a lower cost. The study, “Integration of Behavioral and Physical Healthcare: Licensing and Reimbursement Barriers and Opportunities in New Jersey,” reinforces established evidence about the effectiveness of “whole person” care, but also addresses a host of policy and regulatory obstacles the state needs to remove before this model can thrive.
The study noted that a movement towards integrated care models is under way in New Jersey and nationwide. In the state, however, the effort has been forestalled by byzantine policies and practices, which the report identifies and presents solutions to.
As with previous reports on this issue, the Seton Hall findings illustrate the considerable savings that intergrated care would produce with what are known as “super-utilizers,” people who run up enormous costs to the public sector through repeated emergency room visits. There is also the often cited statistic of the human cost to patients with serious mental illness, whose life-span is 25 years less than the average person’s.
Newark-based Nicholson Foundation funded a team led by John Jacobi at the Seton Hall University School of Law to examine New Jersey's regulations and payment obstacles and then work with state agencies and healthcare stakeholders to implement solutions. The study is an extension of Nicholson’s pilot projects attempting to integrate care in Trenton and Lakewood. Those sites encountered the obstacles the study identifies and seeks to eliminate.
Jacobi, the Dorothea Dix Professor of Health Law & Policy and director of the Center for Health & Pharmaceutical Law & Policy, was optimistic that the state can make the changes necessary to promote integration. “Too often, New Jersey’s regulations continue to reflect a previous era of separation, and create significant barriers to enacting current clinical norms. Our report shows that there is a clear path forward, and the open engagement of representatives of state agencies demonstrates both leadership and cooperation on the part of the state.”
The problem’s roots partly lie in the fact that different state departments have oversight of the physical care and behavioral health realms. The Department of Health has authority over hospitals, health clinics, while the Department of Human Services oversees care for addiction and mental health.
Carolyn Beauchamp, executive director of the New Jersey Mental Health Association, said in an NJ Spotlight article, “You’ve got two competing departments … and there have been ongoing concerns about why it has to be this way. The system has to move and it has to change.”
Further complications arise from the state’s licensure and reimbursement standards. Jacobi noted that payment problems arise due to a burdensome funding stream. In the case of Medicaid clients, there is an intermediary between patient and provider. It may be a managed care entity, an administrative services organization, etc.. But whatever it is, Jacobi said that if the entity does not provide for prompt and proper payments, the patient will suffer.
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John Jacobi
of Seton Hall School of Law
and director of the Center
for Health &
Pharmaceutical Law & Policy.
|
Alli said in many cases, an underlying behavioral health problem, which may go back to childhood, is at the root of this non-compliance. She cited a study by the Kaiser Foundation on the lasting effects of Adverse Childhood Events, traumatic occurrences of abuse that prevent the person from acting rationally.
Despite the challenge of such systems change, Jacobi was encouraged by early signs of progress. He noted the importance of having had a close collaboration with government officials in the creation of the report. Jacobi said, “As a result, key decision-makers became increasingly aware of the problems – and solutions. In October of 2015, the DHS and DOH announced the joint creation of a ‘Shared Space Waiver,’ which would allow providers to offer both behavioral and primary care in the same facility. The departments’ movement in creating the waiver is consistent with our recommendations in this report, and demonstrates that they are interested in continuing regulatory advances to accommodate integrated care.”
NJAMHAA report details
savings of community care
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NJAMHAA Executive Director Debra Wentz
and the Trenton
Rescue Mission’s James Morris
at a press conferencing announcing a new
report
on the economic benefits of community-based
behavioral health care.
|
The economic benefits to the state outlined in a new report on community-based addiction and mental health services came strikingly to life through the story of James Morris, who was rescued by those services. Less than two years before the March 29 press conference at which he recounted his journey to recovery, Morris was in the throes of addiction and contemplating suicide. With the help and hope offered by the Trenton Rescue Mission, all that changed.
The new report, “The Economic Contribution of the Mental Health and Substance Abuse Services Industry to the New Jersey Economy,” was released by New Jersey Association of Mental Health and Addiction Agencies. The report, which was produced by Rutgers University’s Edward J. Bloustein School of Planning and Public Policy, illustrates the tremendous direct and indirect savings to the state seen through the thousands of lives who, like Morris, underwent treatment in a community setting and now add revenue and make other societal contributions.
At a recent press conference in Trenton, Debra Wentz, NJAMHAA’s CEO and president, said the intent of the report was to take, “a point in time snapshot to see the impact, and it is substantial, even by these conservative estimates. Wentz said what is often invisible “is the cost to the health care system.” She noted that people with serious addiction and mental health problems are so-called “superutilizers” of the health care system, consuming more than 50 percent of Medicaid dollars. These individuals regularly rely on expensive emergency room visits for health care.
Describing the benefits, both human and fiscal of community-based care, Wentz recalled a troubled little girl who “has blossomed” into a social young lady. Another example she offered was a veteran who had been in the depths of post traumatic stress syndrome, but who is now gainfully employed. And there are the many young people who lost their way for time in drug addiction and who are now “thriving in schools, jobs and their communities.” All of those examples translate into people who had been a cost to the state now contributing to its economic health.
The comments by Wentz were reinforced by James Cooney, CEO of Ocean Mental Health Services. He noted the reduction in patients being treated in the state’s psychiatric hospitals. Those patients now number only 1,700, but each costs the state a quarter of a million dollars a year. The large majority of mental health patients are now cared for by the community-based mental health centers, producing a savings of many millions of dollars.
When asked if sufficient drug treatment was available, Cooney acknowledged there was a shortfall. In Ocean County, he said was a severe need for outpatient care (Ocean has been among the hardest hit counties by the opiate crisis).
The issue of the new Medicaid reimbursement rates came up during the press conference. Wentz and Cooney said that, while the new rates are certainly an overall improvement and very good for some care and services, in other areas they still fall woefully short. The new addiction rates will take effect on July 1, and the mental health increases will begin in January.
When care is provided, the results are evident. Morris’ story offers a remarkable instance of a life in dire circumstances taking a nearly miraculous turn. After treatment helped Morris enter recovery, he completed his GED and went on to be admitted to an entrepreneur program at the University of Pennsylvania.
Beyond his professional growth, his recovery means that he can now pay visits to his ailing mother in North Carolina. That was not something he did 21 months ago. And as with so many in recovery, Morris has a deep commitment to giving back, which he does by assisting at the Rescue Mission’s Housing Program.
A single screening question about drinking frequency in the past year could help doctors identify adolescents at risk for alcohol problems, according to a new study funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), part of the National Institutes of Health. Conducted by researchers at the University of Pittsburgh, who collaborated with a network of rural primary care practitioners, the study also supports the use of the age-based screening thresholds put forward in NIAAA’s Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide. For the full story, go to: http://www.niaaa.nih.gov/news-events/news-releases/study-supports-single-question-alcohol-screen-adolescents
Substance use disorders common
New research funded by the National Institute on Drug Abuse revealed that of previously incarcerated youths, more than 90 percent of males and nearly 80 percent of females had a substance use disorder at some point in their lifetime. The longitudinal study randomly sampled 1,829 youth -- ages 10-18 years who entered detention in Cook County, Illinois from 1995-1998 -- and examined how lifetime and past-year prevalence of substance use disorders differed by sex, race/ethnicity and substances abused as the group grew to young adulthood. The participants were re-interviewed up to nine times over 16 years and were assessed for substance-use disorders involving alcohol, marijuana, cocaine, hallucinogen/PCP, opiate, amphetamine, inhalant, sedative and other unspecified drugs.
Other key findings included:
• Males had higher lifetime prevalence of alcohol and marijuana use disorder whereas females had higher lifetime prevalence of cocaine, opiate, amphetamine, and sedative disorders. Additionally, the prevalence of substance use disorders among females declined more rapidly than among males.
• Non-Hispanic whites had more than 30 times the odds of having cocaine use disorder than African Americans.
• Prevalence of any substance use disorder (including alcohol and all drugs) dropped as youth aged.
• The most common substance use disorders changed as youth aged. At younger ages, marijuana was the most prevalent substance use disorder. By the end of the study (median age 28), alcohol use disorder surpassed marijuana use disorder.
The findings suggest that substance use disorders after detention differed significantly by sex, race/ethnicity, and substance abused.
For a copy of the abstract, “Health Disparities in Drug and Alcohol Use Disorder: A 12-Year Longitudinal Study of Youths After Detention,” published in the American Journal of Public Health, go to
http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.303032.
Survey finds 43 percent are
In a new poll conducted by The Associated Press-NORC Center for Public Affairs Research at the University of Chicago, few Americans say their communities are doing enough to deal with substance abuse, a problem that many see as particularly serious.
In February, the Obama Administration said it would ask Congress to spend an additional $1.1 billion next year to combat the growing epidemic of prescription painkiller and heroin abuse by expanding treatment facilities, developing programs intended to prevent prescription drug overdoses, and cracking down on illegal sales. The poll suggests there is public support for these policy approaches to the problem.
The nationwide poll of 1,042 adults used AmeriSpeak, the probability-based panel of NORC at the University of Chicago. Interviews were conducted between Feb. 11- 14, 2016, online and using landlines and cell phones.
Key findings:
• Most Americans (62 percent) say at least one type of substance use is a serious problem in their community. Forty-three percent have a relative or close friend with substance abuse issues.
• The public says more should be done to address the problem of substance use in their area. Seven in 10 Americans say their community is not doing enough to find improved methods of treating addiction (68 percent) or to make accessible treatment programs more available (69 percent). Nearly as many, 61 percent, want to see more effort made to crack down on drug dealers. There is a feeling that there is not enough education, either for the public (55 percent) or health professionals (49 percent). Just over half, 53 percent say their community should do more to go after the users themselves.
• A majority of Americans, 61 percent, support the legalization of marijuana, but only a third of them endorse legalization with no restrictions. Forty-three percent say there should be restrictions on the purchase amounts. And a quarter of those who support legalization only approve of its use when prescribed by a doctor.
• The public perceives racial, socioeconomic, and geographic imbalances in conviction rates for drug possession. More than half of the public reports that black, Hispanic, poor, and urban substance users are at least very likely to be convicted of drug possession. Significantly fewer, about 3 in 10, say white, middle class, suburban, and rural substance users are likely to be convicted, and only a quarter think rich drugs users are likely to be convicted.
• Only 21 percent say all or most doctors and dentists regularly prescribe painkillers more than is necessary. But of those who think even a few doctors and dentists overprescribe, the vast majority (89 percent) believe this practice contributes to drug dependence and overdoses.
According to the CDC, opioids, a class of drugs that includes prescription painkillers and heroin, were involved in 28,647 deaths in the United States between 2000 and 2014.That figure has been on the rise in recent years, and today many Americans see drug use as a problem in their communities.
While economic problems, terrorism, and health care top the list of priorities for the country, only 3 percent named drug use as a top-of-mind priority for the nation. However, when asked specifically about drug use, most Americans (62 percent) say at least one type of substance use is a serious problem in their community.
About a third consider the use of heroin and prescription painkillers a very or extremely serious problem in their communities, similar to the number who say the same about the use of alcohol and other drugs such as cocaine or methamphetamines. Fewer say marijuana use is a serious problem, however.
For much of the public, the problem of drug use hits close to home. About 4 in 10 Americans surveyed say they have a relative or close friend who has a problem with some type of substance use. These Americans are more likely to view substance use of all kinds to be a problem in their communities.While few say that overprescribing painkillers is widespread, many say the prescribing practices of doctors and dentists contribute to problems with drug abuse.
Just 21 percent say most or all doctors regularly overprescribe pain relievers more than is medically necessary. But, 89 percent of those who say there is any overprescribing think this practice contributes to dependence on prescription pain relievers and drug overdoses. A majority of Americans see prescription pain relievers and heroin as about equally risky to use (52 percent). Few say prescription pain relievers are more dangerous than heroin (4 percent), especially compared to the reverse (44 percent say heroin is more risky).
Americans favor a wide range of approaches to addressing issues of substance abuse in their communities. Many Americans think their communities are not devoting enough effort to several approaches of targeting this problem. Nearly 7 in 10 say their community is not doing enough to find ways to improve substance use treatment or to make it more affordable and accessible. Six in 10 say their community is not doing enough to crack down on drug dealers. Fewer, but still a majority, say their community is not doing enough to crack down on drug users or educate the public and students in school to prevent substance use. Slightly less than half say they are not doing enough to educate doctors and dentists about the risks of prescribing pain relievers, but a nearly equal amount say their communities are devoting the right amount of effort to this approach.
Click below for a printable version of Perspectives.
http://www.ncaddnjinfo.org/PDF/Pers042016.pdf ------
The issue of the new Medicaid reimbursement rates came up during the press conference. Wentz and Cooney said that, while the new rates are certainly an overall improvement and very good for some care and services, in other areas they still fall woefully short. The new addiction rates will take effect on July 1, and the mental health increases will begin in January.
When care is provided, the results are evident. Morris’ story offers a remarkable instance of a life in dire circumstances taking a nearly miraculous turn. After treatment helped Morris enter recovery, he completed his GED and went on to be admitted to an entrepreneur program at the University of Pennsylvania.
Beyond his professional growth, his recovery means that he can now pay visits to his ailing mother in North Carolina. That was not something he did 21 months ago. And as with so many in recovery, Morris has a deep commitment to giving back, which he does by assisting at the Rescue Mission’s Housing Program.
Study supports single-question alcohol screen for adolescents
A single screening question about drinking frequency in the past year could help doctors identify adolescents at risk for alcohol problems, according to a new study funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), part of the National Institutes of Health. Conducted by researchers at the University of Pittsburgh, who collaborated with a network of rural primary care practitioners, the study also supports the use of the age-based screening thresholds put forward in NIAAA’s Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide. For the full story, go to: http://www.niaaa.nih.gov/news-events/news-releases/study-supports-single-question-alcohol-screen-adolescents
Substance use disorders common
among previously incarcerated youth
New research funded by the National Institute on Drug Abuse revealed that of previously incarcerated youths, more than 90 percent of males and nearly 80 percent of females had a substance use disorder at some point in their lifetime. The longitudinal study randomly sampled 1,829 youth -- ages 10-18 years who entered detention in Cook County, Illinois from 1995-1998 -- and examined how lifetime and past-year prevalence of substance use disorders differed by sex, race/ethnicity and substances abused as the group grew to young adulthood. The participants were re-interviewed up to nine times over 16 years and were assessed for substance-use disorders involving alcohol, marijuana, cocaine, hallucinogen/PCP, opiate, amphetamine, inhalant, sedative and other unspecified drugs.
Other key findings included:
• Males had higher lifetime prevalence of alcohol and marijuana use disorder whereas females had higher lifetime prevalence of cocaine, opiate, amphetamine, and sedative disorders. Additionally, the prevalence of substance use disorders among females declined more rapidly than among males.
• Non-Hispanic whites had more than 30 times the odds of having cocaine use disorder than African Americans.
• Prevalence of any substance use disorder (including alcohol and all drugs) dropped as youth aged.
• The most common substance use disorders changed as youth aged. At younger ages, marijuana was the most prevalent substance use disorder. By the end of the study (median age 28), alcohol use disorder surpassed marijuana use disorder.
The findings suggest that substance use disorders after detention differed significantly by sex, race/ethnicity, and substance abused.
For a copy of the abstract, “Health Disparities in Drug and Alcohol Use Disorder: A 12-Year Longitudinal Study of Youths After Detention,” published in the American Journal of Public Health, go to
http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.303032.
Survey finds 43 percent are
close to person with drug problem
In a new poll conducted by The Associated Press-NORC Center for Public Affairs Research at the University of Chicago, few Americans say their communities are doing enough to deal with substance abuse, a problem that many see as particularly serious.
In February, the Obama Administration said it would ask Congress to spend an additional $1.1 billion next year to combat the growing epidemic of prescription painkiller and heroin abuse by expanding treatment facilities, developing programs intended to prevent prescription drug overdoses, and cracking down on illegal sales. The poll suggests there is public support for these policy approaches to the problem.
The nationwide poll of 1,042 adults used AmeriSpeak, the probability-based panel of NORC at the University of Chicago. Interviews were conducted between Feb. 11- 14, 2016, online and using landlines and cell phones.
Key findings:
• Most Americans (62 percent) say at least one type of substance use is a serious problem in their community. Forty-three percent have a relative or close friend with substance abuse issues.
• The public says more should be done to address the problem of substance use in their area. Seven in 10 Americans say their community is not doing enough to find improved methods of treating addiction (68 percent) or to make accessible treatment programs more available (69 percent). Nearly as many, 61 percent, want to see more effort made to crack down on drug dealers. There is a feeling that there is not enough education, either for the public (55 percent) or health professionals (49 percent). Just over half, 53 percent say their community should do more to go after the users themselves.
• A majority of Americans, 61 percent, support the legalization of marijuana, but only a third of them endorse legalization with no restrictions. Forty-three percent say there should be restrictions on the purchase amounts. And a quarter of those who support legalization only approve of its use when prescribed by a doctor.
• The public perceives racial, socioeconomic, and geographic imbalances in conviction rates for drug possession. More than half of the public reports that black, Hispanic, poor, and urban substance users are at least very likely to be convicted of drug possession. Significantly fewer, about 3 in 10, say white, middle class, suburban, and rural substance users are likely to be convicted, and only a quarter think rich drugs users are likely to be convicted.
• Only 21 percent say all or most doctors and dentists regularly prescribe painkillers more than is necessary. But of those who think even a few doctors and dentists overprescribe, the vast majority (89 percent) believe this practice contributes to drug dependence and overdoses.
According to the CDC, opioids, a class of drugs that includes prescription painkillers and heroin, were involved in 28,647 deaths in the United States between 2000 and 2014.That figure has been on the rise in recent years, and today many Americans see drug use as a problem in their communities.
While economic problems, terrorism, and health care top the list of priorities for the country, only 3 percent named drug use as a top-of-mind priority for the nation. However, when asked specifically about drug use, most Americans (62 percent) say at least one type of substance use is a serious problem in their community.
About a third consider the use of heroin and prescription painkillers a very or extremely serious problem in their communities, similar to the number who say the same about the use of alcohol and other drugs such as cocaine or methamphetamines. Fewer say marijuana use is a serious problem, however.
For much of the public, the problem of drug use hits close to home. About 4 in 10 Americans surveyed say they have a relative or close friend who has a problem with some type of substance use. These Americans are more likely to view substance use of all kinds to be a problem in their communities.While few say that overprescribing painkillers is widespread, many say the prescribing practices of doctors and dentists contribute to problems with drug abuse.
Just 21 percent say most or all doctors regularly overprescribe pain relievers more than is medically necessary. But, 89 percent of those who say there is any overprescribing think this practice contributes to dependence on prescription pain relievers and drug overdoses. A majority of Americans see prescription pain relievers and heroin as about equally risky to use (52 percent). Few say prescription pain relievers are more dangerous than heroin (4 percent), especially compared to the reverse (44 percent say heroin is more risky).
Americans favor a wide range of approaches to addressing issues of substance abuse in their communities. Many Americans think their communities are not devoting enough effort to several approaches of targeting this problem. Nearly 7 in 10 say their community is not doing enough to find ways to improve substance use treatment or to make it more affordable and accessible. Six in 10 say their community is not doing enough to crack down on drug dealers. Fewer, but still a majority, say their community is not doing enough to crack down on drug users or educate the public and students in school to prevent substance use. Slightly less than half say they are not doing enough to educate doctors and dentists about the risks of prescribing pain relievers, but a nearly equal amount say their communities are devoting the right amount of effort to this approach.
Click below for a printable version of Perspectives.
http://www.ncaddnjinfo.org/PDF/Pers042016.pdf ------
Rutgers report
on Medicaid
‘super-users’
urges care integration
A new report released by Rutgers Biomedical and Health Sciences
delves into Medicaid expenditures, finding a great concentration of spending on
a small minority of recipients. These so-called super-users – a term popularized
by Camden’s Dr. Jeffery Brenner – have an extremely high incidence of mental
illness and/or addiction, the report found. Among the changes it calls for most
urgently is integration of behavioral and primary care.
The report came in response to last year’s Budget Address from
Gov. Chris Christie, who identified a critical need for improving health care
delivery for super-users. The examination of the issue was done by a group of
Rutgers researchers under the rubric the Working Group on Medicaid High
Utilizers.
Christie noted in last year’s Budget Address that New Jersey
spends $12 billion in federal and state dollars – a third of the entire state
budget – on Medicaid and NJ FamilyCare. With the goal of improving care and reducing
costs, an agreement between the administration and Rutgers charged the RBHS with
providing a quantitative analysis of Medicaid claims and managed care encounter
data. In addition, they held meetings with expert Medicaid stakeholders, and examined
effective steps being taken in other states.
One of five areas that were identified early on as an area of
special interest was a cohort with complex behavioral health and substance
abuse with a primary behavioral health diagnosis. The prevalence of behavioral
health problems among the high users is extremely high, the report said, with
more than 86 percent of the super-users diagnosed with mental illness,
addiction or both.
The report found that in 2013 Medicaid spent approximately $9.4
billion caring for 1.6 million New Jersey residents, with 28 percent of total
dollars expended on just 1 percent of New Jersey Medicaid recipients. The
monthly cost per super-user is just over $37,000. The study further noted that
the top 10 percent of high users consume 75 percent of the total statewide
Medicaid spending.
The study identified near-term and medium –term steps to improve
care. The medium-term measures included expanding “service-enriched” housing.
It cited programs such as Housing First for its impact on high risk
populations, particularly people with addiction. It noted that SAMHSA Best
Practices for Providers named Housing First as a model to be expanded
and replicated.
The Governor cited the report in his Jan. 12 State of the State,
noting that it illustrated the pressing need for coordinating primary and
behavioral health care. The New Jersey Legislature recently considered a
measure that would have improved such a holistic health approach. The state
Assembly last Legislative Session considered a bill, (A3700/S2375), to
consolidate treatment for primary and behavioral health under a single license.
The proposal passed a vote by the full Assembly but it did not reach a Senate
vote. It will be taken again by the new Legislature.
The report’s major recommendations
are:
- Integrate behavioral health into primary care;
- Identify and find ways to help persistently high users
of health care, such as people who have been homeless or incarcerated;
- Coordinate public health and social services;
- Adopt the best clinical practices; and
- Create innovative payment models based on value not
just volume.
