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Segregated no more

August 16, 2012
by Gary A. Enos, Editor
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Members of the addiction treatment community generally have not been the most vocal commentators in healthcare about the implications of the Affordable Care Act (ACA) and related initiatives, and that should be surprising given this comment from one of the country’s foremost authorities on addiction research and treatment:

“I don’t think there’s another medical condition that’s as affected by what will happen with the enactment of the ACA as addiction,” says A. Thomas McLellan, PhD, co-founder and CEO of the Philadelphia-based Treatment Research Institute (TRI).

McLellan, back at the nationally prominent nonprofit research organization as of early 2012 after serving as deputy director of the Office of National Drug Control Policy (ONDCP), adds, “I think where we’re going to come out in five years is that this will be a wonderful act for patients, their families, and particularly for healthcare.”

What’s less certain to McLellan as part of that equation is how health reform will affect the facilities that currently make up the specialty addiction provider network. Their fate, he says, largely depends on how they respond to changes in a system that will uncover new opportunities that could erase traditional notions of what their core patient population should look like.

To McLellan, the winners will be “the swift, the smart and the flexible” who can meet the needs of new treatment populations who will be identified in an increasingly primary care-driven system. Those who will be in danger, he believes, are providers who fold their arms in anticipation of the old ways of a segregated care system becoming new again.

“I don’t think the ‘good ol’ days’ are coming back,” McLellan says.

Impact of integration

Addiction is by no means the first medical condition to have been segregated from the rest of medical care. In fact, addiction treatment centers at one time in their history became a new destination for patients with another illness after its own segregated specialty care programs began to fall out of favor: that being tuberculosis.

Addiction remains a subject largely unaddressed in medical school curricula, an illness paid for largely outside of traditional medical insurance, and a societal crisis in which only about 1 in 10 of those who need some form of care receive any services, McLellan points out.

The ACA’s implementation will open up avenues of reimbursement for a continuum of substance use services that includes prevention, early intervention, office-based treatment and pharmacological treatment, much as has been the case for chronic illnesses such as diabetes, he says. New markets will be created for decision support tools and medications, he says, and for providers accustomed to receiving referrals only from the justice system, new referral sources might include hospital emergency departments, specialty care medical facilities, and primary care doctors.

Many specialty addiction treatment providers will have to learn the intricacies of insurance billing in order to serve these new populations, but if they do, “They will get patients with better prognoses,” McLellan says.

McLellan can be critical of providers’ resistance to change during his presentations at national conferences, but he is quick to point out that he doesn’t mainly blame providers for the situation in which many have found themselves. Payers and purchasers have failed to appreciate the benefits that can ensue from addressing substance use problems early and effectively, he says.

“Employers don’t realize that they can get people rehabilitated and in recovery and better than they’ve ever been,” McLellan says. “They say, ‘Just fire this guy.’”

McLellan thinks the U.S. Supreme Court’s June ruling affirming the constitutionality of the ACA’s individual mandate will give impetus to another seminal law affecting addiction treatment: the law mandating parity benefits for addiction and mental health. “I don’t think payers can stall longer,” he says, referring to the flagging effort to see parity’s impact come to fruition. “Interim regulations will have to be negotiated in good faith now.”

Physicians’ role

While it is widely believed that generalist physicians can be provided with the screening tools needed to identify patients with substance use problems accurately (and then to refer those who need more than a brief office-based intervention to specialty providers in the community), the existence of these tools of course does not guarantee their effective application in practice.

Physicians will need to have sound information at their disposal about which patient reports of substance use might indicate a problem and which might be largely harmless, McLellan says. “That information needs to be put smoothly into an electronic health record and into systems so that primary care doctors can do [screening] crisply and cleanly,” he says.

He adds, “Unfortunately, we don’t have much [to tell patients] between ‘attaboy’ and “Sir, I think you need to go to Betty Ford.’” And even in cases where a physician is confident that a referral to a specialty provider is needed, most doctors still lack a clear roadmap for how to proceed.

McLellan likens specialty providers’ concerns about losing the field’s identity in a more primary care-driven system to worrying about the sky falling. Primary care doctors are not tripping over one another to raid the specialty sector’s client base, he points out. “They’re happy to refer, but they’re happy to refer to someone who speaks the same language,” he says.

One element of that vocabulary likely will involve wider acceptance among specialty providers of the role of anti-craving medications, for which McLellan sees a potentially booming market as more prospective patients are identified in primary care.

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