In this time of dizzying challenges and opportunities for the addiction treatment and prevention communities, Andrea G. Barthwell, MD, knows that little will be accomplished by continuing to tell the various sectors of the field what they want to hear. Bringing order to the issues that cross multiple disciplines might mean ruffling some feathers now and then, for the overall good of the industry and the individuals it serves.
Witness these statements from Barthwell in a recent interview with Addiction Professional, serving as a preview of some of the content in the longtime field leader's Aug. 24 morning plenary session at the National Conference on Addiction Disorders (NCAD) in St. Louis:
On the stubborn divide between advocates of drug-free and medication-assisted approaches to treatment: “We can't have an expectation that medication-assisted treatment will bring in comprehensive care if in turn in our practices we deny medication for someone who needs it.”
On the opportunities associated with expanded insurance payment for services as a result of the Affordable Care Act's (ACA's) implementation: “Our survival as an industry depends on delivering recovery outcomes to payers—we can't be revolving doors.”
Barthwell's presentation at NCAD is titled “Sorting Through the Chaos of Emerging Trends in SUD Care to Bring Fields Together.” Her own background as a practicing addiction medicine specialist, a researcher, and a high-level government official (she is a former deputy director for demand reduction at the Office of National Drug Control Policy) gives her a focused perspective on what will be needed to unify sectors that often work at cross-purposes.
She also will draw from her most recent experience as director of the Two Dreams treatment facilities in Chicago and the Outer Banks region of North Carolina; she calls Two Dreams her “laboratory” for being able to execute her ideas about effective treatment.
Two Dreams has experienced a business-level transformation that reflects prevailing trends in the field. Just two years ago, its entire payment base came from self-pay arrangements, with scholarships available to some patients who could not finance their treatment. Now about 60% of the organization's revenues are derived from insurance.
“We are aggressively helping people manage their insurance benefits now,” says Barthwell. She believes that treatment organizations that can capably offer intensive outpatient and outpatient levels of care will excel in the new payment environment, but she adds that it will be important not to create siloed categories of service. “It is important not to lose sight of the ASAM criteria and the ability to move up or down levels of care,” she says.
Barthwell adds that while treatment organizations need to gear up internally to be able to serve an expected influx of insured patients, they must at the same time maintain a monitoring role regarding the practices of insurance companies that fly in the face of parity mandates. “We're looking for [the National Association of Addiction Treatment Providers] and others to capture information about denials,” Barthwell says. “As a field we need to be vigilant about denials.”
Providers also need to be aware of clauses in insurance contracts that often require patients to self-manage symptoms during a waiting period before they can access services under their policy. “We need to be sensitive that some patients will need something sooner than what their policy allows,” says Barthwell. “Interim services are needed more.”
She expects to deliver insights from her understanding of the provisions of the ACA to her plenary presentation at the Aug. 22-26 NCAD meeting, sponsored by the publishers of Addiction Professional and Behavioral Healthcare. “I may be one of the only people who have read all of the darn thing,” she says of the law.
Barthwell sees the heightened public and media attention to addiction issues, particularly the spike in opioid dependence and overdose deaths, as offering a significant opportunity for the treatment community. She believes it could create, for example, some momentum toward easing the 100-patient limit that applies to individual prescribers of buprenorphine for the treatment of opioid addiction.
Of course, such suggestions bring to light other divisions within the field, as evidenced recently when a white paper from the American Association for the Treatment of Opioid Dependence (AATOD; generally representing facilities that exclusively or primarily use methadone as their medication-assisted approach) stated that more needs to be learned about the treatment offered in physician practices before action on the patient limit is considered.
On the broader issue of the role of medication-assisted treatment, Barthwell believes this is one of the topics for which there is a critical need to bridge the divide in interests. “We need to unify the field and keep talking,” she says.
That means facing up to some difficult truths, she believes. “Most patients who go on medication do at least as well as what is seen with 12-Step facilitation, even if they go on medication alone,” Barthwell says. “That is a hard pill for many of us to swallow.”
Still, she adds that medication treatment without comprehensive support clearly does not represent the ideal path toward long-term recovery. She also says that the definition of “prescriber” likely will be expanded as medication-assisted treatment evolves. “Prescribers will not just be doctors, in the next iteration,” she says.
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