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Evolution or revolution?

July 30, 2013
by David Mee-Lee, MD
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David Mee-Lee, MD

Consider the following data: When the Affordable Care Act (ACA) is fully enacted in 2014, there will be potentially 30 million people now uninsured who could access health insurance. Not all of those will enroll, and some will live in states that will not expand Medicaid to allow them to get health insurance. But there will be millions more who have health insurance, even if it is just one-quarter of those who will be newly eligible to be covered.

Secondly, in the latest data from the 2011 National Survey on Drug Use and Health (NSDUH):1

  • 21.6 million people ages 12 and older needed treatment for an illicit drug or alcohol use problem.
  • But 19.3 million of those needing treatment did not receive treatment in a specialty addiction agency in the past year.
  • 95.3% of those 19.3 million people did not perceive a need for treatment, so they made no effort to seek treatment.
  • 3.3% of those 19.3 million people felt they needed treatment but did not make an effort to seek treatment; and only 1.5% felt they needed treatment and made an effort to get treatment. A picture is worth a thousand words, so take a look (see chart).


Past-Year Perceived Need for and Effort Made to Receive Specialty Treatment Among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use, 2011


Source: www.samhsa.gov/data/nsduh/2k11results/nsduhresults2011.htm


From 2008-2011, for the people who needed addiction treatment, felt they needed it and even made an effort to receive treatment, nearly half (48.4%) did not get treatment because of either not having health insurance at all or not having a benefit plan that covered addiction treatment, and so could not afford the cost of treatment.1

So what should we make of these data? Here are some challenges to ponder:

  • If there are millions more people who after Jan. 1, 2014 will be covered by health insurance and have access to addiction treatment, how will addiction treatment agencies increase access to care when we already have waiting lists and can’t even meet treatment-on-demand now for the 2.3 million people who did eventually receive specialty addiction treatment? And remember, nearly half of those who did not receive treatment, even when they wanted it, missed out for insurance coverage reasons. If that cost barrier is removed or diminished with the ACA, then this further increases the strain on the treatment system.
  • 19.3 million people did not receive addiction treatment and the vast majority of those were either not screened and diagnosed or, if told, did not agree with the diagnosis of addiction and therefore did not seek help. How will we ever reach these reluctant “customers” for addiction treatment when we already have large caseloads in specialty programs, let alone find the time and resources to reach out to general healthcare—where the vast majority of people with addiction really are?
  • What can addiction treatment professionals do to increase access to affordable care; reach out to general and mental healthcare systems to help identify and attract into recovery close to 20 million people who are now not treated; and collaborate with health homes and accountable care organizations? ACOs, hospitals and clinics are increasingly being held accountable to focus on outcomes and become truly “healthcare” organizations, rather than “sick care” organizations where the financial reward has been based on keeping the hospital census full with those needing sick care.

With the impact of the changing landscape evolving with healthcare reform and the greater awareness that we need to do more to reach out to the 20 million addicted people who haven’t accessed treatment, it could seem we need a revolution in addiction care. Do we have time for the evolution of addiction systems to:

  • Eliminate or significantly reduce waiting lists and increase access to care.
  • Utilize a broad continuum of care from screening and brief intervention (SBI) to easy linkage to a seamless array of services designed for chronic disease management.
  • Shift focus from completing and “graduating” from often fixed length-of-stay programs to payment for monitoring and achieving outcomes that focus on wellness and recovery rather than on placement in a program.

While desperate times may require desperate measures, nobody really wants a revolution. But time is running low for a glacial speed evolution. Here is where the new edition of The ASAM Criteria comes in. The new fifth edition of the American Psychiatric Association’s (APA’s) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) also contributes.


What’s new in the criteria




I enjoyed your piece about the impact of more insured lives on the treatment field. And, like you imply, I agree that higher volumes are but one of many external forces aligning themselves to fundamentally change treatment as we know it today. The Affordable Care Act has only served to accelerate the market forces demanding accountability, reduced costs and better outcomes.

A macro effect of these external forces is today's massive consolidation and absolute integration (i.e., in-house health insurance companies and integrated behavioral and primary care) of health care providers. In tomorrow's world of health care, the game is going to be all about revenue capture, cost containment, patient experience and outcomes. Translated, that means that, among other things, health care providers are going to be providing in-house services to the extent possible. Those who already provide addiction treatment are going to do it bigger and better. Those who aren't yet in the business will be. Health care providers are, by necessity, going to have to get a lot better at identifying patients with addiction issues. They have no other choice. And, with reimbursement tied to outcomes, they're going to have to get pretty good pretty fast. Inevitably, that means that they must build continuum of care models, applying disease management principles to addiction patients.

So what does this mean for today's addiction treatment providers. It means the revolution is upon us. Specialty providers everywhere had better be thinking strategy at the highest level.

Tomorrow's health care providers are either going to be providing their own addiction treatment services or (and only to the extent that they can't figure out how to do it themselves) they're going to enter into strategic alliances with those who meet their qualitative standards. And, with reimbursement tied to outcomes, those standards will be rigorous, to say the least.

If I were in a governance or senior management position in a treatment provider today, I'd be focused exclusively on developing these alliances with integrated health care systems. The surviving treatment providers will be those with a critical mass of these relationships, all of which will be focused on delivering treatment services as a component of continuums of care.

I am CEO of Face It TOGETHER, the Mission of which is to empower communities with proven, innovative and sustainable tools to attract millions of Americans to initiate and sustain recovery from addiction. We are a team of social entrepreneurs out to change just about everything we think and do about addiction in the US. The future we envision will include a network of communities in which there are robust collaborations among employers, health care providers, payors, treatment providers and recovery community organizations (delivering peer-based recovery supports); all dedicated to and invested in solving addiction. (www.wefaceittogether.org)