San Francisco — The California Society of Addiction Medicine (CSAM) urged state leaders to begin adopting effective addiction treatment standards under national healthcare reform to ensure that millions of Californians finally get the care they need.
CSAM President Timmen Cermak, MD, released Unique Opportunity: Expansion of Substance Use Disorder Treatment Within Reach Through Health Care Reform at a recent hearing of the California Assembly Select Committee on Alcohol and Drug Abuse in Sacramento.
The white paper outlines basic medical standards that state lawmakers and regulators must implement for public and private health insurance under national healthcare reform, which requires that all health plans include treatment for substance use and mental health disorders among their basic benefits.
Recent federal parity legislation now assures that these disorders are covered in the same way as all other medical benefits.
"California's budget crisis is decimating state funding for addiction treatment, but health care reform provides the opportunity to make sure that treatment is expanded to nearly everyone who needs it through public and private insurance," Cermak said. "The long history of systemic, institutionalized discrimination against people suffering from addictive disease can finally be ended through health care reform."
Californians with substance use disorders are grossly underserved. According to 2007 state estimates from the National Survey on Drug Use and Health, 2.3 million Californians needed but didn't receive treatment for alcohol abuse and 764,000 needed but didn't receive treatment for drug abuse.
As with many federal mandates, states will have wide latitude in how they carry out the Patient Protection and Affordable Care Act, legislation that is the heart of federal health care reform. The state of California can design its system of substance use disorder treatment through laws and regulations that govern Medi-Cal, private insurers and the new health insurance exchange where individuals will shop for insurance. Many changes from the Affordable Care Act that impact substance use disorder treatment will go into effect in 2014.
Most health care systems have little experience in substance use and mental health disorder treatment, because nearly all insurers and health plans have systematically provided minimal treatment benefits in a discriminatory attempt to reduce costs. The state can set the standard for an effective substance use core benefit that will substantially reduce costs to the public and insurers that result from untreated substance abuse and the expensive medical conditions that often co-occur.
"The National Institutes of Health have established standards for addiction treatment and now California needs to implement these standards, which for the first time would manage substance use disorders as treatable chronic illnesses, just like hypertension, diabetes or asthma," Cermak said. "Discriminatory limits by health plan actuaries must end. The only limit on treatment can be medical necessity, whether it's for diabetes or addiction. People need treatment when they are ill, without arbitrary limitations."
Medically necessary standards for substance use disorder treatment include:
- Treatment dosage: Minimum threshold for improvement is not reached until three months, but this cannot be a limit. Treatment must be continued as medically necessary including for relapse, just like for any other chronic illness.
- Continuum of care: Treatment must include medical detoxification, inpatient and outpatient treatment and aftercare, as well as appropriate medical and psychiatric care, whenever medically indicated. Medications approved for alcohol, tobacco and drug treatment must be a covered benefit for as long as medically necessary. Access to medications cannot be limited to specified clinics.
- Co-occurring disorders: Up to 40% of substance abusers have a mental illness. Treatment for mental illness must be available as part of substance abuse treatment, and substance abuse treatment must be integrated into mental health treatment.
- Adolescent treatment: Only one out of 10 adolescents who needs it receives substance use disorder treatment, and nearly all of it is through the juvenile justice system. A statewide treatment system for youth must be provided through merging of substance use, mental health and pediatric or family medicine to provide extended, integrated care.
- Screening, brief intervention and referral to treatment (SBIRT): In hospitals, health clinics and primary care, SBIRT has been very effective in reducing substance abuse and future emergency room visits. Medical benefits must support and encourage SBIRT through full reimbursement.
To ensure that people with substance use disorder receive adequate treatment under health care reform, California lawmakers and regulators also must ensure that there is effective outreach about newly available treatment, including a state hotline for treatment; upgrade training standards for the treatment workforce; and monitor expansion of substance use disorder treatment under health care reform to assure that true parity is achieved.