Vermont s Approach Treating the Opiate Epidemic Barbara Cimaglio Deputy Commissioner, Vermont Department of Health

Transcription

1 Vermont s Approach Treating the Opiate Epidemic Barbara Cimaglio Deputy Commissioner, Vermont Department of Health State Experiences with Health Care Reform Grand America Hotel Salt Lake City, Utah October 1 3, 2015

2 Roadmap of Presentation Origin and Development of Successful Reform Implementation Outcomes Key Takeaways for Other States State Contacts / Additional Resources 2

3 Origin and Development of Successful Reform The Care Alliance for Opioid Treatment, also known as the Hub and Spoke initiative is designed to expand access to treatment by creating a coordinated, systemic response to the complex issues of opiate and other addictions in Vermont. Key goals: Improve access to addictions treatment Integrate addictions treatment with health care Improve outcomes for addictions patients Key elements: Enhanced health homes for addiction treatment Hub & Spoke Bundled payment/capacity payment for spokes High level results/outcomes: Improved access to care Lower health costs Improved patient outcomes 3

4 Origin and Development of Successful Reform A Hub is a regional opioid treatment center responsible for coordinating the care and support services for patients who have complex addictions and cooccurring substance abuse and mental health conditions. Patients who need methadone must be treated here. Patients who need buprenorphine may be treated here. A Spoke is a medical home such as a primary care practice or health center responsible for coordinating the care and support services for patients with opioid addictions who have less complex medical needs. Only patients who are treated with buprenorphine receive treatment in the spokes. Depending on the patient s needs, support services may include mental health and substance abuse treatment, pain management, family supports, life skills, job development, and recovery supports. 4

5 Origin and Development of Successful Reform Hubs Rate/based Spokes FTEs added/100 patients Basic OTP Rate Nurse case manager Enhanced rate to include health home services Mastersprepared clinician 5

6 Origin and Development of Successful Reform Figure 23. Hub & Spoke Health Home for Opiate Dependence The Hub & Spoke innovation is in the coordinated, reciprocal clinical relations between the specialty addictions centers and the general medical practices. The framework facilitates the 6

7 Origin and Development of Successful Reform Timeline Fall 2011 Planning began 03/2012 Discussions with SAMHSA-CMS 05/2012 Opiate system bill passed 10/2012 Concept paper submitted to CMS 01/2013 First hub begins services 07/2013 State plan amendment submitted to CMS 01/2014 Gov. Shumlin gives State of the State address focusing on opioids 01/2014 Second tier of hubs begin services 03-04/2014 State plan amendment approved (retroactive) 7

8 Origin and Development of Successful Reform Developing the model Number of people seeking treatment for opiate addiction was rising: From 1199 in 2004 to 2944 in 2011 Existing treatment network had limited capacity to treat opiate addiction Limited number of treatment slots/areas with no OTP/long wait lists Not enough physicians who could treat this population Medical expenditures were rising for this population 3x the average per capita costs of other Medicaid beneficiaries Health outcomes were poor for this population Current services were siloed lack of access to full health care for people with addictions 8

9 Origin and Development of Successful Reform Source: Alcohol and Drug Abuse Treatment Programs 6,000 Number of people treated in Vermont by substance Alcohol Marijuana/Hashish Heroin/Other Opioids All Others 5,000 4,000 3,000 2,000 1, Vermont Department of Health Source: Alcohol and Drug Abuse Treatment Programs 9

10 Origin and Development of Successful Reform Opportunity: Affordable Care Act Section 2703 opportunity to create a specialty health home 90/10 match for 8 quarters Requirement to include 6 health home services Comprehensive care management Care coordination Health promotion Comprehensive transitional care/follow-up Patient and family support Referral to community and social support 10

11 Origin and Development of Successful Reform Developing the model Engagement Step 1 AHS Commissioners/Secretary/key staff Data analysis Number of people with opiate addiction/services being received/costs Model development What services were essential OTP/OBOT and health home Caseload expectations for cost effectiveness For specialty Hubs and Spokes 11

12 Origin and Development of Successful Reform Developing the model (cont d) Engagement Step 1 Current Opiate Treatment Providers (OTPs) Community Health Team Partners (PCPs/FQHCs/OBGyns) Willing to take on more/new population? New partners willing to develop new services? Physicians willing to partner with specialty providers? Specialty providers willing to partner with primary care? 12

13 Origin and Development of Successful Reform Developing the model (cont d) Engagement Step 2 Proposed new model to Governor for inclusion in budget Analysis by Administration financial staff to determine whether proposed costs ($6.7M) would be offset by savings Data used was from Vermont Medicaid Governor proposed in budget Based upon 90/10 match for first 8 quarters Reviewed & approved in legislature 13

14 Origin and Development of Successful Reform Developing the model (cont d) Engagement Step 2 (concurrent) Initial review with SAMHSA/CMS (3/12) White paper drafted (10/12) Development of State Plan Amendment (7/13 submitted) Vermont Medicaid Agency (DVHA) Presentation to Green Mountain Care Board Testimony to legislature/governor discussions Timeline approximately one year for development of SPA 14

15 Roadmap of Presentation Origin and Development of Successful Reform Implementation Outcomes Key Takeaways for Other States State Contacts / Additional Resources 15

16 Implementation Provider Selection First Hub: Prototype/used existing provider Next Hubs: RFP process through Medicaid agency New Development: Collaborative process with local hospital 16

17 Implementation Communication Essentials State Team: Weekly meetings through start up Monthly meetings continue External Stakeholders (Providers): Individual meetings to start Monthly meetings together (hubs) Regular updates to leadership Legislative reports/annual 17

18 Implementation Training for Providers Learning Collaboratives with Dartmouth /Geisel School of Medicine Alternate between calls and in-person meetings (everyone other month) Technical assistance from state staff as needed (one FTE dedicated) Regular Hub provider meetings (quarterly) and phone calls (monthly) On-site visits from state staff (twice/year for each site) 18

19 Implementation Communicating results Governor Shumlin is our best communicator!! Media interviews and articles Legislative report due January 2014 Presentation to GMCB Regular updates to AHS Secretary & Commissioners Presentations to community and other states 19

20 Roadmap of Presentation Origin and Development of Successful Reform Implementation Outcomes Key Takeaways for Other States State Contacts / Additional Resources 20

21 Outcomes Results Projected initial savings of $6.7M (Medicaid) reinvested in ongoing treatment Increase in access to treatment Increased number served MAT treatment in Hubs/OTPs (see next slide) 57 spoke practices serving over 2000 patients in primary care Integration of specialty treatment with primary care Initial data is demonstrating improvement in health status 21

22 Census Outcomes VT Department of Health 3000 Hub Census Over Time by Region Department of VT Health Access Rutland/Benn Essex/Orl/Cal Windam/Windsor Wash/Lam/Orange Chit/FGI/Addison Month Date of Last update: 08/25/2015

23 Outcomes Data collection: Medical & Social Health care expenditures Access to treatment Engagement in treatment Drug use Emergency department utilization Hospitalizations Rates of continuous health insurance Incarceration rates Unemployment rates Children in DCF custody Housing stability 23

24 Outcomes Using Vermont Medicaid data, analysis shows: Individuals with an opioid dependent diagnosis receiving MAT have lower medical care costs than those who have an opioid dependent diagnosis and are receiving non-mat substance abuse treatment or no treatment at all Longer MAT engagement corresponds to lower non-treatment related medical care costs 24

25 Roadmap of Presentation Origin and Development of Successful Reform Implementation Outcomes Key Takeaways for Other States State Contacts / Additional Resources 25

26 Key Takeaways for Other States Leadership, leadership, leadership Design the model before beginning to pilot Engage all providers, not just the usual suspects Importance of dedicated staff and staff time It s always more complex that we imagine Need to work with willing providers, at least to start Workforce is a challenge -- not enough, not the right kind Relationships, relationships, relationships & relationships 26

27 Roadmap of Presentation Origin and Development of Successful Reform Implementation Outcomes Key Takeaways for Other States State Contacts / More Information 27

28 State Contacts / Additional Resources Department of Vermont Health Access Aaron French, Deputy Commissioner aaron.french@vermont.gov Beth Tanzman, Blueprint Deputy Director beth.tanzman@vermont.gov Vermont Department of Health Harry Chen, MD, Commissioner harry.chen@vermont.gov Barbara Cimaglio, Deputy Commissioner barbara.cimaglio@vermont.gov Additional resources Vermont Department of Health Website/Care Alliance for Opiate Addiction: Vermont Blueprint for Health: Hub and Spoke Briefing: Hub and Spoke State Plan Amendment: Gov. Shumlin s 2014 State of the State Address: 28