Treatment Program Profile. by Gary Enos, Contributing Editor

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1 Volume 23 Number 12 March 21, 2011 Print ISSN Online ISSN In This Issue Medicaid managed care enters New York addiction treatment... See page 3 From the Field: Measures of success in health care reform: Efficiency and recovery... See page 5 Study looks at which drinkers best respond to naltrexone... See page 6 HEALTH AND MEDICAL WRITING Most treatment admissions for inhalant abuse are adults... See page 6 Obituary: G. Alan Marlatt, Ph.D., critic of zero-tolerance rules, passed away on March See page Wiley Periodicals,Inc. View this newsletter online at wileyonlinelibrary.com DOI: /adaw Oklahoma Medicaid requires Master s degree for substance abuse assessments O Oklahoma is moving ahead with plans to require Master s degrees for substance abuse counselors. On March 10, the board of the Oklahoma Health Care Authority (OHCA), the state s Medicaid program decided that in order to do assessments all Certified Alcohol and Drug Counselors (CADCs) must have Master s degrees. Oklahoma counselors are strongly resisting all moves to require higher level education, saying that this will limit access to treatment since many providers do not have Master s degrees and don t have time or money to get them. However, this initiative has been in process for more than a year in the state. It was a quality of care concern, that CADCs might potentially miss Treatment Program Profile by Gary Enos, Contributing Editor A As part of a hospital-based system of care, the L.E. Phillips-Libertas Treatment Center in Chippewa Falls, Wis., benefits from the resources of a larger organization but still strives to assert its role in a system governed by general health concerns. The 46-bed addiction treatment operation s administrators have learned to be nimble and self-reliant, eager to embrace any service that appears to benefit clients while helping to shore up the bottom line. We have a 12-Step foundation, but that s just the foundation, center director Tom Fuchs told ADAW. mental health diagnoses during the assessment, OHCA spokeswoman Jo Kilgore told ADAW last week. The Medicaid program worked with the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) to develop the Master s requirement, which ultimately will apply to all clinical treatment services, not just assessments. Last year, the legislature passed a bill requiring these changes, which were supported by ODMHSAS, citing quality of care (see ADAW, March 8, 2010). By July 2013, all CADCs will be required to have a state license, which means a Master s degree, in order to be reimbursed by Medicaid for individual or See Oklahoma page 2 Wis. program diversifies operation with residential care, medications He added, It s imperative to look at organizations getting caught in a single-model delivery system. As we move toward pay for performance in the field, organizations in that position will be at a disadvantage. Two major changes in recent years at the center, which is part of the St. Joseph s Hospital system, have diversified and truly transformed the organization. Establishment of an on-site residential treatment component has enhanced continuity of care and has broadened the payer mix to include more private insurance coverage than what planners originally anticipated. Second, significant use of the medi- See Wisconsin page 7 A Wiley Periodicals, Inc. publication. wileyonlinelibrary.com

2 2 Alcoholism & Drug Abuse Weekly March 21, 2011 Oklahoma from page 1 group counseling. By this July, that requirement will be in effect for all CADCs doing assessments. Although Oklahoma s ODMH- SAS has always said that the higher education requirement is a matter of quality, a March 11 article in The Oklahoman newspaper said that the rule changes were required by new federal Medicaid standards. But that was inaccurate. According to the Centers for Medicare and Medicaid Services (CMS), there are no such standards. There is an Affordable Care Act modification to Public Health Services rules requiring Master s degrees, but no revision to Title 19 of the Social Security Act, which is Medicaid, said Mary Kahn, senior public affairs specialist for CMS. States are allowed to determine who they want to be providers, she told ADAW. Steven Buck, ODMHSAS Deputy Commissioner for Communications and Prevention, told ADAW that there are no new federal standards that require a Master s degree. I m not aware of any federal standards, he said. The only federal requirement that is involved here is that for Oklahoma to access federal Medicaid matching funds, it must expend its own Medicaid dollars on a service, he said. Instead of ODMHSAS paying for the services, What matters is what third-party payers will require, what Medicaid in some states, like Oklahoma, will require. Cynthia Moreno Tuohy Oklahoma Medicaid can pay for it and get matching funds from the federal government. In Oklahoma, ODMHSAS currently reimburses certified addiction counselors who are not state-licensed. Medicaid can pay for them only by considering these certified counselors under the rehabilitation benefit, Kahn told ADAW. The services of a licensed counselor would be coverable under the Other Licensed Practitioner (OLP) benefit at 42 CFR , said Kahn. States generally have the option to cover these types of services under either or both the Rehabilitation and/or OLP, depending upon the licensure status or other qualifications of the provider. Kahn noted that both the reha- bilitation benefit and the OLP benefit are optional a state is not required to cover such benefits under Medicaid at all. I guess the bottom line is this is a state call for providers of benefits they don t have to cover in the first place, she said. NAADAC view NAADAC, the Association for Addiction Professionals (NAADAC), supports the move to increased education for counselors. It s happening in Oklahoma right now, and we believe it will become typical, said Cynthia Moreno Tuohy, NAADAC executive director. We are competing in the health care marketplace with social workers, marriage and family counselors, licensed counselors, all of which require Master s degrees, she said. If you re doing clinical work, you need to understand the theory and methods of counseling, and you don t get that in two years of education. Salaries for counselors will stay low unless the field is professionalized, said Moreno Tuohy. She said that whether the Patient Protection and Affordable Care Act requires a Master s degree or doesn t isn t the point. That doesn t matter, she said. What matters is what thirdparty payers will require, what Medicaid in some states, like Oklahoma, will require. Executive Managing Editor Karienne Stovell Editor Alison Knopf Contributing Editor Gary Enos Production Editor Douglas Devaux Executive Editor Isabelle Cohen-DeAngelis Publisher Sue Lewis ISBN Alcoholism & Drug Abuse Weekly (Print ISSN ; Online ISSN ) is an independent newsletter meeting the information needs of all alcoholism and drug abuse professionals, providing timely reports on national trends and developments in funding, policy, prevention, treatment and research in alcohol and drug abuse, and also covering issues on certification, reimbursement and other news of importance to public, private nonprofit and for-profit treatment agencies. Published every week except for the last Monday in April, the first Monday in July, the last Monday in November and the last Monday in December. 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For reprint permission, call (201) Alcoholism & Drug Abuse Weekly is indexed in: Academic Search (EBSCO), Academic Search Elite (EBSCO), Academic Search Premier (EBSCO), Current Abstracts (EBSCO), EBSCO Masterfile Elite (EBSCO), EBSCO MasterFILE Select (EBSCO), Expanded Academic ASAP (Thomson Gale), Health Source Nursing/Academic, InfoTrac, Proquest 5000 (ProQuest), Proquest Discovery (ProQuest), ProQuest Health & Medical, Complete (ProQuest), Proquest Platinum (ProQuest), Proquest Research Library (ProQuest), Student Resource Center College, Student Resource Center Gold and Student Resource Center Silver. Business/Editorial Offices: John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ ; Alison Knopf, (845) To renew your subscription, contact Subscription Distribution US, c/o John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ ; (201) ; It is illegal under federal copyright law to reproduce this publication or any portion of it without the publisher s permission.

3 March 21, 2011 Alcoholism & Drug Abuse Weekly 3 NAADAC members aren t upset by the move toward a Master s. We haven t gotten any pushback because NAADAC has been telling our field this for 15 years, said Moreno Tuohy. If you don t see the writing on the wall, that s unfortunate, because this is where things are going, and they are going there quickly. IC&RC counselors But counselors in Oklahoma have never been happy with the plans, which were originally announced by the state more than a year ago (see ADAW, Dec. 14, 2009). Our board has always taken the stance that our CADCs are some of the most highly qualified substance abuse professionals, and we think they are qualified to provide treatment services, said Ric Pierson, executive director of the Oklahoma State Board of Licensed Alcohol and Drug Counselors. The push for this is coming from people with a mental health background who don t really understand substance abuse, said Pierson. Oklahoma uses the International Certification and Reciprocity Consortium (IC&RC), not NAADAC, standards for credentialing. This is an extremely sensitive and complex issue for our workforce, said Andrew Kessler, IC&RC federal policy liaison. While the substance abuse treatment workforce deserves to be recognized as competent, effective health professionals, Who can treat what in Oklahoma Last June Mike Fogarty, chief executive officer of the Oklahoma Health Care Authority, the Medicaid (SoonerCare) authority in the state, and Terri White, Commissioner of the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS), sent a joint letter to ODMHSAS and SoonerCare contracted substance abuse providers telling them what they can expect in terms of policy changes effective July 1, 2010 and beyond. Here is a list of what Certified Alcohol and Drug Counselors (CADCs) who do not have state licenses or Master s degrees required as part of their credential will not be allowed to do. Some of the provisions were to take effect immediately on an emergency basis, but did not, and are being phased in instead. As of July 1, 2013, CADCs will not be allowed to provide and bill for psychotherapy services. As of July 1, 2010, CADCs will not be allowed to provide or bill for assessments. CADCs and CADCs under supervision can provide and bill for the Substance Abuse Subtle Screening Inventory (SASSI) as a screening, not an assessment. CADCs must be under supervision in order to deliver and bill for the Addiction Severity Index (ASI). CADCs and CADCs under supervision are no longer allowed to bill for treatment plans, but they are allowed to complete treatment planning with the patient for the service they provide, and add the service goals and objectives to the treatment plan. Treatment plans must be signed and billed by a licensed staff member. CADCs who are under supervision are no longer allowed to provide or bill for psychotherapy but may provide and bill for psychosocial rehabilitation services. the situation in Oklahoma ultimately puts the consumers at risk, he told ADAW. Because there is a workforce shortage, in Oklahoma as elsewhere, limiting counselors to those with Master s degrees may result in limiting access, he said. While those with Master s degrees may have a higher level of education, we believe our ultimate goal is to provide service. ICRC is dedicated to working with all parties to assure that the consumer gets the highest level of care possible in a timely fashion. Medicaid managed care enters New York addiction treatment Gov. Andrew Cuomo s Medicaid Redesign Team (MRT) took less than two months to generate recommendations that would dramatically change Medicaid reimbursement in the state, introducing for the first time a Medicaid managed care component statewide. Those recommendations, accepted by the governor February 24, are supported by the addiction treatment field, which also won four key provisions it pushed for during meetings in January and February. The four key changes incorporated into the recommendations: 1) Expansion of the managed care addiction treatment program (MATS) in New York City and upstate. This program specifically reduces unnecessary hospitalizations, and has saved almost $10 million in the past three years, and expands outpatient treatment. 2) Establishing Behavioral Health Organizations to cover addiction and mental health issues. These would be carved-out managed care programs; currently, Medicaid addiction treatment in New York is fee for service. 3) Expanded screening, intervention and referral to treatment (SBIRT) for alcohol and drug use beyond emergency room settings. Continues on next page A Wiley Periodicals, Inc. publication. View this newsletter online at wileyonlinelibrary.com

4 4 Alcoholism & Drug Abuse Weekly March 21, 2011 Continued from previous page 4) Reimbursement for recovery coaches. The legislature, which now has the recommendations in the form of a bill submitted by the governor s office, has until April 1 to approve a budget; this bill would be a part of the budget. The state has a budget deficit of $10 billion, and Governor Cuomo s charge to the MRT was to save money while still providing the highest quality care. Essentially, the MRT report caps Medicaid spending at $15 billion by recommending more managed care, but for the outpatient treatment community, this could possibly mean more money for outpatient treatment with fewer unnecessary and repeat hospitalizations. Our understanding is that the goals are to make the delivery of care more effective and efficient, Now we are supportive of better management of care, as long as it s done in a way that will improve the care people receive and reduce unnecessary expenses, rather than limits necessary treatment. and that we hope will include reduction in repeat expensive detoxifications and more linkage of people to the treatment they need, along with additional funding for that treatment, said Paul Samuels, president and director of the Legal Action Center. John Coppola, executive director of the New York Association of Alcoholism and Substance Abuse Providers (ASAP), also supports the MRT recommendations. ASAP is also asking for a $500,000 allocation in the budget to provide physician training to promote the use of SBIRT. OASAS involvement The Legal Action Center and Paul Samuels ASAP support the establishment of managed care entities that focus specifically on addiction and mental health, but are urging that the state ensure that the Office of Alcoholism and Substance Abuse Services (OASAS) and the Office of Mental Health (OMH) will be writing the rules for how this is done, said Samuels. (Both the commissioners of OASAS and OMH were on the MRT.) Rather than simply privatizing the system and giving the Medicaid dollars to an insurance company to manage, the field wants to make sure OASAS oversees the development of rules and the implementation of whatever contracts are written. Many years ago when managed care was first implemented in the state, treatment advocates were very concerned about simply including addiction treatment in the big managed care plans, said Samuels. Addiction treatment is not included in New York s Medicaid managed care. Now we are supportive of better management of care, as long as it s done in a way that will improve the care people receive and reduce unnecessary expenses, rather than limits necessary treatment, said Samuels. The managed care approach would be only for Medicaid, and not for the block grant or any other separately appropriated funds. Unnecessary hospitalizations Across all specialties, the MRT report includes a shift away from expensive hospitalizations, and toward more treatment in the community. Wouldn t you rather be treated in the community than in the hospital? asked Claudia Hutton, spokeswoman for the Department of Health, which oversaw the MRT. We are the worst state in the nation when it becomes avoidable hospitalizations, Hutton told ADAW. The largest insurance payer in the state is the Medicaid program, and it gets hit hard by these hospitalizations, she said. We have to change the way we do business. Why has Medicaid continued to pay for patients to be detoxified in hospitals often repeatedly but not connected them with follow-up community-based treatment? One reason is that New York was not keeping pace with experts in the field, said Hutton. But she also said that patients can t be forced to go to treatment. Many Medicaid patients are not under any kind of coordinated care program, she said. They don t have a doctor, they just go to the emergency room. The revolving door of substance abuse treatment is partly due to the fact that patients don t have a medical home, a doctor whose office takes care of them, she said. And hospitals don t turn patients away who need care. If you are a hospital and someone is in need of detox, you have to treat them, said Hutton. The MRT proposal has 79 different recommendations, but was presented as one bill to the legislature. Medicaid redesign is at an early stage of development; legislative and regulatory steps still need to take place before these changes can be implemented. Unlike many states, New York has had a very robust benefit for addiction treatment, said Samuels. Providers in the state already know how to bill Medicaid, and just need to have additional funding to treat the patients they will be seeing due to the reduced hospitalizations. So far, so good, said Samuels. We ll see what happens with the legislature. It is illegal under federal copyright law to reproduce this publication or any portion of it without the publisher s permission.

5 March 21, 2011 Alcoholism & Drug Abuse Weekly 5 Measures of success in health care reform: Efficiency and recovery by Michael T. Flaherty, Ph.D. Sometimes our focus gets lost in the intensity of our efforts to fulfill a task. We can over-fixate on an item only to lose recollection of what we were in search of originally. Haven t you ever entered a room only to ask, Now, why did I come in here? Some good news. As a practitioner in behavioral care, I feel certain that 75 years from now our society will view the passage of the Mental Health Parity and Addiction Equity Act of 2008 to be historically of more significance than the bailout of Wall Street in How can I predict this? Over the next 75 years, far more Americans and others across the globe stand to benefit from parity and the unified (body-mind) scientific advancements potentially made possible by an integrated human science than will have benefitted by Wall Street s bailout. Think about it. How does your mind or behavior affect your physical health? More good news. Shortly before parity finally passed, America was also recognizing the lived evidence for and obvious benefits of redefining our understanding of addiction as a chronic, rather than acute, illness whose treatment is enhanced dramatically by approaches that not only focus on the pathology but on the continuing care needed to attain and sustain wellness and recovery. New definitions of recovery came forward and policy, science and medical leaders joined with those in recovery and their families as never before to build community based recovery oriented systems of care (ROSC). The Office of National Drug Control and Policy established a Recovery Branch that by its very existence underscores the importance of recovery as meaningful to both the interdiction and demand reduction approaches now being developed to prevent and/or reduce ALL illicit use. The National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism have established similarly titled offices for recovery. This evolution is continuing further by the Substance Abuse and Mental Health Services Administration s Strategic Plan for that has made building recovery support (and attaining measures of recovery) Strategic Initiative #4. Joining Partners in Recovery, SAMHSA has compiled, among many other documents and trainings, a Recovery- Oriented Systems of Care (ROSC) Resource Guide to show states what is out there and among other states who are building a ROSC. SAMHSA s ATTCs have also trained teams across all regions of America to help states in building ROSC. (This information and many more resources can be viewed at or Now we have the Patient Protection and Affordable Care Act of Whatever your politics, I hope we can agree on the need for health care to become more efficient, higher quality, and accessible to more people. By 2014, experts anticipate 30 million more Americans will need access to behavioral care or should I say, behavioral focused integrated care. Under the overarching goal of Improving the Nation s Behavioral Health, SAMHSA and others are uniting efforts for a more integrated (mind-body) understanding of all illnesses and the systems designed to treat those illnesses. Some of us old-timers are a bit nervous holding a fear of losing our hard-earned specialized knowledge and care in the move toward a more generalist approach to individualized care. The issue of resources also has to be noted as the efficiencies of early identification and screening (e.g. SBIRT) as well as de-institutionalization from hospitals and jails will improve care only if thoughtfully implemented with a true understanding of the nature of addiction and recovery. In a system already short of resources, these efficiencies will not be sufficient alone to support the needed treatment and recovery support services across the continuum of care and the sheer numbers needing attention for it at whatever specialty site or generalist home. New payment methodologies must also better align to quality and transformation and will help establish further efficiencies and recovery. Still, once we have integrated our understanding and aligned our systems of care we have to remember why we came into the room in the first place. Integrating care is only the next step in our understanding of transformed, person-centered continuum needed to address the role of the mind and body connection in our public or private treatment system. I believe we came into this room seeking to improve health outcomes and recovery by treating an illness more comprehensively, scientifically, efficiently and by identifying and linking all pathways of recovery to it. Treatment becomes part of an individual s recovery. Building efficiency and recovery are why we came into the room. At the end of the day we will be judged more critically not by how well we insured this care or transformed the systems and providers providing it but by how well we understood this new opportunity for a Continues on next page From the Field A Wiley Periodicals, Inc. publication. View this newsletter online at wileyonlinelibrary.com

6 6 Alcoholism & Drug Abuse Weekly March 21, 2011 Continued from previous page mind-body integrated approach and the increased number of people who achieve wellness and sustained recovery because of it. By these measures we can mark our ultimate progress. Michael T. Flaherty, Ph.D. is the Executive Director of the Institute for Research, Education and Training in the Addictions (IRETA) in Pittsburgh, Pennsylvania. The above represents his opinion. He can be reached at Study looks at which drinkers best respond to naltrexone A new study has found that people with a certain polymorphism called A118G on the mu opioid receptor gene (OPRM1) are more responsive to naltrexone s ability to recue alcohol-induced euphoria. The study, to be published in the June issue of Alcoholism: Clinical and Experimental Research and currently available online, also found that women are more susceptible to these effects. Naltrexone works well with some alcoholics, but not others, creating questions about how to determine which patients are best suited to this treatment, available in oral form or in a once-monthly injection. For the study, the researchers administered either naltrexone or placebo to 40 social drinkers for six days. All subjects but one were tested for the A118G polymorphism of the OPRM1 gene. At the end of the treatment period, each participant received their favorite drink, and an opportunity to work for more drinks. The study found that the reinforcing effects of alcohol the euphoria were decreased most clearly in people with the endorphin-related gene, and in women. These results support previous research showing that naltrexone works best in a subgroup of alcoholics who have a certain genotype, said study co-author Charles O Brien, M.D., Kenneth Appel Professor in the Department of Psychiatry at the University of Pennsylvania, in a press release from the Addiction Technology Transfer Center Network, which helped publicize the findings. We don t know about other subgroups who may respond, but in future we will genotype first and then select medication. Researchers and clinicians working together might make it possible to predict beforehand who will best benefit from one treatment versus another, said Marco Leyton, William Dawson Chair in the Department of Psychiatry at McGill University and corresponding author. To help create this envisaged personalized medicine we need to identify more so-called biomarkers. In addition to working well with alcoholics with the G allele, naltrexone works well with people with a strong family history of alcoholism, and those with high alcohol craving, said O Brien, noting that he has treated some patients for alcoholism for up to 20 years with naltrexone, but others only six to 12 months. Alcoholism: Clinical & Experimental Research is the official journal of the Research Society on Alcoholism and the International Society for Biomedical Research on Alcoholism. The study was funded by Mc- Gill University, the Canadian Institutes of Health Research, and GlaxoSmithKline Inc. Most treatment admissions for inhalant abuse are adults For the first time, adults predominate treatment admissions for inhalant abuse, according to a new study released last week by the Substance Abuse and Mental Heath Services Administration (SAMHSA) in collaboration with National Inhalant Prevention Coalition (NIPC). Inhalant abuse intentionally inhaling a chemical vapor to get high is a life-threatening risk among children and adolescents, and the cause of sudden sniffing death. However, the study shows that 54 percent of treatment admissions related to inhalant abuse in 2008 involved adults ages 18 or older. In addition to death, which can be caused by even one occasion of inhalant abuse, chronic sniffing or huffing can cause damage to the brain, kidneys, lungs, and other organs. Inhalant abuse is an equal opportunity killer that does not discriminate on the basis of age, background or gender, said H. Westley Clark, M.D., J.D., M.P.H., director of SAMH- SA s Center for Substance Abuse Treatment. Although we have been understandably focused for many years on the danger huffing poses to our kids, these new data highlight the need for everyone to be aware of and effectively address the serious risks it poses to adults and all segments of our society. And Gil Kerlikowske, director of the White House Office of National Drug Control Policy (OND- CP), said that inhalants show that just because a product is legal, doesn t mean it is safe. It is illegal under federal copyright law to reproduce this publication or any portion of it without the publisher s permission.

7 March 21, 2011 Alcoholism & Drug Abuse Weekly 7 Erin Davis, a 42-year-old mother of a 16-year-old daughter, was at a March 17 press conference with federal officials to explain how these inhalants can destroy your life. She inhaled computer duster for two years, starting at the age of 38. I actually passed out driving one time when I was using and came to a stop in the middle of the road, she said. She was ordered to treatment by the legal system, and without that treatment she would still be using inhalants, she said. As much as I don t like dealing with probation and all the money I have to pay out, getting caught probably saved my life. I know I wouldn t have stopped. I couldn t. This year s recognition of National Inhalants and Poisons Awareness Week took a slightly different tack from past years. Traditionally, our focus has been on prevention with children while attempting to locate assistance for those needing help, treatment and support, said Harvey Weiss, executive director of the NIPC. However, more calls have been coming in for older relatives, he said, leading officials to understand that people of all ages are at risk and may need help with this problem. Inhalants can produce a rapid high that resembles alcohol intoxication, according to David Shurtleff, Ph.D., acting deputy director of the National Institute on Drug Abuse (NIDA). Given the wide availability of these substances and the severe health consequences they can produce, inhalant abuse is a serious problem. Just a single session of repeated inhalations can cause permanent organ damage or death. Go to for the SAMHSA Spotlight Study, Adults Represent Majority of Inhalant Treatment Admissions. Wisconsin from page 1 cation treatments Suboxone and Vivitrol have placed the organization at the cutting edge of clinical advances, Fuchs believes. I ask, Are we committed to the latest and greatest tools for recovery? Fuchs said. I continue to preach that if all we have is a hammer, everything looks like a nail. Residential component When Fuchs arrived as director of L.E. Phillips-Libertas in early 2007, the facility was offering adult and adolescent inpatient treatment and adult outpatient treatment. It had become exceedingly difficult to meet medical necessity criteria for adolescent inpatient services, so that operation had to be shuttered. Shortly after that, L.E. Phillips-Libertas decided to develop a residential treatment component, which would open in August While Medicaid and Medicare cover the majority of the center s medically managed inpatient services, leaders realized they would have to receive at least some private insurance support, along with county government dollars, for the 28-day residential component. Most treatment centers, particularly hospital-based centers, felt long ago that insurance wasn t going L.E. Phillips-Libertas Treatment Center Location: On campus of St. Joseph s Hospital in Chippewa Falls, Wisconsin Established: 1977 Inpatient Beds: 46 Average Lengths of Stay: 3.9 to 4.2 days in detox/medical management; 21 days in residential program Payer Mix: Primarily Medicaid/ Medicare for inpatient; 70 to 75 percent private insurance for residential to pay for a 28-day residential program. That s not true, Fuchs said. What L.E. Phillips-Libertas ultimately found was somewhat startling. It created a residential component with conservative spending and estimates, and still expected that county dollars would finance the majority of the services. Instead, nearly three-quarters of reimbursement in the residential program now comes from private insurers. Mindful that other nearby facilities report struggling to gain private insurance reimbursement for residential treatment, Fuchs credits the efforts of staff members who he says are passionate about working with insurance companies. We do an excellent job of utilization review, Fuchs said. When we call to verify rates, we know what we are asking for. He explained that the center has 3.5 full-time equivalent positions in its front-office staff devoted to payment-related issues, with one full-time utilization review specialist and some backup staffing for that person as well. Fuchs said that about 85 percent of the center s residential admissions come from L.E. Phillips-Libertas s own inpatient detox services. But he s seeing a growing trend toward more residential admissions to his site from detox programs elsewhere in the state. He believes that overall, residential services for his organization will continue to grow. This is part of an array of services that we need to do, he said. At present, Fuchs appears more concerned about the long-term health of Medicaid-supported services than he is about the residential program. He has been closely watching the well-chronicled heated exchanges between Wisconsin Gov. Scott Walker and state workers and their union representatives, and he believes impending budget cuts in the state will result in a chilling effect on Medicaid, with increased cost-sharing requirements for beneficiaries. Medication solutions The second transition that has Continues on next page A Wiley Periodicals, Inc. publication. View this newsletter online at wileyonlinelibrary.com

8 8 Alcoholism & Drug Abuse Weekly March 21, 2011 Continued from previous page significantly altered treatment at L.E. Phillips-Libertas involves a full integration of buprenorphine (Suboxone) treatment for opiate addiction and of the extended-release formulation of naltrexone (Vivitrol) for alcohol dependence and now for opiate addiction as well. Both of the main physicians serving the addiction treatment operation are registered to prescribe Suboxone. In both cases, the physicians had been prescribing the medication in office-based settings but found that effort unsustainable because of compliance problems with many outpatient clients, Fuchs said. These physicians won t prescribe Suboxone unless someone is actively engaged in a treatment program, Fuchs said. He said L.E. Phillips-Libertas patients generally will stay on Suboxone for about three to four months, but the program seeks after that to transition them off the maintenance medication with Vivitrol now serving as a viable alternative as it is now federally approved for opiate addiction treatment. Fuchs characterizes longer-term use of Suboxone as one foot in addiction, one foot in recovery, adding, Our job is to increase the client s real estate in recovery. L.E. Phillips-Libertas has found excellent results with the monthly injection Vivitrol, said Fuchs so much so that he said the center has fast become one of the highest-volume users of the medication. Two advantages the center has had are having physicians who are committed to engaging patients in medication treatment and being located in a state where Vivitrol enjoys comparatively broad coverage in insurance plans, including under Medicaid. Fuchs said the transition to medication treatments probably represented a bigger challenge to staff at the outset than the addition of residential treatment, but both are now integral components of the hospital-based program s services. Coming up The National Association of Addiction Treatment Providers (NAATP) will hold its annual meeting May in Chandler, Arizona. Go to for more information. The annual meeting of the National Association of State Alcohol and Drug Abuse Directors will be held June 7-10 in Indianapolis. For more information, go to Along the way, the center has been able to achieve buy-in from the hospital interests overseeing the entire St. Joseph s operation. You need to be able to engage administrators in these models of recovery, Fuchs said. Distributing print or PDF copies of Alcoholism & Drug Abuse Weekly is a copyright violation. If you need additional copies, please contact Sandy Quade at or Obituary In case you haven t heard It is with sadness that we learned of the death of G. Alan Marlatt, Ph.D., last week. Marlatt, who died of cancer March 14, said that zero tolerance rules, including the banning of underage drinking, can contribute to alcohol-related problems by forcing the problem underground and discouraging people from calling for help. Alan was one of my heroes, John De Miranda, CEO of Stepping Stones of San Diego. In my teaching and training I probably quoted him and his work more than anyone else, he told ADAW. Alan was unique because he was truly independent in his thinking. Because he was also an excellent researcher he could also demonstrate the empirical value of teaching young drinkers what they need to know to be safer. He wasn t worried about how this flew in the face of conventional government dogma. He only wanted to find an approach that reduced harm. Asked who will replace him in the research world, De Miranda said I know of no one who could even come close to filling his shoes - he was sui generis. And David J. Hanson, Ph.D., who hosts a website called Alcohol Problems and Solutions, said that Marlatt brought the concept and practice of harm reduction to North America. The field of alcohol studies has lost one of its pioneering leaders. Originally, there were 10, and now there are 8 and not always the same 8. We are referring to SAMHSA s Strategic Initiatives. The first iteration listed Prevention, Trauma and Justice, Military Families, Health Reform, Housing and Homelessness, Jobs and Economy, Health Information Technology, Behavioral Health Workforce, Data/Outcomes/Quality, and Public Awareness/Support (see ADAW, June 14, 2010). Then there were 8: Jobs/Economy and Workforce were removed (see ADAW, October 11, 2010). Then in the Feb. 15 draft, there were still 8 (see ADAW, March 14), but Housing and Homelessness was gone, and in its place is Recovery Support. This was a victory for the recovery movement, but raises questions about SAMHSA s commitment to what many consider the most difficult challenges for any agency these days: Jobs and Economy, Housing and Homelessness, and especially for the addiction treatment field Workforce. A Wiley Periodicals, Inc. publication. View this newsletter online at wileyonlinelibrary.com

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