Substance Use Disorder Treatment in Los Angeles: The Past, Present, and Future Michael Ballue, CADC II, BSBA Chief Strategy Officer Behavioral Health Services Gary Tsai, MD Medical Director & Science Officer County of Los Angeles, Dept of Public Health Substance Abuse Prevention and Control
Some History of SUD Treatment in CA Types 12-step based Therapeutic Community Long Term Residential Medical Model Narcotic Treatment Program Evidence Based Models Faith based Hybrids DUI
SUD History in CA- Challenges Impediments and challenges Often treatment not individualized Silo d Lack of effective advocacy Stigma Low reimbursement Little funding in relation to prevalence and cost Workforce issues age, pay, certification/licensure Lack of Integration
SUD History in CA- Challenges (cont.) Little medication assistance available Life experience at one time considered enough to be an SUD counselor Medication often considered a bad thing period Concept of hitting bottom Rx over prescription and use Marijuana Policy Level of attention from Primary Care Wait lists Lack of full continuum of care availability
SUD History- Bright Spots Robust 12 -step based support available Meetings Clubs Social activities Conventions Significant progress made in some areas Stigma reduction Medication acceptance Evidence based practices
SUD Treatment in Los Angeles: Current 6
Illicit Drug Use in LA County 15.4% of individuals over 12 years of age in LA County (LAC) have used illicit drugs in the past year 1 1.2 million people Prevalence of illicit drug use (%) Age Group 12 or older 12-17 18-25 18 or older 26 or older United States* 9.3 9.2 21.4 9.3 7.2 California* 11.2 9.8 24.1 11.3 8.9 Los Angeles County** 15.4 * NSDUH 2013 estimates of illicit drug use in the past month ** NSDUH 2005-2010 annual average estimates of illicit drug use in the past year 7 1. Substance Use and Mental Disorders in the Los Angeles-Long Beach-Santa Ana MSA. Center for Behavioral Health Statistics and Quality Substance Abuse and Mental Health Services Administration, Rockville, MD. 2013.
California Penetration Rates Penetration rate = # of people who RECEIVED necessary service / total # of people who NEED service Medi-Cal penetration rates, according to the 2012 California Mental Health and Substance Use System Needs Assessment 1 Severe mental illness 22% Substance abuse 4% 8 8 1. California Mental Health and Substance Use System Needs Assessment, 2012. http://www.dhcs.ca.gov/provgovpart/documents/1115%20waiver%20behavioral%20health%20services%20needs%20assessment%203%201%2012.pdf 8
Consequences of Unaddressed SUDs National costs related to crime, lost of productivity, and healthcare as a result of substance use amounts to ~$600 billion annually. 1 Individuals with substance use disorders incur 2-3 times the total medical expenses of people who do not have a SUD. 2 Nearly one-third (32.3%) of all hospital inpatient costs are attributable to substance abuse. 3 1. National Institute on Drug Abuse. Trends & Statistics Retrieved from http://www.drugabuse.gov/related-topics/trendsstatistics. 2. Thomas, Marshall R., et al. Prevalence of psychiatric disorders and costs of care among adult enrollees in a Medicaid HMO. Psychiatric Services 56.11 (2005): 1394-1401. 3. National Center on Addiction and Substance Abuse (CASA) at Columbia University. Addiction Medicine: Closing the Gap Between Science and Practice. 2012. 9
Community Impact > 70 medical conditions requiring hospitalization are attributable to substance use: Cancer, Respiratory disease, Cardiovascular disease, HIV/AIDS, Pregnancy complications, Cirrhosis, Ulcers, Trauma, etc. 1 Individuals with SUD alone died at an average age of 50.5 years 26.1 years younger than the general population. 2 10 1. National Center on Addiction and Substance Abuse (CASA) at Columbia University. The Cost of Substance Abuse to America s Health Care System, Report 1: Medicaid Hospital Costs. 1993. 2. Oregon Department of Human Services. Addiction and Mental Health Division. Measuring Premature Mortality among Oregonians. 2008.
Annual Direct & Indirect Costs of SUD in LA County Cost Category Alcohol Illicit Drugs Total % of Total % of State Total Medical $ 2.2 Billion $ 954 Million $ 3 Billion 7.8% 7.1% Wage Work $ 4.3 Billion $ 1.1 Billion $ 5.4 Billion 13.7% 13.1% Household Work Public Services Property Damage $ 1.6 Billion $ 360 Million $ 1.9 Billion 5.0% 5.0% $ 331 Million $ 857 Million $ 1.2 Billion 3.0% 2.7% $ 497 Million $ 107 Million $ 604 Million 1.5% 1.3% Misc. Motor Vehicle Subtotal: Tangible Costs $ 499 Million $ 20 Million $ 520 Million 1.3% 1.2% $ 9.5 Billion $ 3.4 Billion $13 Billion 32.3% 30.5% Quality of Life $ 21.2 Billion $ 5.8 Billion $ 27 Billion 67.7% 69.6% Total $ 31 Billion $ 9.2 Billion $ 40 Billion 100% 100% 11 Fact sheet prepared by Ted R. Miller (2012). Total Direct and Indirect Costs of SUD in LAC. Pacific Institute for Research and Evaluation.
Los Angeles County: Spending by System of Care $4 Billion $2 Billion $260 Million Dept of Health Services (DHS) Dept of Mental Health (DMH) Substance Abuse Prevention & Control (DPH-SAPC) 12
Three-Legged Stool of Integrated Care Effective care integration and coordination requires strong systems of care across all aspects of health Integrated & Coordinated Care Physical Health Substance Abuse Mental Health 13
Link Between Integration and Parity A truly integrated health system will only be as effective as its weakest link the SUD system of care has historically been an area of necessary improvement. 14
Current SUD Services in LA County General Medi-Cal Voluntary Inpatient Detoxification (only through general acute hospitals with TAR) Medication-Assisted Treatments (MAT, aka: addiction medications; long-acting naltrexone & acamprosate) Drug Medi-Cal (DMC) Outpatient Intensive Outpatient Residential (perinatal only) Opioid Treatment Programs (e.g., Methadone, etc) MAT (buprenorphine, methadone, oral naltrexone, disulfiram) Other County-Contracted Services Residential Withdrawal management (detox) ** DMC waiver would expand the services offered through DMC: - Residential (all cases, including non-perinatal) - Withdrawal management - Case management - Recovery support services 15
Current SUD Referral Process Substance Abuse Prevention and Control (SAPC) - Responsible for oversight Health Providers (HP) - HP responsible for SUD screening, brief intervention, and referral SUD System of Care Community Assessment Service Centers (CASCs) - Responsible for initial triaging and referral to SUD provider - 19 sites in all SPAs - (800) 564-6600 SUD Providers - Responsible for delivery of SUD services - Over 300 sites in all SPAs Self-Referrals * No wrong door approach Communication & care coordination 16
SUD Treatment in Los Angeles: the Future There is no illness that will be more favorably affected by the Affordable Care Act than substance abuse, Thomas McClellan, former Deputy Director of the Office of National Drug Control Policy 17
Opportunities to Transform the SUD System Growing recognition of the need to reform 42 CFR Health Care Reform Parity Chronic disease model of addiction SUD System of Care Drug Medi-Cal (DMC) Waiver Focus on Quality Care Growing recognition of the medical, mental health, and financial impact of untreated SUDs Biopsychosocial approach to treatment 18
Drug Medi-Cal Waiver: Foundational Elements Key goal Provide the right services, at the right time, in the right setting, for the right duration Improve access to services No wrong door approach Quality Improvement program Utilization Management program Provision of services more consistent with chronic disease model Case management Recovery support services 19
Drug Medi-Cal Waiver: Foundational Elements (cont d) Expands DMC funding to support a fuller continuum of care for SUD services, including withdrawal management. 20
Drug Medi-Cal Waiver: Foundational Elements (cont d) Biopsychosocial approach to care Emphasis on expanding the availability of biomedical treatments, such as Medication-Assisted Treatments (e.g.: Methadone, Buprenorphine, Naltrexone, etc.), in order to complement psychosocial interventions Biomedical Social Health Psychological 21
Drug Medi-Cal Waiver: Foundational Elements (cont d) The ASAM (American Society of Addiction Medicine) Criteria Based on Medical Necessity Follows a chronic disease management model for SUD care ASAM Criteria relies on 6 dimensions to comprehensively determine appropriate levels of care: Acute Intoxication and/or Withdrawal Biomedical Conditions & Complications Emotional, Behavioral, or Cognitive Conditions & Complications Readiness to Change Relapse, Continued Use, or Continued Problem Potential Recovery/Living Environment 22
Drug Medi-Cal Waiver: Foundational Elements (cont d) The DMC waiver provides supports the professionalization of the SUD workforce Generally speaking, the current SUD workforce is underpaid, understaffed, and undereducated 1. Professionalizing the SUD workforce will be critical in redesigning and upgrading the system of care for the treatment of addictions. Future SUD workforce will need to more closely reflect the multidisciplinary workforce currently employed by mental health systems (psychiatrists, nurses, therapists and psychologists, social workers, peer support workers, etc). 23 1. Padwa, H, Oeser, B, UCLA Integrated Substance Abuse Programs. White Paper on California Substance Use Disorder Treatment Workforce Development., 2013. http://caade.org/sites/default/files/ucla_workforce%20development%20white%20paper_final.pdf
Raising the Bar for the SUD System The Drug Medi-Cal waiver is an unprecedented opportunity to significantly transform the SUD system of care and elevate quality and efficiencies. End result SUD system should be better positioned for effective care integration. 24
Health Information Exchange Effective care integration between physical health, mental health, and SUD will require effective health information exchange. Longer-term goal Updating 42 CFR. Shorter-term goal Increased collaboration between systems (Counties, health plans etc.) to adopt standardized universal consent forms to allow for care coordination within the privacy confines of HIPAA & 42 CFR. 25
Summary Addiction is a major driver of poor health outcomes and effectively addressing SUDs and integrating care will be key to controlling health costs. SUD treatment in California has often been underfunded, marginalized, and misunderstood. The system of care for those suffering from SUD s has been in large part insufficient to meet demand, and generally not cohesive or integrated. Changes in health care policy, in particular the Drug Medi-Cal Organized Delivery System waiver, are allowing for an opportunity to transform addiction care in LA County into a more accessible & organized system of care, with a full continuum that is clientcentered and based on clinical needs. This transformation will be complex, difficult and require resources, attention, and recognition not previously afforded to the SUD field. 26
Thank you! Michael Ballue, CADC II, BSBA mballue@bhs-inc.org Gary Tsai, MD gtsai@ph.lacounty.gov 27