1. Integration of SUD services Lessons Learned from around the World
with Primary Care
Lessons Learned from around the World
Darren Urada, Ph.D.
UCLA Integrated Substance Abuse Programs
CADPAAC / ADP Quarterly Meeting
Integration Learning Collaborative
May 29, 2013

2. California Department of Alcohol and Drug Programs
Acknowledgements
UCLA team: Jeff Annon, Valerie Antonini, MPH, Desiree Crevecoeur-MacPhail, Ph.D., Thomas Freese, Ph.D., Sherry Larkins, Ph.D., Brandy Oeser, MPH, Howard Padwa, Ph.D., Diego Ramirez, Beth Rutkowski, MPH, Cheryl Teruya, Ph.D., Elise Tran, Richard Rawson, Ph.D.
Research funded by:
California Department of Alcohol and Drug Programs
Kern County
The authors’ views and recommendations do not necessarily represent those of the funders, UCLA, or the UCLA Integrated Substance Abuse Programs.

3. Topics to be covered Financing / Workforce Chronic Pain
Performance – lessons from Britain
“Hot-spotting”
Coming to an exchange near you…
Mention Suzanne’s natl council, NA, etc. Goal is more to talk about what other professions are doing, thinking about SUD

4. Financing / Workforce
With ACOs, currently non-billable BH staff like SUD counselors will essentially be “billable” if the team is credentialed. Rules still in progress and will vary from state to state.
There are 150 “pioneer” medicare ACOs right now, and CMS is awaiting data from them. At first look, not finding huge cost savings.
Source: Capobioanco & Kenerson (National Council), 2013

5. Financing / Workforce
FQHC/BH partnership example: BH center was seeing lots of people very briefly for meds only and were getting paid $17-$34 because billing was based on time.
In FQHCs, the National encounter rate avg is: $143/encounter. 
BH center and FQHC partnered, moved the med-only BH patients over to the FQHC.  Partnership brings in more $$.
Source: Reynolds, 2013

6. Financing / Workforce
FQHCs can contract with BH and still have enough left over to pay their own expenses.
The “sell”: Doctor wants to hand off the crying patient to BH rather than that patient taking up all of the doctor’s time. For bottom line, FQHCs need to see as many pts as possible.
With BH, Doctor hands off, moves to the next patient, but the crying patient still gets quality care.
Partner.“If you’re not at the table, you’re on the table.”
Source: Reynolds, 2013

7. Workforce
In Nebraska, licensed mental health practitioners can bill at FQHCs. This includes social workers, MFTs, and COUNSELORS.
Source: Capobioanco & Kenerson, 2013

8. Financing/Workforce Next steps Rosenberg, Gauthier on financing.
CATES meetings (finance)
SARC Meeting, September 11, 2013 (workforce).

9. CATES follow up Webinars
Topic
Date
Integrating Services with Primary Care
June 19
Marketing
June 26
Contract Negotiations
July 2
Financing Strategies
July 10
Developing Payer Relations
July 17
July 18
July 23
July 31
August 7
August 14

10. Chronic Pain & Prescription Drugs

11. Source: Fishman (2013)

12. Suggestions for Reframing the
Goals of Treatment
Function is primary
Happiness is important
Goal of complete analgesia is unrealistic
In fact, pain relief is not high on the list at all
“You’re taking all the pain meds known to man, and
are still in pain with miserable side effects. We can’t possibly do worse. Let’s try something different.”
Not helpful to use the term “addiction”
Source: Fishman (2013)

13. Source: Fishman (2013)

14. Source: Fishman (2013)

15. Source: Fishman (2013)

16. Lessons from Britain

17. Listen to people who use our services
‘In Your Shoes’ sessions for staff to listen to experiences of service users and their carers
Feedback cards – simple postcard sized feedback from service users and carers
Observations of care – by staff or carers
Source: Ardley, 2013

18. Feedback from Patients
Source: Ardley, 2013

19. Source: Ardley, 2013

20. Source: Ardley, 2013

21. Performance Source: Ardley, 2013
Net promoter score. Required across National Health Service. 
Source: Ardley, 2013

22. Performance
"Net Promoter Score (NPS") - Those scoring services with 9 or 10 are promoters, those scoring 0-6 are detractors and those between 7-8 are passively satisfied or neutral. The NPS is the difference between the percentage of users who would recommend your services minus the percentage of those who would not.
75% or above is considered quite high.
If scores go down, a regulator comes in. If scores are good, they’re left alone.

23. Source: http://www.nta.nhs.uk/
On April the National Treatment Agency for Substance Misuse (NTA) becamse part of Public Health England, part of the Dept of Health.
Source:

24. “Hot Spotting”

25. “Hot Spotting”
Hotspots.  Identify high cost users. Who are they, where are they? Looked at home addresses of patients from 5 years of data.  Costs are highly concentrated geographically.
Source: Jeffrey Brenner, M.D.

26. Source:
Brenner, 2013
Northgate: Low income housing highrise. Abgail House: nursing, rehabilitation.
Could we do this with SUD clients? What would we find? Would we be able to target both treatment outreach and prevention better?

27. One patient, two hospitals running the same tests.
Insurers, docs, pts all complain about each other. It’s the system.
Source: Brenner, 2013

28. Atul Gawande: Video about treating the needs of a high-cost patient
Atul Gawande: Video about treating the needs of a high-cost patient. See: 1hr 13min -1hr 17 min mark.
Source: Gawande, 2013

29. “Hot Spotting”
Why do hospitals like hot spotting?  Doesn’t identifying, addressing high-cost patients take away revenue? 
“You’re going to go off the cliff in the next 5-10 yrs.  How will you succeed in the ACO world?”
“We can influence doctors the most by getting patients to stop driving them crazy.” High cost patients are not always good for their processes.

30. Camden, NJ Source: Brenner, 2013
Insight: Most ER visits are actually insured and are for head colds.  More money if docs run from room to room treating head colds for a few minutes each than by treating one sick person. Might get paid more for the sick person, but it’s a money loser because of the time spent.  Better ft get back to the head colds.
Source: Brenner, 2013

31. Exchanges

32. Exchanges 8 regional exchanges, with different plans.
Outreach - $200 million for marketing, outreach, promotion. More from foundations.
See: Coveredca.com
Source: Peter Lee, Director, Covered California.
Insure the Uninsured Project (ITUP) conference, 2/5/2013

33. Will people buy insurance?
Penalties for not doing so:
2014: $95 per adult or 1.0% of (income minus 10k indiv/20k family), whichever is greater
2015: $325 or 2%
2016 $695 or 2.5%
Confused?  Here’s a penalty calculator:

34. Final Note
“It is important to remember that January 1, 2014 is an important day, but it is just one day; it will be tough day, month and year.”
Source: Alan Weil, Executive Director, National Academy for State Health Policy. Feb 5, 2013, ITUP Conference

35. References
Ardley, J. (2013). Perspectives from Great Britain: Creating the customer focused culture. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 9, Powerpoint available at:
Brenner, J. (2013). “Hot Spotting” - Ideas for psychiatrists working with high utilizers of health care. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 9, Powerpoint available at:
Capobianco, J., & Kennerson, J. (2013). Building the integrated healthcare workforce of the future. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 7, (no powerpoint available)
Fishman, M. (2013). Chronic Pain and Prescription Drug
Abuse: Intertwined Epidemics. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 8, Powerpoint available at:

36. References
Gawande, A. (2013). Better: Lowering Costs and Improving Health Care. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 9, Video available at:
Reynolds, K. (2013). Show Me the Money! Designing a Sustainable Financing Model for Integration. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 8, Powerpoint available at:
Richardson, J. (2013). Show Me the Money! Designing a Sustainable Integration Financing Model. Presentation at the National Council for Community Behavioral Health Conference, Las Vegas, NV. April 8, Powerpoint available at:

37. CONTACT
Darren Urada, Ph.D.
UCLA Integrated Substance Abuse Programs