1. HOW TO PITCH SBIRT TO PAYORS PRESENTED BY: THE BIG INITIATIVE, NATIONAL SBIRT ATTC, NORC, and NAADAC May 8, 2014

2. HOW TO PITCH SBIRT TO PAYORS PRESENTED BY: THE BIG INITIATIVE, NATIONAL SBIRT ATTC, NORC, and NAADAC May 8, 2014

3. Webinar Facilitator and Presenter Eric Goplerud Senior Vice President Director, Substance Abuse, Mental Health and Criminal Justice Studies goplerud-eric@norc.org 301-634-9525

4. Produced in Partnership…

5. 2014 SBIRT Webinar Series  Archived - ACA and Addiction Treatment: Implications, Policy and Practice Issues  Archived - Overview of SBIRT: A Nursing Response to the Full Spectrum of Substance Use  Archived - SBIRT in the Criminal Justice System  Archived - Reducing Opioid Risk with SBIRT  Today – How to Pitch SBIRT to Payors  5/14/14 - Treatment of Tobacco Dependence in the Healthcare Setting: Current Best Practices  6/11/14 - Applying SBIRT to Depression, Prescription Medication Abuse, Tobacco Use, Trauma & Other Concerns  7/9/14 - Training Integrated Behavioral Health in Social Work  8/6/14 - Why Integrative Care?  hospitalsbirt.webs.com/webinars.htm

6. Access Materials  PowerPoint Slides  CE Quiz  Recording hospitalsbirt.webs.com/pitchingsbirt.htm

7. Ask Questions Ask questions through the “Questions” Pane Will be answered live at the end

8. Technical Facilitator Misti Storie, MS, NCC Director of Training & Professional Development NAADAC, the Association for Addiction Professionals misti@naadac.org

9. HOW TO PITCH SBIRT TO PAYORS

10. Footer Information Here 10 Alcohol as a cause or contributor to more than 70 diseases and injuries Under 35 YrsUnder 35 Yrs Over35 yrsOver35 yrs

11. Top 10 Leading Causes of Death in the United States for 2005 (CDC)

12. 12 Estimated Percentage of Adolescents and Adults with a Substance Use Disorder (primarily alcohol use disorders) Recent estimates suggest that almost 8% of the US adults has a diagnosable substance use disorder (NSDUH, 2011) 92% 8%

13. 13 How Many Get Identified? <0.8% of commercial health plan members, 1.2% Medicaid plan members are diagnosed (NCQA, 2010)

14. Substance use screening and treatment in health care: Adding burdens or solving problems 14 : Guwande’s Handwashing and Anaesthetics

15. Where are the patients? Settings where Unhealthy or Dependent Use is common

16. 16 Hotspot 1: Hospitals

17. Cochrane Collaboration review (McQueen et al, 2011) 14 RCTs, adults and adolescents Outcomes favor BI over non-treatment controls Significant drop in 6 month alcohol consumption Significant drop in alcohol consumption at 9 months Self Report at 1 year favor BI Significantly fewer deaths at 6 months and 1 year 17 Screening and Treating Acutely Ill and Injured Patients with Comorbid Substance Use

18. 18 Alcohol Disease Management Utilization and Costs to a Health Insurance Plan Rehabilitation facilities days decreased67% BH inpatient days decreased68% Medical inpatient days decreased 4% ER visits decreased 24% Partial Hospital and IOP visits decreased69% Psychiatrist visits increased 44% Therapist visits increased 35% AUDIT score decrease80% Net total medical cost savings (ROI 2:1)34% (N = 358, 12 month continuous enrollment prior and post enrollment) Trauma Centers: 60% injured have substance use disorders

19. Trauma Recidivism - Statewide injury recurrence days follow-up

20. Changes in Alcohol Intake 6 month follow-up12 month follow-up (p = 0.01)

21. Net cost savings -- $89/patient screened, or $330/patient offered a brief intervention Savings of $3.81/$1 spent Potential savings if universal trauma center SBI -- $1.82 billion annually (2000 $)

22. 9 NNT to reduce 1 DUI arrest ~2000 DUI incidents/arrestee

23. Screening and Brief Interventions in Hospital Emergency Departments Systematic review of ED SBI 12 RCTs with pre- and post-BI results 11 or 12 observed significant effects on alcohol intake, risky drinking practices, alcohol related negative consequences, injury frequency Nilsen et al, J Sub Ab Treat. 2008

24. 24 Consequences that matter to hospitals Unstable discharges, rehospitalization risk

25. American College of Surgeons-Committee on Trauma Accreditation Requirements Joint Commission SBIRT Metrics 25 Hospital Accreditation and Performance Metrics CMS Inpatient Psych Incentive 2014 SUB-1

26. Falmouth Hospital (MA) Denver General Hospital (CO) Gunderson Lutheran Hospital (WI) Oregon Health Sciences University (OR) Christiana Hospital (DE) Salina Regional Hospital (KS) Temple University Hospital (PA) 26 Practical Examples of Hospital SBIRT

27. Collaborations between Substance Use Programs and Hospitals: Gosnold-Falmouth Hospital  100 Bed Med-Surg Hospital; 50 Bed Addiction Treatment Center  Courteous but Distant Neighbors since 1982  Mutually Necessary but not Collaborative  Gosnold “a place to send ‘those’ people” SO WHAT CHANGED???

28. ICU Transfers -- Pre & Post Project Cost per day Med-Surg Floor vs. ICU 30%-40% LOWER IN MED-SURG PREPOST

29. Average Length of Stay Before Collaboration 14.6 Days After Collaboration 6.2 Days

30. Project Engage at Christiana (DE) Hospital Targeting hospitalized substance users at withdrawal risk, significant comorbid addiction Bedside Peer-to-Peer intervention using Motivational Interviewing Addictions Community Social Worker to assist in removing barriers to transition to care and help with integration into the hospital milieu

31. Preliminary Claims Analysis Modified from Wright, Delaware Physicians Care Inc, 2010 Claims from June 1, 2009 - November 30, 2009 3 months before and after claims review, n = 18 MetricPrePostFinding Medical inpatient admits 128 33% decrease $35,938 ER visits5433 38% decrease $4,248 BH/SA inpatient admits710 43% increase ($1,579) BH/SA outpatient visits1216 33% increase ($847) PCP office visits2751 88% increase ($1,281) Total Savings = $36,479

32. Claims From Next 2 Cohorts Modified from Wright, Delaware Physicians Care Inc, 2010 Claims from January 1, 2010 - December 30, 2010 6 months before and after claims review, n = 25 MetricPrePostFinding Medical inpatient admits17758% decrease : $68,422 saved ER visits13311612.7% decrease : $3,308 saved Total Savings = $71,730 Claims from January 1, 2011 - December 30, 2011 6 months before and after claims review, n = 30 MetricPrePostFinding Medical inpatient admits4222 48% decrease : $184,236 saved ER visits1531511% decrease : $8,690 saved Total Savings = $192,926

33. Salina Regional Health Center Outcomes 199 Bed Acute Care Regional Health Center-Level III Trauma Center 27,000 ED presentations per year Alcohol/Drug DRG was 2 nd most frequent re-admission Services provided 24-7 coverage of ED Full time SUD staff on medical and surgical floors Warm hand off provided to all SUD/MH services Universal Screening and SBI beginning in 2013 Re-admission DRG moved from 2 nd to 13th 70% of alcohol/drug withdrawal LOS were 3 days or less 83% of SUD patients triaged in ED were not admitted 58% of patients recommended for further intervention attended first two appointments (warm hand off) Adverse patient and staff incidents decreased by 60%. CKF detox admissions increased 450% in first year 300% increase in commercial insurance reimbursement

34. Hotspot 2: Prenatal Screening and Case Management 34

35. Kaiser-Permanente Northern California’s Early Start: A transformational program that is cost beneficial Universal Screening of ALL pregnant women Screening questionnaire Urine toxicology (with consent) Place a licensed mental health provider in the department of OB/GYN Link the Early Start appointments with routine prenatal care appointments Educate all women and providers

36. Rate of Preterm Delivery (<37 Weeks) Note: The rate of Preterm Delivery is 2.1 times higher in S group than SAF (Early Start patients)

37. RATE OF NEONATAL ASSISTED VENTILATION The rate of the babies needing a ventilator is 2.2 times higher in the S group that the SAF and 3.1 times higher than the controls.

38. RATE OF INTRAUTERINE FETAL DEMISE (stillborn) Stillborns (IUFDs) were 14.2 times more likely in the S group than the SAF or C groups

39. Maternal and Infant Mean Costs Comparison Positive Screen, No SA Treatment

40. Hotspot 3: Youth and Young Adult High Risk Users 40

41. Teen and Young Adult School Health and Ambulatory Health SUD Treatment Data were pooled from 16,915 adolescents from 148 local CSAT-funded programs and followed quarterly for 6 to 12 months In 2009 dollars, adolescents averaged $3,908 in costs to taxpayers in the 90 days before intake ($15,633 in the year before intake). This would be $3.9 Million per 1,000 adolescents served. Within 12 months, the cost of treatment was offset by reductions in other costs producing a net benefit to taxpayers of $4,592 per adolescent.

42. Hotspot 4: Ambulatory Primary Care SBIRT 42

43. StudyCost SavingsReference Randomized trial of primary care brief treatment in the UK Reductions in one-year healthcare costs $2.30 cost savings for each $1.00 spent in intervention UKATT, 2005 Project TREAT randomized clinical trial: Screening, brief counseling in 64 primary care clinics Reductions in future healthcare costs $4.30 cost savings for each $1.00 spent in intervention (48-month follow-up) Fleming et al, 2003) Randomized control trial of SBI in a Level I trauma center Reductions in medical costs $3.81 cost savings for each $1.00 spent in intervention. Gentilello et al, 2005 Propensity matched Medicaid disabled adults in Washington State Emergency Departments, Reductions in Medicaid costs $336 per member per month post SBI for all patients $542/member/month if no prior SA tx Estee et al, 2010 Screening and Brief Substance Use Treatment Reduces Healthcare Costs

44. Impact of SBI on Utilization in an Employment-Based Health Plan BH inpatient days decreased63% Medical inpatient days decreased 51% ER visits decreased 20% Partial Hospital and IOP visits increased81% Psychiatrist visits increased 31% Therapist visits increased 22% Net total medical cost savings15% (N = 247, 12 month continuous enrollment prior and post SBI)

45. Hotspot 5: Treatment of SUDs with Medications 45

46. Baser O, Chalk M, Fielin DA, Gastfriend DR. Cost and utilization outcomes of opioid-dependence treatments. Am J Managed Care, 2011:17(6);S235-248.

49. Comparison of Massachusetts Medicaid Treatment Alternatives: 2003-2007 BuprenorphineMethadoneDrug FreeNo Tx Medicaid expenditures/ person/month in 6 months post-index date (average $1,220/month)$0.00$28.70$50**$148.5*** Relapse Odds Ratio in 6 months post-index date1.00.72***1.25***2.97*** Deaths Odds Ratio in 6 months post-index date1.00.911.75***2.25*** Clark RE, Samnaliev M, Baxter JD, Leung GY. The evidence doesn’t justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine. Health Affairs. 2011:30(8);1425-1433.

50. Baser O, Chalk M, Fiellin DA, Gastfriend DR. Alcohol dependence treatments: comprehensive healthcare costs, utilization outcomes, and pharmacotherapy persistence. Am J Manag Care. 2011:17(8);S222-234.

53. Investing in Substance Abuse Treatment Results in a Positive Return on Investment (ROI) Substance abuse treatment has an ROI of between $1.28 to $7.26 per dollar invested. Consequently, for every treatment dollar cut in the proposed budget, the actual costs to taxpayers will increase between $1.28 and $7.26. How will this happen? Individuals needing substance abuse treatment will not disappear but instead interface with much more expensive systems such as emergency rooms and prisons. Source: Bhati et al., (2008); Ettner et al., (2006)

54. Discussion: Practical experiences talking with Payers Les Sperling Central Kansas Foundation Jim Winkler Oregon Health Sciences U Roger Kathol Cartesian Solutions

55. Citations and a website Smyth, Hoffman, Fan, Hser, Years of potential life lost among heroin addicts 33 years after treatment. Prev. Med, 2007; 44(4) 132-140. Jones, Moore, Sindelar, O’Connor, Schottenfeld, Fiellin. Cost analysis of clinic and office-based treatment of opioid dependence. Drug Alcohol Depend. 2009;99(1-3): 132-140 Knudsen HK, Abraham AJ. Perceptions of state policy environment and adoption of medications in treatment of substance use disorders. Psych Services. 2012:63(1);19-25. Baser O, Chalk M, Fielin DA, Gastfriend DR. Cost and utilization outcomes of opioid-dependence treatments. Am J Managed Care, 2011:17(6);S235-248. Clark RE, Samnaliev M, Baxter JD, Leung GY. The evidence doesn’t justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine. Health Affairs. 2011:30(8);1425-1433. Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999—2008 MMWR, November 4, 2011 / 60(43);1487-1492 Baser O, Chalk M, Fiellin DA, Gastfriend DR. Alcohol dependence treatments: comprehensive healthcare costs, utilization outcomes, and pharmacotherapy persistence. Am J Manag Care. 2011:17(8);S222-234. Bhati et al (2008) To Treat or Not To Treat: Evidence on the Prospects of Expanding Treatment to Drug-Involved Offenders. Washington, DC: Urban Institute. Health Serve Res. 2006 February; 41(1): 192–213. Susan L Ettner, David Huang, Elizabeth Evans, Danielle Rose Ash, Mary Hardy, Mickel Jourabchi, and Yih-Ing Hser The economic costs of substance abuse treatment: Updated estimates and cost bands for program assessment and reimbursement, Journal of Substance Abuse Treatment(2008) Information about the Hospital SBIRT Initiative is posted at http://hospitalsbirt.webs.com/. http://hospitalsbirt.webs.com/ Join in monthly conference calls on integrating SBIRT into routine hospital practice: http://hospitalsbirt.webs.com/progress.htm

56. Thank You! Eric Goplerud Senior Vice President Substance Abuse, Mental Health and Criminal Justice Studies NORC at the University of Chicago 4350 East West Highway 8th Floor, Bethesda, MD 20814 goplerud-eric@norc.org | office 301-634-9525 | mobile 301-852-8427

57. Ask Questions Ask questions through the “Questions” Pane Will be answered live at the end

58. In Our Last Few Moments…  PowerPoint Slides  Recording  Survey  Follow-up Email hospitalsbirt.webs.com/pitchingsbirt.htm

59. 2014 SBIRT Webinar Series  Archived - ACA and Addiction Treatment: Implications, Policy and Practice Issues  Archived - Overview of SBIRT: A Nursing Response to the Full Spectrum of Substance Use  Archived - SBIRT in the Criminal Justice System  Archived - Reducing Opioid Risk with SBIRT  Today – How to Pitch SBIRT to Payors  5/14/14 - Treatment of Tobacco Dependence in the Healthcare Setting: Current Best Practices  6/11/14 - Applying SBIRT to Depression, Prescription Medication Abuse, Tobacco Use, Trauma & Other Concerns  7/9/14 - Training Integrated Behavioral Health in Social Work  8/6/14 - Why Integrative Care?  hospitalsbirt.webs.com/webinars.htm

60. Thank You for Attending! www.naadac.org www.norc.orghospitalsbirt.webs.comwww.ireta.org/ATTC