may 8, 2014
DESCRIPTION
HOW TO PITCH SBIRT TO PAYORS PRESENTED BY: THE BIG INITIATIVE, NATIONAL SBIRT ATTC, NORC, and NAADAC . May 8, 2014. HOW TO PITCH SBIRT TO PAYORS PRESENTED BY: THE BIG INITIATIVE, NATIONAL SBIRT ATTC, NORC, and NAADAC . May 8, 2014. Webinar Facilitator and Presenter. Eric Goplerud - PowerPoint PPT PresentationTRANSCRIPT
HOW TO PITCH SBIRT TO PAYORS
PRESENTED BY:THE BIG INITIATIVE, NATIONAL SBIRT ATTC, NORC, and NAADAC
May 8, 2014
HOW TO PITCH SBIRT TO PAYORS
PRESENTED BY:THE BIG INITIATIVE, NATIONAL SBIRT ATTC, NORC, and NAADAC
May 8, 2014
Webinar Facilitator and Presenter
Eric Goplerud Senior Vice PresidentDirector, Substance Abuse, Mental Health and Criminal Justice [email protected]
Produced in Partnership…
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
Access Materials
PowerPoint Slides
CE Quiz Recording
hospitalsbirt.webs.com/pitchingsbirt.htm
Ask Questions
Ask questions through the “Questions” Pane
Will be answered live at the end
Technical Facilitator
Misti Storie, MS, NCCDirector of Training & Professional DevelopmentNAADAC, the Association for Addiction Professionals [email protected]
HOW TO PITCH SBIRT TO PAYORS
Footer Information Here 10
Alcohol as a cause or contributor to more than 70 diseases and injuries
Under 35 Yrs
Over
35
yrs
Top 10 Leading Causes of Death in the United States for 2005 (CDC)
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
How Many Get Identified?
<0.8% of commercial health plan members, 1.2% Medicaid plan members are diagnosed (NCQA, 2010)
Substance use screening and treatment in health care: Adding burdens or solving problems
14: Guwande’s Handwashing and Anaesthetics
Where are the patients? Settings where Unhealthy or Dependent Use is common
0%
10%
20%
30%
40%
50%Ambulatory Medical
Inpatient Medical
Emergency Dept
Outpatient MentalHealthInpatient Psychiatry
Trauma Center
16
Hotspot 1: Hospitals
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
Alcohol Disease Management Utilization and Costs to a Health Insurance Plan• Rehabilitation facilities days decreased 67%
• BH inpatient days decreased 68%
• Medical inpatient days decreased 4%
• ER visits decreased 24%
• Partial Hospital and IOP visits decreased 69%
• Psychiatrist visits increased 44%
• Therapist visits increased 35%
• AUDIT score decrease 80%
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
Trauma Recidivism - Statewide
0
0.025
0.05
0 250 500 750 1000
intervention control
injuryrecurrence
days follow-up
Changes in Alcohol Intake
0
-21.6
0 2.3
-17.9
-14.1
-25
-15
-5
5
15
25intervention control
6 month follow-up 12 month follow-up
(p = 0.01)
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 $)
9 NNT to reduce 1 DUI arrest
~2000 DUI incidents/arrestee
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
Consequences that matter to hospitalsUnstable discharges, rehospitalization risk
Crude Rates and Risks of Recurrent Acute Care Hospital Utilization Within 30 Days After Index Hospitalization
No SUDs (n = 615) SUDs(n = 123) P
Rates of reutilization Acute care reutilizations*: visits/patient/30 days 0.32 0.63 <0.01 ED visits: no. visits/patient/30 days 0.16 0.37 0.02 Rehospitalization: visits/patient/30 days 0.16 0.26 0.09
Risks of reutilization
Subjects with any acute care reutilization* in 30 days 38% 52% <0.01 Subjects with any ED visit in 30 days 23% 34% <0.01 Subjects with any rehospitalization in 30 days 23% 33% 0.02
Forsythe S, Chetty VK, Mitchell S, Jack BW. Acute care hospital utilization among medical inpatients discharged with a substance use disorder diagnosis. J Addict Med 2012;6:50-56. Rubinsky AD, Sun H, Blough D et al. AUDIT-C alcohol screening results and postoperative inpatient health care use. J Am Coll Surg 2012;213:296-305.
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
• 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
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???
ICU Transfers -- Pre & Post Project
Cost per day Med-Surg Floor vs. ICU
30%-40% LOWER IN MED-SURG
Did not go to ICU
50%
Went to ICU 50%
Did not go to ICU 90%
Went to ICU 10%
PRE POST
Average Length of Stay
0 2 4 6 8 10 12 14 16
Before Collaboration14.6 Days
After Collaboration6.2 Days
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
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
Metric Pre Post Finding
Medical inpatient admits 12 8 33% decrease
$35,938
ER visits 54 33 38% decrease $4,248
BH/SA inpatient admits 7 10 43% increase ($1,579)
BH/SA outpatient visits 12 16 33% increase ($847)
PCP office visits 27 51 88% increase ($1,281)
Total Savings = $36,479
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 = 25Metric Pre Post Finding
Medical inpatient admits 17 7 58% decrease : $68,422 saved
ER visits 133 116 12.7% 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
Metric Pre Post Finding
Medical inpatient admits 42 2248% decrease : $184,236 saved
ER visits 153 151 1% decrease : $8,690 saved
Total Savings = $192,926
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 2nd 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 2nd 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
Hotspot 2: Prenatal Screening and Case Management
34
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
Rate of Preterm Delivery (<37 Weeks)
8.1%9.7%
17.4%
6.8%
0.0%
5.0%
10.0%
15.0%
20.0%
SAF SA S Controls
Note: The rate of Preterm Delivery is 2.1 times higher in S group than SAF (Early Start patients)
RATE OF NEONATAL ASSISTED VENTILATION
3.2%
4.2%
6.9%
2.2%
0.0%
2.0%
4.0%
6.0%
8.0%
SAF SA S Controls
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.
RATE OF INTRAUTERINE FETAL DEMISE (stillborn)
Stillborns (IUFDs) were 14.2 times more likely in the S group than the SAF or C groups
Maternal and Infant Mean Costs Comparison
$0
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
SAF SA S Controls
Maternal Total Costs Infant Total Costs Maternal and Infant Costs Combined
Positive Screen, No SA Treatment
Hotspot 3: Youth and Young Adult High Risk Users
40
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.
Study Cost Savings Reference
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
Impact of SBI on Utilization in an Employment-Based Health Plan
• BH inpatient days decreased 63%
• Medical inpatient days decreased 51%
• ER visits decreased 20%
• Partial Hospital and IOP visits increased 81%
• Psychiatrist visits increased 31%
• Therapist visits increased 22%
• Net total medical cost savings 15%
(N = 247, 12 month continuous enrollment prior and post SBI)
Hotspot 5: Treatment of SUDs with Medications
45
Detox/Rehab Inpatient -Opiate Inpatient -Other0
100
200
300
400
500
600
700
800
900
Admissions in 6 months post index dateA
dmis
sion
s/10
00 p
atie
nts
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.
Detox/Rehab Inpatient -Opiate Inpatient -Other0
1000
2000
3000
4000
5000
6000
7000
8000
9000
Inpatient Costs/Opiate-Dependent Patient in 6 months post index date
Cost
/Pati
ent i
n 6
mon
ths $
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.
Series10
2000
4000
6000
8000
10000
12000
14000
16000
18000
Total Cost/Opiate Dependent Patient in 6 months post
Cost
per
pati
ent $
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.
Comparison of Massachusetts Medicaid Treatment Alternatives: 2003-2007
Buprenorphine Methadone Drug Free No 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 date 1.0 0.72*** 1.25*** 2.97***
Deaths Odds Ratio in 6 months post-index date 1.0 0.91 1.75*** 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.
Detox/Rehab Alcohol-related Inpatient Non-alcohol-related Inpatient0
100
200
300
400
500
600
700
6 Month Post-index Inpatient Utilization per 1,000 Alcohol-Dependent Patients
visi
ts/1
000
patie
nt in
6 m
onth
s
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.
Detox/Rehab Alcohol-related Inpatient Non-alcohol-related Inpatient Total Inpatient0
1000
2000
3000
4000
5000
6000
7000
8000
6 Month Post-index Inpatient Cost/Alcohol-Dependent Patient
Cost
per
pati
ent
in 6
mon
ths
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.
Series1$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
6 Months Post-index Total Cost/Alcohol Dependent Patient
Cost
per
pati
ent
in 6
mon
ths
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.
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)
Discussion: Practical experiences talking with Payers
Les Sperling Central Kansas FoundationJim Winkler Oregon Health Sciences URoger Kathol Cartesian Solutions
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/. Join in monthly conference calls on integrating SBIRT into routine hospital practice: http://hospitalsbirt.webs.com/progress.htm
Thank You!
Eric Goplerud Senior Vice PresidentSubstance Abuse, Mental Health and Criminal Justice StudiesNORC at the University of Chicago 4350 East West Highway 8th Floor, Bethesda, MD 20814 [email protected] | office 301-634-9525 | mobile 301-852-8427
Ask Questions
Ask questions through the “Questions” Pane
Will be answered live at the end
In Our Last Few Moments…
PowerPoint Slides
Recording Survey Follow-up
hospitalsbirt.webs.com/pitchingsbirt.htm
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
Thank You for Attending!
www.naadac.org
www.norc.org hospitalsbirt.webs.com www.ireta.org/ATTC