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 President

Director, Substance Abuse, Mental Health and Criminal Justice Studies

goplerud-eric@norc.org

301-634-9525

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 Development

NAADAC, the Association for Addiction Professionals

misti@naadac.org

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 MentalHealth

Inpatient 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

02.3

-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 = 25

Metric 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.

Hotspot 4: Ambulatory Primary Care SBIRT

42

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 -Other

Depot NTX 69 93 234

Oral NTX 84 145 387

Bupe 79 249 397

Meth 101 198 561

Drug-free 770 677 731

50

150

250

350

450

550

650

750

850

Admissions in 6 months post index dateA

dm

iss

ion

s/1

00

0 p

ati

en

ts

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 -Other

Depot NTX 216 213 2003

Oral NTX 193 137 3428

Bupe 219 440 2290

Meth 264 457 7976

Drug-free 2082 1823 4184

500

1500

2500

3500

4500

5500

6500

7500

8500

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.

1000

3000

5000

7000

9000

11000

13000

15000

17000

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 Inpa-tient

Depot NTX 42 82 109

Oral NTX 76 184 205

Disulfiram 98 268 250

Acamprosate 120 317 343

Drug-free 563 660 407

50

150

250

350

450

550

650

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-re-lated Inpatient

Total Inpatient

Depot NTX 105 474 730 1309

Oral NTX 192 618 1092 1902

Disulfiram 203 874 1498 2575

Acamprosate 288 1168 3885 5341

Drug-free 1350 2646 2751 6747

500

1500

2500

3500

4500

5500

6500

7500

6 Month Post-index Inpatient Cost/Alcohol-Dependent Pa-tient

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.

$1,000

$3,000

$5,000

$7,000

$9,000

$11,000

$13,000

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 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

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 Email

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