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 Studiesgoplerud-eric@norc.org301-634-9525

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 DevelopmentNAADAC, 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 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.

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 -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 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

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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!

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www.norc.org hospitalsbirt.webs.com www.ireta.org/ATTC