Medicaid, The ASAM Criteria and Planes and Pilots
The older I get, the more I think the greatest gift is good health. If you have health insurance, contemplate what it must be like to not have that peace of mind. Regardless of your political party leanings, before the Affordable Care Act (ACA) there were about 47 million Americans who had no health insurance nor peace of mind. The New York Times (8/12/15, A11, Pear, Subscription Publication) reported:
- The number of Americans without health insurance “continues to decline and has dropped by 15.8 million, or one-third, since 2013.”
TIME (8/12/15) reported:
- Nearly 90% of Americans now have health insurance.
- Overall, “the percentage of people in the US who were uninsured was 9.2%” during the first quarter of this year.”
I’ve always thought of Medicaid as just for poor and disabled people; and historically it has been an adjunct to state welfare programs. However “Medicaid has evolved….to the nation’s largest health insurer.” (JAMA, July 28, 2015, p.343).
- “Medicaid insures more than 71.1 million people (an increase of 12.3 million since the first Marketplace open enrollment began) and
- In 2015, Medicaid is projected to account for $343 billion in total spending.” (JAMA)
Medicaid is playing an increasingly important role as a payer for services provided to individuals with addiction in the United States. There have been some exciting developments regarding The ASAM Criteria in Medicaid’s expanding role……”exciting” for me anyway, because I have been on a mission for 25 years to have The ASAM Criteria accepted as the model for addiction treatment’s continuum of care.
Last month, the Center for Medicare and Medicaid Services (CMS) announced new opportunities for states to design service delivery systems for Medicaid beneficiaries with a substance use disorder (SUD). Numerous federal authorities are offering states the flexibility to implement system reforms to improve care, enhance treatment and offer recovery supports for SUD. The ASAM Criteria is mentioned in several places as integral to that service delivery design.
Here are excerpts from that announcement. If you want to read more, here’s the link: http://medicaid.gov/federal-policy-guidance/downloads/smd15003.pdf
- “An estimated 12% of adult Medicaid beneficiaries ages 18-64 have an SUD.
- An estimated 15% of uninsured individuals who could be newly eligible for Medicaid coverage in the New Adult Group have an SUD.
- CMS is committed to helping states effectively serve these individuals and introduce benefit, practice and payment reforms through the technical assistance and coverage initiatives described below.”
“States have compelling reasons to provide Medicaid coverage for the identification and treatment of SUD, many of which are given urgency by the national opioid epidemic. Untreated substance use disorders are associated with increased risks for a variety of mental and physical conditions that are costly.”
- “In 2009, health insurance payers spent $24 billion to treat SUD. Of those expenditures, Medicaid accounted for 21%.
- Two of the top ten reasons for Medicaid 30-day hospital readmissions are SUD-related.
- Individuals with SUD and co-morbid medical conditions account for high Medicaid costs, such that $3.3 billion was expended in one year on behalf of 575,000 beneficiaries with SUD as a secondary diagnosis.
- Beyond health care risk, the economic costs associated with SUD are significant. States and the federal government spend billions every year on the collateral impact associated with SUD, including criminal justice, public assistance and lost productivity costs.
- Alarmingly, the rate of fatal drug overdose in the U.S. has quadrupled between 1999 and 2010.
- Drug overdose has become the leading cause of injury death, causing more deaths than traffic crashes.
- Other problems also relate to opioid prescribing including opioid exposed pregnancies, drugged driving, and increases in Hepatitis C and in some circumstances HIV from prescription opioid injection.”
“As states expand Medicaid coverage to millions of new beneficiaries that may have been previously uninsured, states are also expanding access to behavioral health services including covering these services in Alternative Benefit Plans as required by the Affordable Care Act. CMS has received a number of requests from states and stakeholders interested in enhancing care for individuals with SUD.”
The CMS announcement mentioned examples of practice changes including “Enhancing provider competencies to deliver SUD services with fidelity to industry standard models, such as the American Society for Addiction Medicine (ASAM) Criteria.” Here are more excerpts from the CMS announcement that align with what The ASAM Criteria has been advocating since the first edition in 1991:
“Strong Network Development Plan”
“States will be asked to develop a network development and resource plan to ensure there is a sufficient network of knowledgeable providers in each of the levels of care recognized by ASAM and recovery support services. In addition, the state should have the resources to ensure that providers have the ability to deliver services consistent with the ASAM Criteria and provide evidence-based SUD practices. The network should be sufficiently robust so that access can be assured in the event that some providers stop participating in Medicaid, are suspended or terminated.”
“Care Coordination Design”
“Coordination of care design is integral to SUD delivery reform. This entails developing processes to ensure seamless transitions and information sharing between levels and settings of care (withdrawal management, short-term inpatient, short-term residential, partial hospitalization, outpatient, post-discharge, recovery services and supports), as well as a collaboration between types of health care (primary, mental health, pharmacological, and long-term supports and services). CMS encourages states to test how to best achieve care transitions across the care continuum, including aftercare and recovery support services.”
“Short-term acute SUD treatment may occur in inpatient settings and/or residential settings. …Inpatient services are described by the ASAM Criteria as occurring in Level 4.0 settings, which are medically managed services. Inpatient services are provided, monitored and observed by licensed physician and nursing staff when the acute biomedical, emotional, behavioral and cognitive problems are so severe that they require inpatient treatment or primary medical and nursing care. ”
“Residential services are provided in in ASAM Level 3.1, 3.3, 3.5 and 3.7 settings, which are clinically managed and medically monitored services typically provided in freestanding, appropriately licensed facilities or residential treatment facilities without acute medical care capacity. ”
California was one of the first states to seize new opportunities from CMS for demonstration projects. These projects are approved under section 1115 of the Social Security Act (Act) to ensure that a continuum of care is available to individuals with SUD. Section 1115 demonstration projects allow states to test innovative policy and delivery approaches that promote the objectives of the Medicaid program.
The California Initiative
California calls its Medicaid services “Medi-Cal.” This month Medi-Cal received some welcome news from CMS. Here, in part, was California’s announcement on August 13, 2015: “The Department of Health Care Services (DHCS) announces the Center for Medicare & Medicaid Services (CMS) approval of California’s Drug Medi-Cal Organized Delivery System (DMC-ODS) Waiver amendment which provides a continuum of care for substance use disorder treatment services.”
As the Chief Editor of The ASAM Criteria who happens to live in California, I can’t help but feel proud that we now have a chance to truly implement the spirit and content of the Criteria in my home state. And who knows- maybe many more states in the USA.
If your state is considering enhancing care for individuals with SUD, take a look at what California is just now embarking on in their system of care redesign.
Here is the introduction to California’s system re-design states:
“The Drug Medi-Cal Organized Delivery System (DMC-ODS) provides a continuum of care modeled after the American Society of Addiction Medicine Criteria for substance use disorder treatment services, enables more local control and accountability, provides greater administrative oversight, creates utilization controls to improve care and efficient use of resources, implements evidenced based practices in substance abuse treatment, and coordinates with other systems of care.
This approach provides the beneficiary with access to the care and system interaction needed in order to achieve sustainable recovery. The DMC-ODS will demonstrate how organized substance use disorder care increases the success of DMC beneficiaries while decreasing other system health care costs.”
The State Implementation Plan and Standard Terms and Conditions for the DMC-ODS are located at http://www.dhcs.ca.gov/provgovpart/Pages/Drug-Medi-Cal-Organized-Delivery-System.aspx
Mann, Cindy and Osius, Elizabeth (2015): “Medicaid’s New Role in the Health Care System” Journal of the American Medical Association (JAMA), Volume 314, No. 4 pp. 343-344.
skills and sharing solutions
If your agency, county or state is preparing to implement The ASAM Criteria, here are some tips to get you started.
Involve all systems and stakeholders in the implementation process from Day 1.
Whenever I am asked to train or consult for a “kick-off” for implementing The ASAM Criteria, one of the first strong recommendations I offer is to make sure ALL stakeholders affected by The ASAM Criteria are in the room from the beginning.
Why is this? Because implementing the true spirit and content of the Criteria affects everything:
* How you engage and attract people into recovery;
* How you conduct screening and assessments;
* How you collaborate with clients, patients, families and referral sources on individualized treatment;
* How you design, deliver and pay for a continuum of addiction services; and
* How you move people through a disease management continuum of care.
* Not least of all, how you select and train staff on all these processes.
Implications for stakeholders
- Counselors and clinical staff will need to move away from program-driven services to individualized, person-centered, outcomes-driven treatment.
- Administrators and supervisors must figure out how to use economies of scale to provide a broad continuum of care, to stretch resources to achieve good outcomes.
- Payers and managed care companies will have to ‘speak’ the common language of The ASAM Criteria – to collaborate with treatment providers on care and utilization management decisions.
- Quality improvement and auditors must understand the correct application of The ASAM Criteria and what it really means for documentation, treatment plans and continuing care decisions.
- Referral sources, especially mandated treatment settings like Drug Court and other criminal justice personnel, Child Protective Services, employers and schools, will have to understand that mandating assessment and treatment adherence is the correct stance – rather than mandating a particular level of care and length of stay.
Broaden understanding of the clinical application of The ASAM Criteria beyond intake, admission and level of care placement.
Some counselors and clinicians think The ASAM Criteria is a checklist of levels of care to justify admission to the program. Then they think they are done- to pursue treatment as usual. Nothing could be further from the truth, which is why we removed the wording “patient placement” from the 460-page 3rd edition (2013) book.
It is much more than initial placement criteria. That’s why there are multiple chapters on application of the criteria to special populations. There are chapters on working effectively with managed care, tobacco use disorder and gambling disorder. Appendices on withdrawal management instruments were added to address Dimension 5, Relapse, Continued Use or Continued Problem Potential.
Take a look at www.ASAMCriteria.org and “How to Really Use the New Edition of The ASAM Criteria: What to Do and What Not to Do” Counselor Magazine Nov-Dec., 2013
There are some proprietary instruments to help you. The Change Companies® is the sole distributor for Evince Clinical Assessments, the field’s most complete system of clinically-driven assessment, diagnostic and patient placement and planning tools compatible with the DSM-5 and The ASAM Criteria – Third Edition.
Included in this comprehensive system is the DAPPER (Dimensional Assessment for Patient Placement Engagement and Recovery), the assessment tool most closely aligned with the new ASAM Criteria. To view a description and sample pages click https://www.changecompanies.net/products/?id=DA-T
Consider Interactive Journaling to help you use Evidence-Based Practices.
Many states now require counselors and programs to use Evidenced-Based Practices. In this new initiative California requires at least two of the following evidenced-based treatment practices (EBPs):
1. Motivational Interviewing
2. Cognitive-Behavioral Therapy
3. Relapse Prevention
4. Trauma-Informed Treatment
What too few realize is that there is actually one evidence-based practice that incorporates most of these EBPs above in one method. Interactive Journaling (IJ) is an EBP on the Substance Abuse and Mental Health Services (SAMHSA) National Registry of Evidence-based Programs and Practices (NREPP)
If you missed it, you can read all about IJ in the May 2014 edition of Tips and Topics:
For a Standardized Assessment learn more about The ASAM Criteria Software.
The ASAM Criteria Software is now branded as Continuum ™, The ASAM Criteria Decision Engine. Continuum ™ provides counselors, clinicians and other treatment team members with a computer-guided, structured interview for assessing and caring for patients with addictive, substance-related and co-occurring conditions. By branding the software as “Continuum” it means The ASAM Criteria isn’t just about assessment at the front intake part of treatment in order to make a placement decision. It means that The ASAM Criteria is about ongoing chronic disease management across a whole continuum of care.
The book and Continuum ™ are companion text and application. The text delineates the dimensions, levels of care, and decision rules comprising The ASAM Criteria. The software provides an approved structured interview to guide adult assessment and calculate the complex decision tree to yield suggested levels of care, which are verified through the text.
For more information, go to the website www.asamcontinuum.org
Miller, W. R. (2014). Interactive Journaling® as a Clinical Tool. Journal of Mental Health Counseling, 36(1), 31-42.
Have you ever been stuck in gridlock on the highway with no clue why you are now in a parking lot!? You see some drivers pulling out to the shoulder, trying to catch a glimpse of what’s up ahead: “Is it a bad car accident? Or roadwork? A collapsed bridge? Is it 4 lanes narrowing down to 2? Maybe it’s just thousands of people interested in going to the same place as me?”
When you hear sirens and ambulances, you guess there is indeed an accident. Then you settle back for the long wait while cars crawl by rubbernecking at human tragedy. What’s frustrating is when you have no idea why you are speeding along at 3 miles per hour.
Switch scenes now. You’re sitting on a plane which was late taking off and now late arriving. This is threatening the very close connection to your next plane that you can’t wait to board. You want to get home after a long week “on the road”. Yes, that’s me.
Here’s my beef with airplane pilots. They can see perfectly well why the plane is 50 feet from the jet bridge and why we aren’t docking to let connecting passengers race to their next gate. Haven’t they ever been in a gridlocked parking lot on the highway? Don’t they know what it feels like to be stuck- with no idea why we aren’t moving?
Yes, they do usually give some brief explanation but:
- Sometimes it is so general, it doesn’t help: “Folks, we aren’t at the gate yet, so please stay seated with your seat-belts fastened and your luggage stowed.”
- Then a long silence with no explanation on why we are not at the gate yet. Is it because the gate is occupied by another plane that is nowhere near ready to push back? If so I almost certainly will miss my connection. Or is there a new trainee struggling to operate the jet bridge joystick and wobbling all over the airport, missing alignment with the plane door? Could we be waiting for a tow vehicle to hook up the plane to pull us into the gate? Pilot…..please tell us what is going on!
- Even when they do tell us something more specific like: “There isn’t a gate agent yet to maneuver the jet bridge” or “There is a plane occupying our gate” or “We’re waiting for a tow vehicle,” they never keep you informed. They are up front looking through the windshield. We passengers have blank walls and no-smoking signs to look at. A few play-by-play updates would be nice: “Looks like the gate agents are busy, still no-one showing up. I’ve called them again.” Or “The plane does look like it is starting to push back, shouldn’t be long now.” Or “I can see the tow operator headed our way.”
- Worst of all, is when they say: “It’s just going to be a few minutes and we’ll be at the gate” and then you get radio silence with no explanation and no updates AND it certainly is NOT a few minutes.
Maybe I’ve had too many frustrating plane trips lately, but next time I sit next to a pilot traveling to their next assignment, I’m going to bare my SOUL.