Strengthening Patient-Centered Addiction And Mental Health Care In The United States – Health Affairs
The United States is facing an unprecedented need for mental health and substance use disorder (SUD) services that has been worsened by the COVID-19 pandemic. More than 1 million Americans lost their lives to drugs, alcohol, or suicide between 2010 and 2019, and those numbers have been increasing during the current decade. After years of overdose deaths predominantly increasing among Whites, deaths have been increasing more sharply among Black people.
The sliver of good news amidst this loss of life is that there increasingly are highly effective treatment options available for people with SUD. Medications are available to treat opioid and alcohol use disorders. Therapeutic approaches work for many people with SUD, especially when addiction is treated as the chronic, recurring disease that it is. And promising practices are being put into place to address the rise in deaths among those who use methamphetamine and other stimulants.
Too often, though, people do not receive the right care, leaving a sharp gap between “what is” and “what should be” when they seek help for their addiction and related mental health disorders. Without a stronger structure that connects people to highly effective treatment, the well-meaning initiatives launched by governments and philanthropic partners may prove ineffective.
To help ensure that resources dedicated to the SUD crisis are used well, Manatt Health, the American Society of Addiction Medicine (ASAM), and Well Being Trust collaborated on Speaking the Same Language: A Toolkit for Strengthening Patient-Centered Addiction Care in the United States. At its core, the toolkit outlines pathways to help ensure that payers, providers, patients, and families are “speaking the same language.” This means working from a shared and comprehensive framework of SUD treatment rooted in evidence-based practice and standards.
One important example is the ASAM Criteria, which is the most widely used set of evidence-based guidelines for patient placement, continued treatment, and transfer of patients with addictive, substance-related, and co-occurring conditions. It provides a consistent way to (1) assess the treatment needs of patients with SUD, (2) determine the type of care that they need, and (3) identify where they can receive the appropriate care.
Providing people with evidence-based care that meets their individual needs is an almost-embarrassingly straightforward idea, one that already is embedded in the way that people receive care for many other medical conditions. But more work is needed to fully implement this concept for addiction treatment, which continues to experience repercussions from the long history of marginalization and stigma associated with SUDs.
Since the toolkit’s publication in November 2021, new data from the Centers for Disease Control and Prevention have been released documenting that drug overdose deaths in the United States exceeded 100,000 in a single year—a terrifying “first” that highlights the importance of strengthening and expanding access to evidence-based addiction care across the country. With a strong basis for addiction treatment and related mental health treatment, it will be significantly easier to help ensure that people receive the right type and level of care, thus reducing death and the devastating impact of addiction on those who live with the condition, their family, and friends.
Current Gaps In Addiction Care
Over the past decade, there have been significant expansions in coverage of and access to addiction care. This is due in large part to the Affordable Care Act (ACA), which required individual and small-group insurance plans, sold on and off the Marketplace, to cover SUD treatment. The ACA also granted coverage through Medicaid expansion to a significant number of people with low incomes, including those with SUD. The ACA builds on the Mental Health Parity and Addiction Equity Act (MHPAEA), which generally prevents group health plans and health insurance issuers that provide mental health or SUD benefits from imposing more restrictive limitations on such benefits than apply to comparable medical and surgical benefits. Despite these developments, major gaps in coverage for SUD treatment persist, and there are people who lack coverage entirely. Even among those with coverage, the stigma long associated with SUD still too often results in limited use of a clear, organizing framework for the delivery and coverage of addiction care, which manifests itself in multiple ways:
Lack of information on the type of care offered by SUD providers. While there has been a proliferation of SUD treatment programs in recent years, it is difficult to discern which providers offer treatment in accordance with evidence-based standards.
People with SUD and their families often make treatment decisions based on limited information and without knowing which providers are best equipped to meet their needs. As a result, people with SUD often receive treatment at the provider that they first reached out to for assistance rather than from a provider that is offering the type and level of care that they require.
Treatment may be provided in residential settings even when less restrictive clinical settings, such as outpatient care, may be appropriate. For example, a recent national study of residential addiction programs found that one-third of people seeking treatment were offered admission prior to a clinical evaluation, and most programs required upfront payments. The study also found that most residential treatment programs did not offer highly effective medications for addiction treatment.
These are major concerns given that people face higher risk of relapse and worse mental and physical health outcomes when they are not linked to the appropriate type and level of care.
Insufficient access to SUD care in insurer networks. Even with MHPAEA, insurer coverage of mental health and SUD services has lagged behind medical and surgical benefits. For example, a Milliman study of insurer data from 2013 to 2017 found widening disparities in out-of-network use of behavioral health services versus out-of-network use of medical and surgical services across inpatient, outpatient, and office-based settings. In particular, more than half of residential treatment for behavioral health conditions was provided by out of network providers in 2017. When people need to go out of network for any services, they pay more out of pocket, reducing access and service utilization.
Restrictive coverage policies for SUD treatment. Payers continue to authorize services using their own definitions of medical necessity, and they are generally (except under some state laws) not obligated to adhere strictly to specified standards of care. In Wit v. United Behavioral Health (UBH), the judge found that UBH was using clinical guidelines that were more restrictive than evidence-based standards such as those reflected in the ASAM Criteria. For patients and their families, many of whom will be desperate for treatment, this means that they may have to decide whether they can afford to pay out of pocket or pursue an appeal to secure coverage. Several federal, state, and legal developments have led to increased scrutiny and enforcement of medical necessity requirements requiring insurers to use generally accepted standards of care like the ASAM Criteria for coverage decisions. These include Illinois and California, which passed laws in 2015 and 2020, respectively, supporting implementation of, and expansion of, federal parity requirements and medical necessity standards.
Strategies To Improve Addiction Care
Speaking the Same Language: A Toolkit for Strengthening Patient-Centered Addiction Care in the United States helps address some of these challenges. It is designed to assist states looking to establish a common framework, such as the ASAM Criteria, for addiction care, and to identify strategies that can facilitate continuity in SUD treatment delivery and coverage. By rooting SUD services in a common framework such as the ASAM Criteria, states can ensure that everyone—from providers and payers to patients and families–is “speaking the same language” when it comes to SUD prevention and treatment.
As a grant-making organization, Well Being Trust is constantly working to assure that the nation is moving toward addressing mental health and addiction in a more integrated and comprehensive way. This body of work with ASAM provides a clear-eyed resource for those looking to build on existing policies, funding mechanisms, and treatment systems to support the full continuum of care for addiction.
Exhibit 1 Select Strategies For Integrating Use Of The ASAM Criteria Into SUD Services
Source: Guyer, J. et al. Speaking the Same Language: A Toolkit for Strengthening Patient-Centered Addiction Care in the United States. American Society of Addiction Medicine, November 9, 2021.
Some of the most important strategies available to help meet this objective are detailed in Exhibit 1. They range from ensuring that people are given an assessment of the care that they require before unnecessarily being referred to costly or extended residential care, to requiring insurers to adhere to clinical standards for what constitutes medically necessary care. They address the role of the insurer and the provider, as well as the importance of educating families about how to make sure their family member is linked to the right care. Ultimately, it is only when all key stakeholders involved in addiction care have a common reference point, as is often standard for other medical conditions, that it will be possible to connect individuals to the best care in a systematic way.
Conclusion
The worsening mental health and SUD crisis makes it clear that more work is needed to ensure that people are directed to the right level and type of care. More medical providers must be equipped to assess people for SUD and other mental health needs, and to deploy evidence-based standards when treating people with these conditions or refer them to providers who can. Insurers can be required to use the same framework as providers to determine when care should be covered for people based on their individual circumstances consistent with evidence-based standards. States can play a key role by ensuring that there is a strong regulatory and oversight framework that supports the consistent delivery and coverage of high-quality and integrated addiction care that meets the needs of each person.
For philanthropic organizations, the toolkit offers a cautionary tale as well as ideas and options for ways to move forward. Philanthropic organizations investing in this space cannot readily assume that, similar to what is available for many other medical conditions, there is an equally strong basis for addiction treatment that works to connect people to appropriate, evidence-based care. But philanthropy can fund efforts to build out such a system, trainings for providers so that they can deliver care consistent with evidence-based criteria, strategic public education initiatives, and/or the implementation of various engagement tools to help make stakeholders more aware of what’s possible for SUD care. States, localities, and foundations can work together to build and then bolster a shared and comprehensive framework of SUD treatment rooted in evidence-based practices and standards.
