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Commentary: Parity and the Path to Change the Treatment of Substance Use Disorders

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Doctor explaining diagnosis to her female patient

The Treatment Research Institute recently welcomed The Honorable Patrick J. Kennedy, one of the major architects of parity legislation, and a tireless advocate for improving substance abuse care through better policy, to our hometown of Philadelphia. His important insight about how the Parity Law will transform substance abuse and mental healthcare is certainly worth talking about some more.

Recent legislative changes in the healthcare organization and financing through the Affordable Care Act (ACA) and the Parity Act will end the past 40 years of separate and unequal resources for the treatment of substance use disorders. This legislation, combined with new knowledge from basic, clinical and health services research over the past two decades, has set the stage for a new public health-oriented approach to managing substance use disorders with the same insurance options, healthcare teams, clinical goals and clinical methods presently used to manage other, similar chronic illnesses such as diabetes, asthma or chronic pain.

These changes are much needed. Contemporary addiction treatments are based upon outdated concepts about the nature of addiction and, in turn, the nature of the care needed to bring about recovery. Virtually all existing treatments for addiction are “programs” – every patient gets the same care, regardless of the type of addiction or the other medical and social problems that coexist with addiction. Because everyone gets the same care, there has been no need to evaluate other influences including medical, employment, drug, legal family and psychiatric problems that could affect the course of change and recovery. Insurance coverage that has been built to service programmatic care has always been time or session limited. The financial limitations on insurance coverage have restricted the range of treatment components (tests, medications, therapies, family support services, etc.) that could be provided within any treatment program. The interim goal of treatment for virtually all existing treatments – residential or outpatient – is “program completion” with traditional symptom and function outcomes (drug use, employment, health, etc.) typically measured 6 – 12 months following completion.

These traditional features of treatment design and financing are no longer legal. With the passage of the Affordable Care Act, care for addictions is now required to be similar in content, structure and patient burden as care for other chronic illnesses. This will be a very substantial change in the concept, type, amount and evaluation of addiction treatment.

We believe recovery is now an expectable outcome and a new standard for high quality addiction treatment.

Representative Kennedy discussed the importance of leveraging the current innovations in research, treatment, policy and public education to take advantage of every opportunity to change the way addiction and mental illness are perceived and cared for and to move toward a chronic care model of treatment for addiction.

The Treatment Research Institute is working on methods to offer individualized approaches to illness management for individuals suffering from alcohol and other addictions. The ultimate goal of these efforts will be sustained, patient-managed recovery – specifically, sobriety, personal health and good social function. Patients are transitioned through a system of care that is coordinated with all other aspects of their health to anticipate and intervene promptly to help patients prevent relapses, reduce emergency department visits and hospitalizations and subsequent poor health outcomes.

We also want to ensure that promises of the Affordable Care Act and Parity are fulfilled through effective implementation; and that a chronic care model can exist for addiction. Working with our partners at the Legal Action Center, the Parity Implementation Coalition and Truven Health, we are tracking and analyzing the impact of implementation; informing and educating purchasers, payers, and other stakeholders; and documenting the impact of successful prevention and early intervention programs. We are assisting states, counties and health plans to implement the ACA and Parity legislation in a cost-effective manner that maximizes outcomes for patients and providers. This is a core priority for our organization and for our field.

It is through the work of Patrick J. Kennedy and the efforts of many others that we are at a watershed moment in behavioral health. Public awareness about addiction and mental illness is growing thanks to outlets such Join Together. We are starting to see the legislative advances bring us closer to integrated care, and the research base is expanding so that we can better address the social and biological determinants of these disorders. Like no other time in our history, we have an enormous opportunity to significantly impact the way in which these illnesses are perceived and managed in our society.

We look forward to sharing more details about these projects in the months ahead. In the meantime, we invite you to watch Patrick J. Kennedy’s presentation here. If you are interested in learning more about our efforts, please check out the Parity Tracking Initiative document and other impact projects on our website.

Mady Chalk and Abigail Woodworth

Mady Chalk, Ph.D., MSW, has more than 30 years of experience in addiction and mental health treatment, policy and research. In the federal government she was Director of the Division for Services Improvement in the Center for Substance Abuse Treatment in SAMHSA, and was Director of its Office of Managed Care. Chalk is an expert in the organization and financing of treatment systems in both the public and private sectors – and in the policies that govern treatment delivery, including strategies for quality and performance improvement. She was an architect of the Target Cities and the State-wide Screening, Brief Interventions and Referral to Treatment (SBIRT) programs. With the Robert Wood Johnson Foundation as a partner, Chalk provided Federal support for the development of the Network for Improvement of Addiction Treatment, the first national initiative to promote better treatment access and broader service availability through implementation of best practices. She was also responsible for linking the Addiction Technology Transfer Centers with NIDA and creating the Blending Program to foster dissemination and adoption of evidence based practices in the treatment field. Prior to moving to the Washington, DC area, Dr. Chalk was a clinician and clinical administrator at Yale University School of Medicine for 15 years.

Abigail Woodworth, Vice President for Strategy and Public Affairs supports TRI’s overall strategic growth, including creation of partnerships and alliances that enhance mission value, the communications and public outreach efforts of the organization, and its products and services. Ms. Woodworth has extensive experience managing organizational development within non-profit and public health organizations. From 2004 until her appointment at TRI, she occupied senior management positions at the University of Pennsylvania as well as Johns Hopkins, developing and directing external relations efforts for mental health and substance abuse programs. In addition, she has served as co-chair of the Public Policy Committee for the National Network of Depression Centers, representing 20 leading academic Departments of Psychiatry. Prior to her work in mental health and substance abuse, Ms. Woodworth founded and ran a non-profit community arts center in West Philadelphia. She earned both her BA in Psychology and her MS in Social Policy from the University of Pennsylvania.

5 Responses to this article

  1. Avatar of Pat
    Pat / July 28, 2014 at 1:33 pm

    As someone who has worked in a treatment facility for the past few years, I look forward to seeing what kind of difference the implementation of parity will make. So many patients are declined coverage in what appears to be a :one size fits all” approach to treatment — in other words the patient needs detox and some stay in the “bubble” to get grounded, but the insurance company will deny it if the patient has not been in outpatient treatment in the past 6 months to one year. If they are lucky enough to have inpatient granted, length of stay can be 7 to 14 days and then you are stepped down to an outpatient program regardless of readiness, your ability to get to the outpatient program due to transportation issues, ability to pay the co-pay, housing problems, etc. And if you have racked up any legal charges along the way, getting a job as part of a structured day so that you are not triggered by boredom or fall back to dealing to pay bills, can be problematic. I suspect that parity will be just a start – what we need is a comprehensive program that provides support on multiple levels and for years, nit just a few weeks or 30 days.

  2. Chuck / July 17, 2014 at 5:04 pm

    It about time that mental health and substance used disorder become better regulated. So far what I have seen is that very frequently counselor and facilities made decision based on the mood that staff I is in. Am not too sure they are thinking in “the best interest of the patient”.

    Make sense when the profession has been talking about evidence based treatment and assessment for the last thirty years. Little has been accomplished, it is a lot easier to blame it
    on the patient when outcomes are poor. About time that staff and facilities are made accountable

    Using a urine test as a weapon to discharge patients has to change to a tool to help the patient. Too frequently patients are discharge for the same behavior they came in with. Why would a patient be discharge for relapse. This is kin to kicking a schizophrenic from treatment because his/her hallucinations while in the hospital or a cancer patient because their condition get worse. As a result clinicians have never learn to deal well with a patients relapse. Instead of an opportunity they make the patient feel like a failure,

    They come to treatment because they do not know how to stop, why should we discharge them for exhibiting the same behavior?

  3. Barry Schecter / July 17, 2014 at 3:11 pm

    Parity laws were passed almost 10 years ago. Why is this occurring again? On a more specific note to my practice, treating opiate dependent people, I have utilized Urine Drug Screens as a quick measurement of what was actually present in a human’s body. Since May, some insurers have jumped on the CMS bandwagon of only paying for 1 Urine Drug Screen per visit. How can one give good care if one cannot check for presence of prescribed medications and absence of illicit substances. If we were living under medical parity, in theory, a physician could order a CBC or CMP, but only 1 gets reimbursed. Is that what evidenced based treatment has become? Going to the least quality measures instead of the best? Am I missing something. Most of my patients have been thriving, do I no longer have the ability to use instant testing? So if I send specimens to the Lab, it doesn’t tell me what the person in front of me at that moment has on board (chemically). Yes, I’ll know in a few days, but how is that providing better care? If someone from CMS reviews these posting, perhaps someone could get back to me. My office lab is CLIA certified.

  4. Andrew Kessler / July 17, 2014 at 9:03 am

    The authors cite that “Virtually all existing treatments for addiction are “programs” – every patient gets the same care, regardless of the type of addiction or the other medical and social problems that coexist with addiction.” Is there any data to back up this claim? If not, I would respectfully request that the authors not make such absolutist claims in the future. Data on substance abuse treatment programs is sorely lacking and most of us welcome research in order to improve treatment protocols. To make such a statement without supporting data is dangerous and irresponsible.

  5. meltee / July 16, 2014 at 10:54 pm

    The parity provisions of the ACA will be a boon for persons with alcohol or drug problems. It may not be boon for the traditional treatment agencies that have for years relied on state and federal funds for their revenues. As the authors pointed out the expectations for treatment outcome have changed. Also, since private insurance funds are now available in much larger amounts than ever before, private for profit and “traditional” medical care entities are becoming much more interested in providing AOD services. Insurers will be negotiating with providers to get the most efficient and effective services for their dollars. This will require providers to show evidence of effectiveness at a level rarely required in the past. Finally, the push to finally merge treatment for mental health and addiction into a truly integrated set of treatment services is growing stronger. All these factors will put enormous pressure on existing publically funded programs to change how they conduct their programs. If they do not adapt and grow, they will fall by the wayside. I hope the field will use its skills and resources to embrace the new opportunities for service improvement, and not “circle the wagons” clinging to old perspectives.

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