September 2012

In the July edition of Tips and Topics, I wrote about some of the implications for addiction treatment and addiction medicine in the changing environment of healthcare reform. For SAVVY this month, here are some readers’ reactions and my responses. If you missed the July edition, take a look: https://changecompanies.net/tipsntopics/2012/07/july-2012-tips-topics

Reader 1
Dear Dr. Mee-Lee,

I read with interest your latest issue of ‘Tips and Topics’ for July, 2012. Let me be clear right from the start. I am one of the many Americans who believes that the Affordable Care Act (ACA) does not adequately and completely address the needs of those Americans who are without healthcare, but instead will be a tremendous burden on the middle class to provide for those who are unable to provide for themselves.

But to my point. You stated:
“When the Supreme Court affirmed the Affordable Care Act (ACA) on June 28, the plan to expand insurance coverage for millions of Americans who need addiction treatment got back on track. A minority of those newly-covered people will seek formal addiction treatment. Most will not; they will be found in general healthcare settings, not even interested in treatment”. This statement make little sense to me, and only confirms that the new law will place an undue burden on Americans more than it will solve problems. I have worked in the addictions field for the last 16 years.

In my time doing the work on the ‘frontlines’ of addiction, caring for those who are, perhaps, at the end of the scale of addiction, what I have seen is that many addicts seek healthcare first in the emergency rooms of America, not in the counseling office, which places a burden on those of us who ultimately pay the bills through higher insurance premiums. Now, with the new ACA, the burden will be higher. I have no illusions that, just because “the plan to expand insurance coverage for millions of Americans who need addiction treatment got back on track” means that adequate treatment and care will be the end result. Quite the opposite. My firm belief is that it will continue to be an uphill battle for the addicted person to enter treatment, especially knowing that they can now merely enter the physicians’ office for whatever might ail them, having no idea that their addiction is at the root of their illness.

Sincerely,
Jeffrey Ayres, BS
Addictions Counselor; Current Student

My Response to Reader 1:
You are right that “that many addicts seek healthcare first in the emergency rooms of America, not in the counseling office”, which is why I said: “A minority of those newly-covered people will seek formal addiction treatment. Most will not; they will be found in general healthcare settings, not even interested in treatment”.

Where I disagree is that “the new law will place an undue burden on Americans more than it will solve problems”. Untreated addiction for the estimated 20 million or more Americans 12 years and older who need, but do not seek addiction treatment, already costs all of us billions of dollars in emergency services and healthcare costs for the complications of addiction, and social and legal costs not to speak of the enormous human cost of untreated addiction. Making insurance coverage more available to treating addiction more directly should decrease the burden of all of us.

I agree that “it will continue to be an uphill battle for the addicted person to enter treatment, especially knowing that they can now merely enter the physicians’ office for whatever might ail them, having no idea that their addiction is at the root of their illness.” The problem is not just that the patient has no idea that addiction is the root cause, unfortunately too many physicians and healthcare professionals also have no idea that addiction is the illness that needs primary care. That is why we have to integrate addiction and behavioral healthcare much more intimately with general healthcare. That is why we cannot wait for people to show up in the counseling office or the addiction program. We have to show up where most of the customers present for help.

Reader 2
“Right on, David.
Your statement “It is not then a matter of ‘completing them in the program’…It involves transferring them to whatever level is the least intensive level which can safely provide the services they need” initially seemed self-serving, sounding as if you are advocating ongoing endless treatment (albeit at the individually-determined least intensive level).

However, your examples convey your meaning more precisely.

I would like to suggest another way to approach these right-level-of-care matters, a way that might make Kaylum’s decision easier to make. It’s crude and perhaps a bit simplistic, but…:

Imagine you are working in a capitated system (as many of us will soon be). Then ask the question: “How many limited resources (i.e. money) do I want to devote to this person, knowing that resources expended on one person will limit what might be used to help others?”

One thing that can be said for no “treatment”: the client will no longer be being helped, will no longer be involved in important relationships in which there is an inherent power imbalance. Let’s face it, no matter how much we try to alter these dynamics, clients are one-down (hence infantilized?) in relation to we treatment providers. In my view, the sooner someone can get out of such relationships (safely and appropriately) the better for them.”

Fred Olson, LCSW
Biddeford, Maine

My Response to Reader 2:
Let me underline a few points Fred makes:

1. Because the level of healthcare cost inflation is unsustainable, we must all look at providing care in the most cost-effective but quality manner. Fred alerts us that increasingly payment will move away from fee-for-service to new financing systems including capitation. This is where organizations are paid an amount per month for each person in the population or catchment area for which the healthcare organization is responsible to keep healthy. This is “healthcare” versus “sick care”.
2. When you are deciding when to transfer a person to another level of care, Fred points out that unnecessary or inefficient use of limited resources spent on one person, only makes it hard to give all the necessary services for the next person who needs help.
3. Finally, Fred reminds us that it is too easy to keep clients and patients in a “one-down” position with the clinician. It is our job to make ourselves as obsolete as soon as it is possible and safe; and to engage and facilitate individuals in self-directed, responsible recovery.

Reader 3
“I always look forward to receiving your Tips and Topics. I read the July issue today and have a concern. You use the term “addiction” throughout. There is a difference between misuse, abuse, dependence, and addiction. Of course you know this, but everyone doesn’t. We work hard in South Carolina to educate our providers so they will not misdiagnose, as a diagnosis may follow them for a lifetime. We treat those who are at risk of substance misuse as well as those addicted. However, the majority of our clients identified as “dependent” are not addicted. Addiction indicates a change in the brain has occurred giving substance use a different meaning for those clients. Dependence is physical, and applies to all kinds of medications and/or substances. Understanding this is critical in providing appropriate services and information. I will be interested in hearing your thought!”

Jenny R. Bouknight, MSW, LISW-CP
Planning Coordinator
Dept of Alcohol and Other Drug Services, South Carolina

My Response to Reader 3:
Hi Jenny:
Thank-you for your thoughtful comments. Of course your are right that there are differences between use, misuse, abuse, dependence and addiction; and we all need to be careful not to use these terms loosely or lump all use under addiction. As you say there are different implications for different kinds of services and education to meet each client’s specific needs.

As regards my use of “addiction” in last month’s Tips and Topics, I was reporting on the CASA Report that was focused on Addiction Care, Addiction Treatment and Addiction Providers using “addiction” in that context to cover the range of addiction services. So I was using addiction not to mean that we should address all people who use, experiment, misuse or “abuse” as having the illness of addiction and get full addiction treatment. I was using addiction as a generic term for addiction care, much like I might say hypertension services or mental health care or diabetes services and treatment. In those areas, we should also recognize that there is a wide variety of presentations that involve prevention and early intervention services and a range of treatment options that are person-centered and individualized.

So yes, you are right that we need to assess and diagnose whether a person is experimenting with alcohol or other drugs; socially using alcohol or other drugs with no lasting negative consequences; is physically dependent on a drug because of extended use, but without the biopsychosocial effects defined in addiction illness; or whether they have now crossed the line into addiction illness with brain changes that may have predisposed them to developing addiction and/or resulted from extended use of alcohol and or other drugs. Each person needs individualized assessment and education and service interventions.

Reader 4
Jennifer Harrison offered some responses about points in last month’s SAVVY section.

As regards:

1. “Inadequate Integration of Addiction Care into Mainstream Medical Practice”
2. “Inadequate Education and Training of Addiction Treatment Providers” and “The Education, Training and Accountability Gap”There are not enough qualified people in addictions with training in Evidence-Based Practices or other health needs – this is a challenge for us based upon the history of addictions treatment, which unlike mental health did not grow up along a medical model. This offers advantages (seeing the whole family as the target of intervention, honoring and understanding self-help as a high outcome intervention, understanding how important actual peers in recovery are to our work), but also distinct disadvantages (we aren’t always from the same universe or have the same world-view as medical practitioners).William White’s book Slaying the Dragon: The History of Addiction Treatment and Recovery in America speaks to this divide quite eloquently. And I think it’s a challenge, thinking about how much you want to be absorbed by another field, (medicine), or that’s how it feels. But, it needs to happen if we want to have outcomes for addiction approach our hard won outcomes for diabetes, asthma, depression, and other chronic health conditions.
3. “Inadequate Accountability for Addiction Treatment Providers” and “Less than Half of Treatment Admissions Result in Treatment Completion”Making this change above, is also going to mean that we transition to a more professionalized (read “have a license to practice”) model. Traditionally, addictions treatment has been licensed at the program or agency level, which supported some staff without advanced degrees providing even very high-level clinical services. The Affordable Care Act and the findings of the CASA report give us a potential charge to be more oriented towards individual practitioner licensing and competency. Incidentally, individualized treatment also pushes us in this direction, since everyone can’t fit into a bundled 28 day or IOP program, meaning you have to establish medical necessity and provider qualifications for each and every service provided.

On point #5:
“Physicians and Other Health Professional Should Be on the Front Line Addressing this Disease” and “Most People in Need of Treatment Do Not Receive It”

Actually this is the part of our summary that I challenge the implications some. The National Survey of Drug Use and Health (NSDUH) (https://nsduhweb.rti.org/) self-report telephone survey done annually, has roughly the same results as the CASA study, that only one in 10 people who need specialty addiction treatment receive it in any given year. However, they ask follow-up questions, about the why? The most frequently endorsed reason among people who “made an effort to get treatment but did not receive treatment” was “no health coverage or could not afford” (38.1%), another 7.4% had health coverage but not addiction treatment coverage, and another 8.4 percent endorsed transportation as a barrier.

So, for this, system change remains necessary, but this finding from CASA can be explained most clearly as an access problem, not a provider problem (not that access isn’t a provider problem). So, we need to continue our advocacy for parity in substance use disorder treatment, and on equitable coverage for all people how all of their health care needs. This is the right thing to do, but it will also provide us a good return on investment.

Jennifer Harrison LMSW, CAADC
Field Coordinator, School of Social Work
Western Michigan University
Kalamazoo, Michigan

(Jennifer is my co-author of “Tips and Topics: Opening the Toolbox for Transforming Services and Systems” by David Mee-Lee, MD with Jennifer E. Harrison, MSW. 158 pages; Sells for $19.95. Call The Change Companies at (888) 889-8866. Ask for the Tips and Topics book. You can also go online and get started on ordering at https://changecompanies.net/products.php?prod=TNT

My Response to Reader 4:
Hi Jennifer:
I wanted to follow up to be sure I understand your comments on #5 in SAVVY last month. The 38.1% who could not access treatment due to insurance coverage and cost explains only the 3.3% of people who realized they have a problem and attempted to seek treatment. The implications I addressed spoke to the 95% who have an addiction problem, but don’t think they do have a problem and don’t reach out for treatment.

That is the vast majority of people who need treatment and don’t even reach out to an addiction facility to find out that they don’t have insurance coverage. So parity and access issues are important for the 5% who think they have a problem and do reach out for treatment. But it was for the 95% that are the implications I addressed in #5.

Jennifer Harrison:
Good clarification. I wonder still if there are some confounding variables though, between readiness to seek treatment and knowing that whether you are ready it doesn’t matter because it’s totally out of your reach. I think my point was that unless we have reasonable access to “strike while the iron is hot” with the appropriate care for people, we will not be able to catch them when they are ready to address their substance use issues.

The Final Word:
Yes, to “strike while the iron is hot” requires that we do a much better job of integrating addiction and behavioral health services with general healthcare services.

SKILLS

Even if you want to make changes in your clinical practices or program policies, it’s not always easy to get there from here. So here are a couple of tips to get started.

TIP 1

Do a pilot change rather than try to change your whole practice, program or procedures.

It feels less daunting to make a change if you frame it to yourself and/or your team that this new policy, procedure or practice is just that…a practice change, a pilot project to test out. Of course we’ll hang in through some uncomfortable moments and not give up too quickly. But also, we aren’t fixing this in stone either.

NIATx calls this Rapid-Cycle testing.  See for yourself: http://www.niatx.net/Content/ContentPage.aspx?NID=148

There are all kinds of things you can try:

• In just one group or individual session per week, you can ask each client: “What do you want to get out of our session today that will advance your treatment plan?” See what they say. If they look at you blankly, then you might not have a very meaningful collaborative plan with them. If they say “I just have to be here and get my attendance checked off”, you know you have a “doing time” client not a “doing treatment” one.
• For just two assessments a week, try starting off with: “Thank-you for coming and choosing to work with me today.” If they object and tell you that they didn’t choose to come, you can gently lead them to look at how they actually did choose to come to get what they want – people off my back; keep my job or a relationship; stay out of jail; keep my housing or benefits.
• For three of your clients this week, try to have each one write their Progress Notes with you, rather than your rushing and scribbling something down that sounds generic like: “Client attended group, gave positive feedback to others and is gaining insight. Continue current treatment objectives.” See if you could write, with the client a Progress Note that was a Progress Note – one which actually related to specific progress the client was making on a treatment issue.

TIP 2

Experiment with eliminating waiting lists.

I was reading in the October 2012 edition of Inc. magazine (page 60) some interesting statistics:

• “Each year, Americans pay a billion visits to doctors’ offices, waiting an average of 20 days to get an appointment.
• Yet on any given day, even physicians with busy practices and long waiting lists lose 12 percent of their available appointment times because of patients who don’t show up or cancel at the last minute
• Some 40% of appointments scheduled more than 20 days ahead get canceled or are no-shows.”

You can probably relate to these sorts of numbers for cancellations and no-shows. Now if you aren’t in private practice or under strict productivity expectations, you may welcome that no-show – gives you time to catch up on your paperwork and all those pink telephone slips of calls you missed.

If waiting lists are bad in general health, they are at least as bad as, or worse, in addiction and mental health services. Not a good thing to tell an ambivalent person with alcohol problems to show up to an assessment in ten days time!

So here’s one pilot you could do to start eliminating waiting lists:

• Instead of giving a client an intake appointment in two days, a week or even longer, run an intake orientation group at 9 AM and 3 PM everyday. Or if that is too much, try just one time, maybe 12 Noon daily. So if someone calls, at 9 AM, have them come to learn of the services we offer at 12 Noon. Or if they call at 4 PM, come tomorrow at Noon. They are never more than 24 hours away from being engaged, and usually even less than 24 hours away.
• The Orientation group explains what services you offer, has attendees start some paperwork which can be explained in a group, but completed privately without anyone sharing details. There can be time for questions and some clients may even get some relief from being immediately engaged, rather than to wait a week for an intake session.
• You could even have two staff people as back up to start an individual engagement session straight after the group. This 20 minute session could start some paperwork and get the person engaged to come back for a fuller assessment.

SOUL

I have a longtime childhood friend in Australia who, for many years, was a Senior Policy Advisor to the Prime Minister plus Official Secretary to two Governors-General of Australia. (The Governor- General  represents the Queen of England.)  Australians receive nearly as much daily news about the Presidential election as we do in the USA.

My friend recently wrote: “Hope all is well – I don’t know how you can stand all that election hype David – it’s bad enough here.  I think I’d emigrate.  Having had a lifetime working in the political arena, I think I’ve reached saturation point.”   I don’t even live in one of the several vital swing states like Ohio or Florida on which the election results will hinge; and yet I’m almost saturated too. The poor people of those states must be feeling like they’ve been hit by a tsunami.

Actually, I wouldn’t be saturated if all the election news was a thoughtful explication of each candidate’s specific plans including analysis of pros and cons of each person’s vision and proposals for real solutions.  I’m interested in solutions to the problems we face.  But I am saturated with the attack ads and the rhetoric of Personal Destruction.
(See SOUL in TNT January 2012, on the Politics of Personal Destruction)
https://changecompanies.net/tipsntopics/2012/01/january-2012-tips-topics/#more-2176

I must have been on the same wavelength as Don Kuhl, because as I was thinking where my SOUL was this month, I read Don’s September 19 Mindful Midweek and how he has to brace himself every four years for the unfair attack ads.
https://www.changecompanies.net/mindfulmidweek/?p=3914

So here’s my proposal:
I propose a new political party called the Compromise Party. I’m re-branding “compromise” that has become a bad word. The Compromise Party “com-promises” with others to brainstorm on solutions believing that no one person or party holds all truth. That’s “com-promises” as in communicate, community, come together to promise solutions that consider all sides of a challenge. Com-promise that brings together the best ideas no matter where they come from, so long as the outcomes solve the problems.

I know I am politically naïve and unrealistically idealistic about people of good will working together to com-promise rather than declare empty promises to score political points. My elevator speech (the way you quickly describe your values in the ride between the second and twelfth floor) is this: “I’m the Solutions Psychiatrist. I shrink problems not people.”

Here’s the new Party’s elevator speech: “We’re the Compromise Party.  We attack problems not people. We demonstrate for constructive collaboration not criticize for destructive demonization. We com-promise.”