Greg Warren, MA, MBA President/CEO Baltimore Substance Abuse
System, Inc.
Slide 2
Workshop Outline Introductions and objectives Baltimore
Buprenorphine Initiative Review basic principles The Challenge of
Change Practical issues Wrap up
Slide 3
Workshop Objectives Describe principles for thinking about
incorporation of medications Provide framework for change as
related to incorporation of medications Share practical tools that
can apply to incorporation of medications Describe real-life
successful models for integrating medications Interactive sharing
of ideas, challenges and solutions to incorporating medications
into substance abuse treatment
Slide 4
Slide 5
Baltimore Achievements Innovative Practice by Agency
recognition by federal Agency for Healthcare Research and Quality
2008. National Association of County and City Health Officials
(NACCHO) Model Practice Award 2009. Network for the Improvement of
Addiction Treatment (NIATx) iAward for Innovation in Behavioral
Healthcare Services 2010. 5
Slide 6
BSAS is a quasi-public agency incorporated in 1990. It was
established by the Baltimore City Health Department to manage the
Center for Substance Abuse Treatments Targeted Cities Project. In
1995, BSAS became responsible for the management of the
publicly-funded substance abuse treatment and prevention service
system and is now an independent 501 3-C organization. The Chairman
of the 27 member Board is the Citys Health Commissioner.
Slide 7
BSAS funds about 60 treatment, prevention, and intervention
programs. Prevention 29 Residential 35 Outpatient 15 Medication
Assisted 22 Ancillary Services Need analysis based on: The number
of HIV cases Number of drug arrests Number of treatment admissions
BSAS-Funded Programs Darker areas have high need
Slide 8
71% Unemployed 50% < $10,000 per yr. 71% Unemployed 50% <
$10,000 per yr. 83% Black, 16% White Less than 1% Hispanic 83%
Black, 16% White Less than 1% Hispanic Characteristics of Clients
in Baltimore City Programs FY 2009 70% between 30- 50 years of age
70% between 30- 50 years of age 13% Homeless 45% less than a 12 th
grade education 45% less than a 12 th grade education 77% use
tobacco 77% use tobacco 57% arrested in the past 2 years 60% male
60% male Treatment Episodes n = 21,000,.
Slide 9
Baltimore City Heroin addiction remains high Treatment capacity
falls short of demand despite expansion in treatment system
Estimated 30,000 individuals with opioid dependence ~4,000
methadone treatment slots Over 8,000 treatment admissions for
opioids in FY 2009 Consequences from heroin addiction are severe
Crime Family and community disruption Medical complications 1 in 48
Baltimore City residents are living with HIV and/or AIDS
http://www.dhmh.state.md.us/AIDS/Data&Statistics/MarylandHIVEpiProfile122008.pdf
Slide 10
Slide 11
Principle #1: Change Happens Accept change as a reality and an
opportunity Nothing is permanent, but change Heraclitus 535-475 BCE
It is not the strongest of the species that survive, nor the most
intelligent, but the one most responsive to change Charles Darwin
1809-1882
Slide 12
Grant to PAC Transition As of Jan 1, 2010, the Maryland Primary
Adult Care (PAC) Medicaid waiver program covers outpatient
addiction treatment Assessment IOP/OP OMT Significant transition
from grant to Medicaid fee-for- service funding mechanisms
Slide 13
Healthcare Reform H.R. 3590 Patient Protection and Affordable
Care Act and Reconciliation Bill H.R. 4872 Implications for
Substance Abuse Treatment Expands Medicaid eligibility to 133% of
FPL SUD/MH services included in the basic benefits package required
in exchange and for Medicaid recipients All plans in exchange must
adhere to Wellstone/Domenici parity act provisions
Slide 14
Principle #2: Have a Method Use a systematic method for making
changes to your program Individualize it Be flexible Acknowledge
non-linear process of program change Examples NIATx model
(www.niatx.net)www.niatx.net Transtheoretical models
(http://www.attcnetwork.org/explore/priorityareas/techtrans/tools/chan
gebook.asp)http://www.attcnetwork.org/explore/priorityareas/techtrans/tools/chan
gebook.asp TAP 31: Implementing Change in Substance Abuse Treatment
Programs www.samhsa.gov Adaptive models
(http://www.drugabuse.gov/about/organization/despr/hsr/da-
tre/DeSmetAdaptiveModels.html)http://www.drugabuse.gov/about/organization/despr/hsr/da-
tre/DeSmetAdaptiveModels.html
Slide 15
Common Change Principles Know, and involve, your population
Including community, patients, and staff Culture, attitudes, and
knowledge level Pick, and equip, at least one leverage and
additionally a change agent or champion in your program Given them
appropriate authority and time Plan, do, reassess, revise and
repeat
Slide 16
Principle #3: Data is Your Friend Make it simple and relevant
Know it Use it Update it Knowledge is power Sir Francis Bacon
1561-1626
Slide 17
Principle #4: Why and Why Not? Keep asking the Why? questions
Improves the process and the outcome Encourages critical thinking
by everyone Helps articulate program messages Millions saw the
apple fall, but Newton was the one who asked why Bernard M. Baruch
1870-1965 Ask the Why Not? questions Clarifies program vision
Prevents stagnation I dream of things that never were, and ask why
not? Robert F. Kennedy 1925-1968
Slide 18
Case Scenario You are an administrator of an urban facility
that has been providing drug-free, outpatient substance abuse
treatment for 30 years. Sixty percent of the funding for your
organization comes from the state block grant. The Governor of your
state has recently announced that he wants to double the number of
individuals receiving buprenorphine by the year 2012. Your state
agency enthusiastically supports this deliverable. How will your
agency respond?
Slide 19
Questions for Consideration What does my program gain by
incorporating medications? What do individuals accessing services
in my program gain? What does my program risk by incorporating
medications? What are the costs and how does my program sustain
them? Others.
Slide 20
Questions for Case Scenario How will patients react to this?
How will your staff react to this? What other issues do you need to
consider? What are your next steps going to be?
Slide 21
Potential Challenges to Integrating Medications Program culture
and philosophy Counselor attitudes and knowledge Patient, family,
and community attitudes about medications
Slide 22
Problem Solving Form change team with representation from key
stakeholder groups Gather and use data to identify critical
measures to impact Patient surveys Staff surveys Relevant local and
state data Outcomes for treatment as usual Ensure change team and
others have sufficient information on medications to make informed
decisions
Slide 23
Prescription Opioids Growing problem among adolescents and
young adults* Allegany County -- 20% of 12 th graders reported ever
having tried prescription opioids for non-medical purpose Talbot
County 12% of 12 th graders reported currently using prescription
opioids for non-medical purpose Effectively treated with
buprenorphine** *Maryland Adolescent Survey:
2007http://www.marylandpublicschools.org/NR/rdonlyres/852505C8-7FDB-4E4E-
B34E-448A5E2BE8BC/18944/MAS2007FinalReport_revised111808.pdf
**Woody G. et al. JAMA 2008;300(17):2003-2011
Slide 24
Outcomes for Treatment As Usual Of 3753 admissions to Level I
treatment in FY08, 51% retained for 90 days or more Of 11,013
treatment discharges in FY08, only Prince Georges county had
smaller change in substance use Relapse rates high In methadone
studies, 50-80% relapse within one year after detoxification 91% of
patients receiving buprenorphine for 4 months had relapsed to
prescription opioids within 2 months of taper* *Weiss R. et al.
NIDA CTN Prescription Opioid Treatment Study.
http://www.medscape.com/viewarticle/722342
Slide 25
Treatment Programs 911 Broadway Center A Step Forward Baltimore
City Needle Exchange Baltimore Community Resource Center Bon
Secours ADAPT Cares Bon Secours New Hope Bon Secours - Next Passage
Daybreak/MBA Dees Place Family Health Centers of Baltimore Harbel
Prevention and Recovery JH CAP JH BPRU IBR Reach Man Alive Partners
in Recovery Pauls Place Powell Recovery Recovery in Community Sinai
SHARP Bup Sinai SHARP - OMT Total Health Care Tuerk House ICF &
HH Tuerk House OP Turning Point UMD - ADAP UMD - DTC Total Sites:
28
Slide 26
Suboxone: 9 Drug Free: 5 Methadone:11 Other: 3
Slide 27
27
Slide 28
Financial Considerations for Medication Assisted Treatment
Programs
Slide 29
BHCA and the PAC expansion Cost per client to have a BHCA
advocate:$142.47 Outpatient Cost Savings (based on $5,500 cost per
slot): Cost of OP treatment with avg. LOS at 130 days:$1,964.00
Cost of OP treatment if client is insured within 60 days: $916.67
Cost of BHCA advocate + 60 days of OP Treatment: $1,059.14 Savings
per patient: $904.86 Total savings in OP treatment, based on total
of 50 OP slots, turnover 2.8x annually:* $126,680.40 Estimated
savings for 800 clients (2 advocates): $723,888
Slide 30
BHCA and the PAC expansion Cost per client to have a BHCA
advocate:$142.47 Methadone Cost Savings: Cost per patient in OMT
Slot (avg) of 1 client per slot, annually: $4,000.00 Cost per
patient if insured within 60 days: $657.53 Cost of BHCA advocate +
client who obtains insurance within 60 days: $800.00 Savings per
patient: $3,200.00 Total annual savings for 100 OMT slots:
$320,000.00 Estimated savings for 400 clients (1 advocate): $1.28
million
Slide 31
What Does Your Program Look Like?
Slide 32
Other Issues Program policies on medication management
Dispensing vs. only prescribing Clinical policies on medication
recalls, pill counts, etc Laboratory testing Resources needed
Additional staff Medication costs Supplies and equipment State and
federal regulations and licensing requirements
Slide 33
Factors to Consider In Medication Management Policies Risk of
medication diversion Medication safety and side effect profile
Staff input Existing policies Urinalysis testing Approach to
positive urines Approach to late or missed payments for services
Program behavior policies
Slide 34
Dispensing vs. Only Prescribing Pros of Dispensing Better
control over patient adherence More control over medication
Additional, potentially reimbursable, contacts with patients Cons
of Dispensing Need more equipment More paperwork for labeling and
tracking medication Cost of purchasing medications
Slide 35
Medication Costs Buprenorphine (Suboxone) 8mg/2mg tablet --
$6.18 per pill ($371 per month for 16 mg daily) 2mg/0.5mg tablet --
$3.35 per pill Naltrexone Oral (Revia) -- $170 per month for 50 mg
per day Injectable (Vivitrol)* -- $700 for once monthly injection
Acamprosate (Campral) -- $360 per month for 666 mg thrice daily
Topiramate (Topamax) -- $240 per month for 200 mg per day
Buproprion SR (Zyban) $300 per month for 150 mg twice daily
Varenicline (Chantix) -- $110 per month for up to 1 mg twice daily
*MD Medicaid does not cover Vivitrol
Slide 36
Resources Needed Physician to prescribe medication Physician
coverage for vacations and emergencies Malpractice insurance Nurse
to dispense and/or administer medication if physician does not
Supplies and equipment Appropriate storage of medications, if
dispensing Bottles, caps, labels, label printing software, if
dispensing POC buprenorphine urinalysis testing kits
Slide 37
Regulation and Licensure Requirements DATA 2000 allows
qualified, office-based physicians to prescribe approved
medications for treatment of opioid dependence Sublingual
buprenorphine currently is only medication approved for this
purpose Nurse practitioners are currently not allowed to prescribe
buprenorphine Practices subject to regular DEA visits To prescribe
SUD medications physicians need Active state medical license
Current state controlled substances license Current Federal DEA
license
Slide 38
Clinical Program Goals and Medications Increase retention
Improve counseling attendance Increase program completion rates
Provide treatment options for patients Improve abstinence rates
Others..
Slide 39
Buy-In and Mix of Patients Listen to staff concerns Start small
Have clear program and clinical policies for selection and
management of patients on buprenorphine Model behavior Measure
impact and celebrate successes Consult with peers
Slide 40
Resources Grant funds State Local government Foundations
SAMHSA/CSAT Third party payers Bill for all reimbursable contacts
Ensure patients enrolled in all entitlements they are eligible for
Look at payer mix Partner with a community health center or local
physician practice Partner with another treatment program
Slide 41
Baltimore Buprenorphine Initiative
Slide 42
42 Business Case for BBI in 2006 Baltimore needs more effective
treatment for opioid dependence Review of literature and studies by
UMBC Medical costs are increased for patients with drug abuse
Opioid addicts on methadone consume far fewer Medicaid resources
than addicts who go untreated Buprenorphine is economically viable
alternative in city with limited methadone treatment capacity
Slide 43
BBI Goals Expand treatment for heroin addiction Access funding
from larger medical care system Increase retention in treatment
Link patients with ongoing medical care
Slide 44
Link from Treatment Program to Primary Care Is Key Initially 6
treatment providers In FY 2009 moved to 9 providers 58 continuing
care physicians
Slide 45
45 Transfer process Criteria for transfer Patient compliant
with medication and counseling Patient opioid-free; reduced other
drug use Patient responsible with take home medication and
prescriptions Patient has insurance
Slide 46
BBI Results Currently, 357 patients receiving full BBI services
in treatment program Approximately 6% drop-out from continuing
care
Slide 47
Number of Clients Still in Counseling after Transfer 47
Slide 48
Achievements 4 times as many buprenorphine slots in Baltimore
from 112 slots in 2008 to 506 slots in 2009 Four-fold increase in
physicians trained to provide buprenorphine from 50 to 200 Patients
receive buprenorphine within 48 hours of first treatment
appointment 48
Slide 49
Sustaining Efforts Medicaid Primary Adult Care expansion
Buprenorphine Medicaid Workgroup Increased Medicaid substance abuse
service reimbursement rates BBI Clinical Guidelines Revise for PAC
billing Recruiting for additional continuing care physicians
49
Slide 50
6 months later The demand for buprenorphine has been
overwhelming Patients are not getting PAC as quickly as you
expected Clinical supervisors are wondering what to do with
patients who continue to use cocaine or benzos BUT.. You just got
your first check from Maryland Physicians Care for $20,000 and even
got paid by Aetna for one patient Your treatment incompletion rate
has gone from 50% to 39% You are getting many more self-referrals
Staff morale has improved
Slide 51
Resources Healthcare Reform http://www.healthreform.gov/
http://www.healthreform.maryland.gov/
http://www.lac.org/index.php/lac/342
http://www.saasnet.org/drupal-6.6/taxonomy/term/18 ONDCP Drug
Control Strategy Information:
http://www.whitehousedrugpolicy.gov/strategy/
Slide 52
Resources Buprenorphine Information
http://buprenorphine.samhsa.gov/bwns/index.html
http://buprenorphine.samhsa.gov/bwns/tip43_curriculum.pdf
http://buprenorphine.samhsa.gov/bwns/presentations.html Dispensing
Regulations COMAR Title 10, Subtitle 19 (10.19.03) COMAR Title 10,
Subtitle 13 (10.13.01) Federal DEA Controlled Substances Act Title
21, Chapter 13, Subchapter 1, Section C
(http://www.justice.gov/dea/pubs/csa.html)http://www.justice.gov/dea/pubs/csa.html
Slide 53
Primary Adult Care A Limited Medical Assistance benefit
Slide 54
54 Maryland Medicaid Provides benefits for an average more than
850,000 people one in 7 Marylanders Costs nearly $7 billion in
state and federal funds PAC covers approximately 42,000 people (or
4.8% of the total Medicaid population)
Slide 55
55 Program Enhancements Effective January 1, 2010 substance
rates were increased for community providers HealthChoice and
fee-for-service rates were increased Substance abuse was added to
PAC
Slide 56
56 What is PAC? The Primary Adult Care (PAC) Program began in
July 2006 Federal eligibility requires that adults have dependent
children to be Medicaid eligible. PAC was developed to provide
benefits for adults without dependent children. Combined resources
from state programs in public health and Medicaid A Medicaid
program providing a limited benefit package for adults, including
primary care, pharmacy, and outpatient health benefits to those
over age 19 Eligible individuals must have incomes below 116% of
the Federal Poverty Level (FPL) Administered through 5
participating Managed Care Organizations (MCOs)
Slide 57
57 Who is eligible for PAC? Adults without dependent children
19 years or older who are: Maryland residents, Not on Medicare, and
U.S. Citizens and legal residents ( five years residency) Enrollees
do not need to have a medical disability to qualify Original income
and asset requirements: For an individual: income less than 116%
FPL and assets less than $4,000 For households greater than one:
incomes less than 100% FPL and assets less than $6,000 April 1,
2009 - regulations changed to exclude asset requirements and income
threshold is 116% FPL for all family sizes. This change mirrored
standards for families with children. Most persons with children
were also given the opportunity to receive full benefit
package.
59 Which health services are covered? PAC Covers the following
health services: Free primary health care Prescriptions drugs
Co-payment of u p to $2.50 for generic drugs and $7.50 for brand
name drugs (pharmacist can deny drug if copayment is not paid) Free
in-office mental health services through a counselor or
psychiatrist Limited lab and diagnostic services Community-based
substance abuse services (January 2010) Facility fees for emergency
room visits (January 2010) Some benefits are carved out and covered
fee for service, including Specialty Mental Health System services
and drugs, and HIV/AIDS drugs
Slide 60
60 How are services provided? Managed Care Organizations
receive a monthly capitation payment for each enrollee All MCOs
must participate in HealthChoice to serve PAC enrollees 5 MCOs
currently provide services to PAC enrollees Maryland Physicians
Care Priority Partners United Jai (Baltimore City & County
only) Amerigroup To search participating providers by MCO online:
https://encrypt.emdhealthchoice.org/searchable/main.action
https://encrypt.emdhealthchoice.org/searchable/main.action
Slide 61
61 PAC Expansion of Services PAC was scheduled to expand
services to enrollees in July 2009, but this has been delayed due
to budget limitations In January 2010, there were program changes,
including: Substance rates were increased for community providers
Substance abuse services are covered Some emergency room services
are covered
Slide 62
62 Codes and Rates for Self-Referred Community-Based Substance
Abuse Services ServiceCodeHCPC DescriptionUnit of ServiceNew Rate
Comprehensive Substance Abuse Assessment (CSAA) H0001Alcohol and/or
drug assessmentPer assessment$142 Individual Outpatient Therapy
H0004Behavioral health counseling and therapy Per 15 minutes$20
Group Outpatient Therapy H0005Alcohol and/or drug services; group
counseling by a clinician Per 60-90 minute session $39 Intensive
OutpatientH0015Alcohol and/or drug services; intensive outpatients
(treatment program that operates at least three hours/day and at
least three days/week and is based on an individualized treatment
plan), including assessment, counseling, crisis intervention, and
activity therapies or education. Per diem (minimum two hours of
service per session) Maximum four days per week $125 Methadone
Maintenance H0020Alcohol and/or drug services; methadone
administration and/or service (provision of the drug by a licensed
program) Per week$80
Slide 63
63 Total PAC Enrollment July 2006 December 2009
Slide 64
64 Five Counties with Highest PAC Populations CountyJuly 2008
Share of PAC PopulationDec 2009 Share of PAC Population Baltimore
City14,58650%19,46347% Baltimore County2,8149%4,26110% Prince
George's2,0307%3,1268% Anne Arundel1,2624%2,3356%
Montgomery1,4935%2,0275%