Untangling the managed care system

Part II on treatment options under Affordable Care Act

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By La Risa Lynch

Contributing Reporter

The state's move to a managed care system for its Medicaid program is raising concerns among health care providers looking to enroll substance addicts in treatment programs via the Affordable Care Act, i.e. Obamacare.

In 2011, Illinois passed a law mandating that half of its Medicaid recipients be covered by managed care plans by 2015.

These plans are operated by state-contracted private health insurers like Blue Cross Blue Shield. Treatment providers must now be accepted into a health insurer's network. And many treatment providers find themselves negotiating with insurers to get the level of care needed for clients.

Habilitative Systems Inc. (HSI), an Austin-based organization, offers outpatient drug treatment and operates two residential facilities — Tabitha House, a 16-bed recovery home for women, and Empowerment House, a 32-bed halfway house for men who can stay up to four months.

The change to managed care, however, puts profit over people, insists Richard Jackson, vice president of external relations for Habilitative Inc.

Insurance companies, he said, will determine the length of treatment a person can receive "based upon financial determination, not anything to do with therapy or anything to do with the person's need."

Insurers, he explained, will push for fewer days in residential treatment and more outpatient care. But outpatient treatment is not adequate for many long-time drug users who are often low-income, homeless or on bad terms with their family, Jackson said.

Those individuals need more intensive case management in a sober environment to cope with stressors that could cause a relapse, Jackson said.

"Being in an outpatient program, they don't have very much chance of ever getting a foothold into being drug free," Jackson said.

Callie Haggie, addiction unit manager at LorettoHospital, agreed. Most people need residential treatment after detox since most long-term drug users likely won't stay clean after detoxing for just 72 hours, she said.

Loretto Hospital, 645 S. Central, is the only West Side detox facility west of Western Avenue. The hospital offers a 28-day residential treatment program that provides case management, housing placement and addiction education. Haggie said the hospital has a holistic approach to treatment that goes beyond detox.

That care, she said, could be compromised if insurers skimp on treatment    just paying for detox services and not for extended aftercare.

Treatment-on-Demand

For the past decade, U.S. Rep. Danny Davis (7th) has been leading a movement for "treatment on demand" – the idea that anyone who wants and needs substance abuse treatment should be able to get it promptly, regardless of their ability to pay.

"The idea being that the best time to service substance abuse users and individuals with mental health problems is when they decide that now is the time to get treatment," Davis said. "If they go seeking treatment and there is no treatment available for them, they may change their minds and never come back."

Delvertis Duke's plight — finding jail as his best option for treatment after years of drug abuse — shows how badly treatment-on-demand is needed. Davis hopes the Affordable Care Act is a move in that direction. The congressman also notes the high number of Americans who have used or become addicted to an illicit substance.

The National Survey of Drug Use and Health estimated that in 2012, 22.2 million people aged 12 or older, or 8.5 percent of Americans, were classified as having a substance dependence or abuse problem. Additionally, 20.6 million people needing treatment for drug and alcohol use but did not receive it, according to the agency.

Davis said many congressmen recognized this fact in deciding to include substance abuse treatment under Obamacare.

"You couldn't say you were doing any type of comprehensive health care unless you were making some attempt to deal effectively with the issues of substance abuse," according to the congressman.

In 2005, Davis backed a county-wide, non-binding ballot referendum to boost state funding to provide greater access to drug treatment — even as state budget cuts for substance abuse and mental health services loomed.

The referendum, he noted, raised awareness among state legislators about the importance of keeping funding levels for drug and mental health treatment on par with demand. But while the ballot initiative received more than a million votes, it did little to maintain funding for drug and mental health treatment. Since 2007, funding for addiction treatment from the state's general revenue fund dropped from $111 million to $65 million for the 2014 budget.

Daphne Baille of Treatment Alternatives for Safe Communities, Inc. sees the health care law as a move toward treatment on demand.

"This is a wonderful affirmation of what the voters asked for," said Baille, the organization's director of communications. "It shows that the policies being enacted are indeed responsive."

Her optimism is cautious, however. Greater access to treatment, she stressed, does not necessarily mean those who are in the throes of drug addiction will avail themselves of it.

"What the Affordable Care Act does is it is an avenue to pay for treatment," Baille said. "[ACA] reduces one of the burdens that have kept people from treatment."

Still, state officials contend that expanded Medicaid has had tremendous impact on recipients by providing mental health coverage, substance abuse treatment and prescriptions benefits. Illinois Department of Human Services spokesperson Januari Smith said these individuals are "full participants in our healthcare system," where they were disenfranchised before.

But in terms of access to substance abuse treatment, Smith said the agency has set up a care monitoring system. This, she explained, will continually review the type of services needed for each client, including the need for admission to residential treatment programs and outpatient services.

"We intend to make sure that every client has access to the right treatment, for the right amount of time, from the right provider," Smith said. "The review is to ensure that the client is making progress and is receiving the appropriate level of care."

Ultimately, experts say, treatment capacity will still have to be expanded. Also, reimbursement rates must be increased, as well as managed care concerns addressed, according top experts. Those and other issues will have to be worked out to approach true treatment on demand, experts insist.

CONTACT: larisalynch@yahoo.com

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