Navigators and assisters have hit the streets for round two of open enrollment for health insurance plans available as a result of the Affordable Care Act. With more people gaining access to care, this is a crucial time to strengthen the way we provide and pay for health care. Integrating services for drug and alcohol problems with other care can play a big role in transforming the health system and meeting goals of better care, better health and lower costs. The Centers for Medicare and Medicaid Services (CMS) are promoting this change in Medicaid, following a few states that are leading the way. Improving care for substance use disorder under Medicaid, which now covers at least 8 million people with substance use disorders, has the potential for profound change nationwide.

Let’s take a look at some service delivery innovations already underway. Washington state is using a prevention and early intervention model called SBIRT – screening, brief intervention, and referral to treatment to help prevent and treat drug and alcohol problem. This initiative reduced hospitalizations among Medicaid enrollees and led to significant savings for the state. Massachusetts saved money and improved care for Medicaid enrollees through medication-assisted treatment (MAT), which combines counseling with prescription drugs that blunt addiction. The research for MAT is strong but states are often reluctant to support it because it conflicts with traditional abstinence-based treatments. Massachusetts has opened the door for other states to use this evidence-based practice.

CMS is launching an initiative to promote more of this type of innovation by highlighting state successes, providing technical assistance and building a cross-state learning community. CMS spotlighted these best practices in a recent memo:

  • Provide a comprehensive benefit package for substance use disorders ranging from prevention to treatment to recovery services.
  • Integrate care for physical and behavioral conditions, incorporating the whole health of the patient by using health homes, primary care medical homes, and other integrated care models.Coordinate care across transitions in both physical and behavioral health care.
  • Implement prevention efforts and strategies to alleviate prescription drug misuse.
  • Head off alcohol and drug misuse in youth, including strategies in primary care such as Screening, Brief Intervention, and Referral to Treatment (SBIRT).

Advocates should urge their states to sign up for the Medicaid Innovation Accelerator Program (IAP) to learn from other states and get technical assistance from CMS. The program will feature monthly calls and webinars as well as hands-on support in preparing the technical documents (waivers or state plan amendments) that may be needed to help transform Medicaid to better treat substance use disorders. The deadline for submitting an "Expression of Interest" is this Friday, November 21. CMS is requiring stakeholder input from states that are selected to participate.

This initiative in Medicaid, coupled with other transformation projects, such as Accountable Care Organizations and the demonstration projects for people eligible for both Medicaid and Medicare, will help make our health system work better for all of us, including individuals with substance use disorders.

Impressive enrollment and reenrollment efforts are expected over the next few months. Let’s leverage this momentum and ensure all consumers – especially those with behavioral health care needs – have access to a coordinated and effective health care system.

Melissa Ough, policy analyst
and Alice Dembner, project director

We’re Calling the Play: Ready, Set, Enroll!

 The Affordable Care Act’s second open enrollment period starts tomorrow! On Saturday, November 15, millions of Americans can begin enrolling in and renewing their quality, affordable health coverage through the Marketplaces. Consumer health advocates and enrollment assisters have been planning for months, further developing the strategies they employed last year to reach the remaining uninsured and assist them with enrolling in coverage. To view the immense impact of their work last year, please watch our video: Getting to Covered.

 They are up to the task and will use innovative tactics, tools and tested messages to meet the goal for this open enrollment period.  Like a head coach before kickoff, we know advocates and enrollment assisters are fine tuning their game plans for this open enrollment season. Perhaps the biggest difference for this season is that advocates and enrollment assisters have two important audiences during this enrollment season: 1) the currently enrolled who need to renew and 2) the remaining uninsured. To reach these groups, we’ll have to use two playbooks.

Playbook 1: Helping Insured Consumers with Renewals

While recent research shows that the majority of consumers who enrolled last open enrollment season are satisfied with their plan, this same research also shows that most of the currently-insured are unaware of the renewals process. Though many consumers will be auto-enrolled in their 2014 plan, the features and benefits of their plan may change beginning in 2015, as well as the amount of financial assistance they may receive. To help ensure consumers enroll in the plan that best meets their needs, advocates and enrollment assisters should encourage currently-insured consumers to review the features of their current plan. In addition, we should work with people who have Marketplace plans to update their information so they continue to receive financial assistance. Lastly, consumers who need to renew should be encouraged to shop around to see if a different plan better meets their needs. Since the currently-enrolled value their coverage and are motivated to keep it, helping them renew hinges on letting them know what they need to do and when.

Playbook 2: Reaching the Remaining Uninsured

While the uninsured rate has dropped from 18.1 to 13.4 percent, which is the lowest uninsured rate since 2008, there are still millions of uninsured Americans in need of affordable coverage. Recent focus group research concluded that the remaining uninsured are less motivated to enroll than the those who were uninsured last year. In addition, they report that cost remains their main barrier to enrollment. However, many of the remaining uninsured are still unaware of the availability of financial assistance to help pay for the cost of premiums and cost-sharing obligations. Messages emphasizing that low-cost plans and financial help are available, as well as in-person application assistance, will be most effective at galvanizing the currently uninsured to explore their Marketplace plan options.

Knowing messages about financial help and in-person assistance are the most likely motivate consumers, what are the best ways to spread this message? Last year we learned that meeting consumers where they are, such as local, highly-frequented venues within the community, was a highly-efficient approach to reaching large amounts of community members in a small period of time. Additionally, using trusted messengers to spread enrollment messages, such as faith leaders, local or ethnic media sources, and family members, was a successful strategy to ensure those messages resonated with consumers. Lastly, lifting up the voices of those who’ve successfully enrolled through story banking can be a compelling way to motivate the remaining uninsured to explore their options.

Having groups of consumers with distinctly different enrollment needs is a change from last year’s open enrollment period, but the tools to achieve both goals are already in the hands of those who contributed to open enrollment’s success last year. Spreading the word about things that matter most to consumers – the renewal process, financial help, and in-person assistance – and using these messages by building on last year’s successful  tactics and strategies, is the playbook to follow to ensure millions of Americans gain or keep quality, affordable health coverage.

 “The healthcare world is changing; providers who have been serving a certain population are now serving a completely new population, a more diverse population. When you talk about cultural competency, what you really need to look at is what the customs, beliefs and values of these individuals are.”

Dr. Terri Mack-Biggs, Geriatrician, Hospice of Detroit, Michigan

There is a significant demographic shift taking place in the United States, particularly for older adult populations. According to the Diverse Elders Coalition, the older population will grow far more diverse in racial, ethnic and cultural dimensions over the coming few decades, as the cohort of Americans age 65 and older doubles in size from 2010 to 2050. A particularly vulnerable population within this broad demographic shift is the Medicare-Medicaid enrollee population, sometimes referred to as “dual eligibles.” According to data from 2008, 61 percent of dual eligible beneficiaries are 65 and over. They have trouble navigating through these two complicated health care systems, often feeling lost in a maze of multiple doctors, medications and programs, and these challenges are often exacerbated for individuals from communities of color.

The Centers for Medicare and Medicaid Services’ financial alignment demonstration projects currently underway in more than a dozen states seek to integrate and coordinate care across Medicare and Medicaid for dual eligibles, and to redress many of the problems experienced in the current disjointed system.

Dual eligibles generally have poorer health status and account for a significant and disproportionate cost burden on Medicare and Medicaid, totaling more than $300 billion annually. People of color comprise 44 percent of the Medicare-Medicaid enrollee population, compared to 17 percent of the Medicare-only population. Diverse dual eligibles face a particularly great challenge in finding culturally and linguistically competent care.

A new paper by Community Catalyst examines provisions in the documents guiding the demonstration projects as they relate to addressing racial and ethnic health disparities and lays out a set of recommendations to move toward achieving health equity for dual eligibles. There is much work to be done. As Patrick Aitcheson of the Diverse Elders Coalition explains, “Equitably meeting the health care needs of diverse populations first requires gaining a deeper understanding of the range and richness of the cultural and linguistic groups you are serving. That is the necessary starting point for delivering culturally competent services.”

Findings from Community Catalyst’s survey of the dual demonstration project documents published to date reveal that while the addressing of health disparities is often present as a broadly stated goal, details of how this goal will be operationalized are largely missing. The paper makes recommendations in the following areas:

Cultural Competency in Care Delivery - The rapidly changing landscape calls for increased training of health care professionals and organizations to provide effective, high-quality care that is responsive to the very diverse cultural and linguistic needs of dually eligible beneficiaries of color.

Language Access - Implementing appropriate language access services can reduce barriers and create clearer pathways for dual eligibles to access the right services, which in turn can improve their health,   their satisfaction with the care they receive, and very often reduce costs by more efficiently connecting beneficiaries to the proper services for their needs.

Quality and Monitoring – Ongoing monitoring and development of appropriate quality measures can lead to a more effective demonstration project.

Consumer Engagement – Having representatives from communities of color participating in consumer engagement opportunities is  critical  to ensuring consumers receive the right services, at the right time in the right setting.

The Centers for Medicare and Medicaid Services, participating states, health plans and providers have a unique window of opportunity in these demonstration projects to improve care for dual eligible beneficiaries of color and point the way forward for the health care system more widely. But success will depend on these stakeholders taking concrete, targeted steps to address health disparities, as well as on strong ongoing involvement by consumers from communities of color and their advocates.

Adolescent drug and alcohol abuse is a major public health issue that has been gaining national attention recently as more and more young people die from opioid overdoses. The prevalence of adolescent drug use is staggering. Imagine a classroom of high school seniors. Using national data, we can estimate that in a class of 30, about 12 adolescents used alcohol and seven used marijuana in the past month. Five adolescents abused prescription drugs in the past year. This is especially troubling given that 90 percent of adults with drug or alcohol dependence began using before age 18.

There are many efforts under way to address this epidemic. The latest is a guide from the National Association of State Alcohol and Drug Abuse Directors (NASADAD) to help state agencies enhance the adolescent addiction treatment and recovery systems, maximizing the opportunities afforded by the Affordable Care Act (ACA). The ACA expands coverage for behavioral health treatment, promotes prevention efforts, and encourages the integration of physical and behavioral health. This generates new opportunities for providers to tackle adolescent substance use; but providers can’t do it alone.

The State Adolescent Substance Use Disorder Treatment and Recovery Practice Guide outlines principles of good care, specific guidance for providers on delivering treatment, and considerations for decision makers who coordinate services for adolescents. Treatment standards and guidelines from 24 states were used to craft these recommendations. Though targeted to the state agencies that oversee substance abuse treatment, the underlying principles are relevant for state officials, providers and advocates alike.

Most importantly, we need to catch adolescents upstream, before a problem begins. Simple, quick screenings can be conducted by a wide range of people, from school counselors to community outreach workers to pediatricians. One specific approach that fulfills the recommendations from the report is called SBIRT (screening, brief intervention, and referral to treatment). SBIRT is an effective prevention tool that can be used in a variety of medical and nonmedical settings. It involves asking young people a few questions about their drug and alcohol use and providing guidance or referring to treatment, if a problem exists. Community Catalyst is leading a national project to promote SBIRT for youth.

For young people who require treatment, we need to recognize that the available treatments for addiction are largely designed for adults. Adolescents benefit the most from specialized services geared toward their emotional and physiological development.

States should adopt systems of care that are recovery-oriented and promote best practices for reaching and treating young people. Services provided using this philosophy are person-centered—the young person directs their treatment as they draw on their own priorities and personal goals for recovery. This approach often employs peer support and mentors, which are key ingredients in a young person’s recovery.

It’s also important to remember that adolescents with addiction often receive fragmented services through multiple state systems (e.g., child welfare and juvenile justice). States can address this through better coordination of services across youth agencies, and a more streamlined continuum of care.

These are just a few key takeaways from the report, which provides a roadmap to addressing adolescent substance use statewide. Only with a coordinated approach, supported by best practices from the field, can we begin to tackle this epidemic. The ACA means that more young people will have insurance coverage, access to screening and expanded and improved behavioral health treatment. States should seize this opportunity to build comprehensive, state of the art systems of care, which will protect young people now and head off future addiction among this generation. 

--- Melissa Ough, policy analyst 

Recently, I had the great pleasure of welcoming participants – advocates, providers, health plans and funders -- at the second annual Voices for Better Health grantee convening. When we first met a year ago, the Centers for Medicare and Medicaid Services (CMS) was just at the beginning of launching a set of demonstration projects for individuals with both Medicare and Medicaid (dual eligibles). At the time, Washington state was four months into a health homes demonstration and Massachusetts was a mere three weeks into its managed care (fully capitated) project. So much has happened in the past year: seven states have now launched their projects, more than 200,000 beneficiaries are now enrolled and several more projects are set to begin in the next few months.

While the goal of these projects is to provide high-quality, cost-effective, integrated care to dual eligibles, some of the most vulnerable people in this country, it will be a long time until we know whether that has been achieved. Until then, we see both the promise and the pitfalls illustrated in two stories I shared with convening participants:

First, the promise:

Maria, a middle aged woman with complex medical and psychiatric needs, had approximately 30 Emergency Room visits in the two months prior to enrolling in the demonstration. She has a chronic substance use disorder and has few social supports. She had no effective primary care and her complaints were not validated or listened to. After an initial assessment by her new plan, her care team came together, collected all of her medical records and worked with her to identify a primary care provider and specialists. She received daily support from her care team. Her care manager and behavioral health specialist were available to answer her phone calls, visit her in her home, and accompany her to appointments. Maria has engaged in psychotherapy and psychopharmacology treatment. She is going to the Methadone Clinic daily. Her care team is working to help her with other supports including a change in her living circumstances. She has not had any Emergency Room visits or hospitalizations since she joined

Now the pitfalls: 

Angela has been living with a spinal cord injury for many years and is confined to a wheelchair. For 20 years, she had the same care manager who worked with her to develop a care plan that allowed for a team of personal care attendants to assist her with her activities of daily living. Earlier this year, she received a letter saying she would be enrolled in a new demonstration project and that she needed to select her health care plan. Her deadline for choosing her plan came before any information was available about the plans’ networks. Since that time, the care plan that she had so carefully crafted disappeared. And, months later, she still does not have a new care plan. She has had trouble finding a primary care doctor that is participating in the demonstration or accepting new patients. But, most importantly, the individual caregivers that came into her home to help her can no longer come because they’re not able to get paid through the demonstration.    

These two stories show that the demonstrations are still works in progress. We are very grateful for the leadership and hard work coming out of CMS and, in particular, the duals office. They have been responsive to the concerns of consumers in the design and early implementation. We know that transforming the health delivery system to make it work for dual eligible beneficiaries is a challenging endeavor. Meeting those challenges will not be easy. But to tackle those challenges, consumers, their advocates and allies – like those taking part in the Voices for Better Health convening – must stay engaged throughout each stage of the process: the design, implementation and monitoring.

It is only through this type of engagement that we can realize the vision of a more just, equitable health care system that provides high quality care to the most vulnerable people and allows them to live their lives with dignity and independence.