Dennis McCarty and Traci Rieckmann, Oregon Health& Science University
Twentieth Century alcohol and drug treatment programs tended to be small, free-standing, not-for-profit corporations that provided specialty addiction treatment services with minimal interaction with physicians and medical care. Certified counselors guided patients on the use of 12-step programs. Women and men who failed to maintain abstinence were discharged as non-compliant and told to return to care when they were ready to change. An autonomous treatment system developed because health systems and healthcare practitioners failed to address alcohol and drug use and aggressively discriminated against and stigmatized those struggling with substance use disorders.
The individuals and families struggling with addictive disorders and the communities they live in no longer can afford the shortcomings of segregated medical and behavioral health care. Patients and their families require nurses, physician assistants, and physicians who recognize and address alcohol and drug misuse and abuse. Patients and their families need licensed psychologists, social workers and counselors trained in treating addiction using evidence-based behavioral and pharmacological therapies. Patients and their families need access to recovery medications, and medical care for co-morbid medical complications of alcohol and drug use disorders. A 21st Century system of care for alcohol, tobacco and drug use disorders must be integrated with mainstream medical care.
The organization and structure of an integrated medical and behavioral health care system, however, must evolve and develop over time with active planning. Roles, responsibilities, and relationships must be negotiated. Efficient patient identification, treatment, and referral systems must emerge.
Health Care Transformation in Oregon. Oregon is at the center of this conversation. The Oregon Health Plan (Medicaid) is changing. State legislation authorized Coordinated Care Organizations (CCOs) (similar to the Affordable Care Act’s Accountable Care Organizations) and integrated care for alcohol, drug and mental health disorders within primary care systems to improve patient outcomes and reduce costs. Medicaid managed care organizations evolved in partnership with local stakeholders and consumers into CCOs and accepted a broad range of public health and population health mandates. CCOs are accountable for the cost of care, management of care, and access to care. CCOs receive a global budget that merges previously separated Medicaid funding streams for behavioral and physical health and creates incentives to incorporate behavioral health specialists to address alcohol, drug and mental health disorders as members of primary care medical teams. The Oregon Health Authority has approved 16 CCOs.
CCO Study. With support from the National Institute on Health (R01 MH1000001; R21/R33 DA035640), our multi-disciplinary study team uses mixed methods research to assess CCO implementation and the impacts on prevention and treatment for alcohol and drug use disorders. A review of the CCO applications, the transformation plans, and interviews with stakeholders in each of the CCOs provide initial descriptions of integration strategies.
Screening for alcohol and drug use disorders is one of 33 CCO performance metrics; incentive payments require CCOs to achieve specified rates for population based screening. CCOs must develop intervention and referral systems for linking those who screen positive to brief interventions and referral to care when required. Our study monitors Medicaid utilization data and tracks access to outpatient and residential care and prescriptions for medications to treat alcohol and opioid use disorders. We anticipate that more aggressive CCOs will adopt the National Quality Forum’s National Consensus Standard of Care for Substance Use Disorders. In addition to routine screening, the Standards require use of evidence-based pharmacological and behavioral therapies for alcohol, tobacco and drug use disorders. Changes in Medicaid utilization data should reflect implementation of these standards or failure to incorporate the standards into systems of care. Analyses also examine potential impacts on the number and costs of alcohol and drug related emergency visits and inpatient admissions.
To further understand variations in Medicaid utilization data, we interview CCO leaders, stakeholders, and providers. The interviews reveal CCO variation in adoption of standards, integration strategies, and roles for existing drug and alcohol treatment programs. CCOs differ in size, location, governance, and structure. Mixed methods analyses examine how these features affect change or lack of change in measures of integrated care.
The story is just beginning. We anticipate a complex set of case studies and aggregate summary analysis. Systems of care do not change without concerted attention and leadership. The analysis of Oregon’s healthcare transformation should facilitate an understanding of how 21st Century systems of care will mature and how integrated care enhances treatment for alcohol and drug use disorders.