11/18/2015

The Health Care Costs of Stigma

Sosunmolu Shoyinka, M.D. Medical Director Cenpatico & Sunflower Health Plan

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• Drugs of abuse

– Illicit drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants.

– Legal substances like alcohol and cigarettes, and increasingly, marijuana.

– Also synthetic or plant- derived substances (“legal highs”, Kratom)

– Prescription-type psychotherapeutics (pain relievers, tranquilizers, stimulants, and sedatives) used non-medically.

• Addiction costs $700 billion annually in

treatment costs, crime and lost productivity

NSDUH 2013

Statistics

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• A leading cause of disability worldwide.

• 43.7 million (18.6%) of Americans (>18) experienced mental

illness (MI).

• In the past year, 20.7 million adults (8.8%) had a substance use disorder.

• 8.4 million people had both a mental disorder and substance use disorder (co-occurring mental and substance use disorders).

• Cost: over $700 billion annually from

crime, lost work productivity and health care

SAHMSA 2013, NIDA 2014

SUD Prevalence

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SAHMSA 2013

SUD Health-Related Costs Health Care Overall

Tobacco $130 billion $295 billion

Alcohol $25 billion $224 billion

Illicit Drugs $11 billion $193 billion

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Access to Care

• Individuals with SUD often do not get the care they require due to

– Stigma. – Poverty. – Insurance barriers, historically – Provider/system barriers.

• In 2009, only 2.6 million (11.2 %) of those who needed treatment received it at a specialty facility.

– <1/3rd of those who do get treatment receive

care considered to be minimally adequate

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• Individuals with co-occurring substance use and mental health disorders generally have higher health care costs

• Medical Costs are 2-3 times higher than for those who don‘t have the comorbid MH/SUD conditions

• Estimated $293 billion in 2012 across commercially-insured, Medicaid, and Medicare beneficiaries in the United States

Cost of Untreated Behavioral Health Disorders

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A Centene Health Plan

Acute Medical Inpatient Utilization (% of all admissions)

1. Substance Use Disorders 23% 2. Cardiac conditions 7% 3. Abdominal pain 5% 4. Asthma/Emphysema 3% 5. Diabetes 1%

Behavioral Health Outpatient Spend (Highest cost by code)

1. H0020 Methadone 2. H0011 Acute Treatment Services 3. H0010 Clinical Support Services

Prescription Drug Spend (Highest cost by drug/category)

1. Suboxone 2. Insulin 3. HIV drugs

Data is for the 12 months ending May 31, 2015

3

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Average Medicaid Medical Expenditures per Person per Year

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Percent Newly Diagnosed with Hypertension or Cardiovascular Disease

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Mortality Statistics

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Difference Between Groups in Annual per Person Medical Costs in SFY 2008

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Relative Risk of Death by SFY 2008

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Substance Use Disorder Treatment Makes a Difference

• A ranking of 25 preventive services recommended by the United States Preventative Services Task Force (USPSTF) based on clinically preventable burden and cost effectiveness found that alcohol screening and intervention rated at the same level as colorectal cancer screening/treatment and hypertension screening/treatment.7

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Systemic Stigma • Stigma remains a barrier to recovery

• Manifests as discrimination in areas of health care, education, financial assistance, and employment.

– employers turn away recovering individuals that report their drug histories 75% of the time (Marks, 2002)

• Also manifests as treatment denied or restricted.

• Results in individuals not seeking treatment.

• Individuals with SUDs have valid concerns related to getting treatment.

– negative effects on their job (13.3%) – neighbors and the community will have a negative opinion of them (11.0%) – May lead to lack of health care coverage (36.3%)

(NSDUH, 2007)

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Inequitable Coverage of SUD Treatment = Systematic Stigma

• A large percentage of this population reports not

receiving treatment.

– 20.8 million of the 23.2 million people needing treatment for drug or alcohol use did not receive it (NSDUH)

• Funding often does not match needed services.

• Public payers accounted for the majority of the expenditures.

• Private insurance payments grew at an average rate of 0.1% annually 1993-2003, compared with the private payment annual growth rate for all health care of 7.3% (Marks et al., 2007).

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Affordable Care Act and Parity

• Mental health and substance use disorders are considered an “essential health benefit”

• Individual plans available on the Health Insurance Marketplace offer benefits that cover mental health and substance use disorder treatment equally with medical benefits

• Applies to all small group and individual market plans created after March 23, 2010.

– For those with other plans, such as those provided by large employers, it’s more of a gamble.

• Although the Mental Health Parity and Addiction Equity Act (MHPAEA) passed in 2008 to address the issue of unequal coverage, there are many exemptions to MHPAEA.

• Many employers are not required to offer coverage under the MHPAEA. The law only requires that employers who do offer coverage for mental health and addictions treatment "to offer coverage for those services that is no more restrictive than the coverage for medical/surgical conditions." (SAMHSA, 2014)

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The Business Case for SUD Coverage and Treatment

• Every dollar spent on substance abuse treatment saves $4 in healthcare costs and $7 in law enforcement and other criminal justice costs. 10

• Treatment costs $1,583 per patient and is associated with a cost offset of $11,487, representing a greater than 7:1 ratio of benefits to costs.

• Some states have found that providing adequate mental health and addiction-

treatment benefits can dramatically reduce healthcare costs and Medicaid spending.

• For example, providing a full addiction-treatment benefit resulted in a per-patient savings of $398 per month in Medicaid spending.12 (Washington State)

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• Randomized trials of Screening and Brief Intervention for substance use disorders show that the intervention saves money and improves outcomes.

• UK: $2.30 cost savings for each $1.00 spent in intervention

• US Level 1 Trauma Center: $3.81 cost savings for each $1.00 spent in intervention

• U.S. Primary Care Clinic: $4.30 cost savings for each $1.00 spent in intervention.

The Business Case for SUD Treatment

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The Business Case for Effective Substance Use Disorder Treatment

• Kaiser Permanente Northern California analyzed the average medical costs during 18 months pre and post SUD treatment.

– SU treatment group 35% reduction in inpatient cost, 39% reduction in ER cost, and

a 26% reduction in total medical cost, compared with a matched control group. 8,9

• Family members of patients with SUD disorders had high healthcare costs

and were more likely to be diagnosed with a number of medical conditions than family members of similar persons without a SUD condition.

• Families of SUD patients who were abstinent at one-year after treatment began, the healthcare costs of family members were no longer higher than other Kaiser members.

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• Washington State compared disabled Medicaid enrollees receiving SU treatment with

the untreated population.

– average monthly medical costs were $414 higher for those not receiving treatment – with the cost of the treatment added in, there was a net cost offset of $252 per month or $3,024 per year

• For individuals with opiate-addiction, cost offsets rose to $899 per month for those who remain in methadone treatment for at least one year

• Washington State: Prior to their SU treatment expansion initiative, healthcare costs for Medicaid disabled clients with SU problems were rising at a rate of 11% per year.

• Under the SU treatment expansion initiative, the growth in healthcare costs was slowed to 2.8% per year.

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The Business Case for SUD Treatment

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Benefits of Implementing a Recovery-oriented System of Care in Connecticut

• Applying recovery-oriented strategies to the Opioid Agonist Treatment Protocol (OATP) produced the following results:

– 69% fewer admissions to costly acute inpatient care, including detoxification, six months after the implementation of the initiative.

• Individuals participating in residential detoxification - 35% more likely to obtain follow-up care than individuals not in OATP

• At 6 months in OATP, the days between discharge from the OATP inpatient episode and readmission to acute care increased - 30 days to 234 days on average

• Dollars saved in reducing more expensive acute care episodes and in reducing the numbers of admissions were reinvested in other parts of the system

• Acute care claims expense for OATP clients decreased during the past 5 years as a recovery oriented system was implemented

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Conclusion