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Part I: Looking into the "crystal ball"

July 15, 2010
by Dennis Grantham, Senior Editor
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Hyde, McLellan, and Compton envision the future at SAAS/NIATx gathering

Before a crowd of about 800 at this year’s State Associations of Addiction Services (SAAS) and NIATx Summit, three key officials—SAMHSA administrator Pamela Hyde, ONDCP deputy director Tom McLellan, and NIDA division director Wilson Compton—highlighted federal efforts and initiatives that will impact funding, care methodologies, care delivery, and technology implementation for providers of behavioral health and substance use treatment services now entering into what Hyde called “the brave new world” shaped by national health reform and parity.

Because 50 percent of adult mental health issues manifest symptoms before the age of 14 and 75 percent manifest before the age of 25, the trio emphasized the need to build a “system of prevention” implemented locally and focus community-based supports on children, adolescents, and young adults.

“Our number one priority is prevention,” asserted Hyde, who asked, “How can we develop emotionally healthy kids?” The key, she explained, is to reach them early by fostering the development of “prevention prepared communities,” or PPCs. McLellan remarked that such communities would foster coordinated programs among multiple groups—parents, schools, law enforcement, and local governments, for example—with the goal of surrounding young people with “relevant, age appropriate messages and interventions that span the timeframe of risk.”

“The antecedents are the same for the things that harm our young people—dropping out, bullying, depression, family issues,” he explained. “Yet, there is evidence that if you employ a practice that reduces even one of these factors, you can help to reduce all of them. Think of the policy implications: If you can get to age 21 without developing an alcohol or substance use problem, you probably won’t get one.”

At present, McLellan said that 164 agencies are working together to coordinate the goals, performance requirements, RFPs, and purchasing/grant processes used to drive the development of many types of PPCs. These groups are guided by five demand-reduction priorities developed by the ONDCP through a 35-agency workgroup that sought to link research, policy, and practical implications to guide programs:

1. Prevention
2. Screening and early intervention
3. Expanded access to treatment
4. Special SUD programs for offenders
5. Common means of performance management

While the federal government can provide strategic direction areas such as prescription drug abuse, suicide prevention, and grants for PPCs, Hyde emphasized the importance of local government action, noting—to a round of applause—that “the two most effective measures against alcohol abuse among youth are to raise alcohol taxes and get rid of happy hours.”

Interagency cooperation will also be critical to implementation of the many pieces of healthcare reform, said Hyde, noting that the effort will pan out in four ways:

1. Implementation of the Affordable Care Act;
2. Work with CMS to coordinate the addition of 16 million new Medicaid patients, five to six million of whom are expected to have significant behavioral health and substance use issues;
3. Evolution of SAMHSA’s block grant structure; and
4. Incorporation of parity requirements, which require that mental health and substance use treatments are managed and funded in a manner equal to other medical services.

“These are going to change the way we do business, who is eligible, and the nature of the services we provide,” says Hyde, adding that a major effort is now underway to define a range of services. “We’re looking at what ought to be provided across the continuum, then trying to define how the services will be paid for—what Medicaid must or will not pay for, what insurance will or will not pay for, and what block grants will or will not pay for.”

She also made plain the implications of these changes for providers in terms of operating income, referral structure, and technological capabilities. “For those of who don’t have a good means of billing Medicaid, I’d suggest that you develop it. For those of you who don’t have really good relationships with your FQHC and your primary care providers—I’d suggest that you get them. There are tremendous changes coming.”

Coming up next: How “medicalizing addiction” can make a difference—and what it means for providers.

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