Health reform is forcing hospitals to address the untreated substance use problems that cause unnecessary readmissions, but a leading physician and researcher says the current vehicle for integrating general health and substance use treatment has largely failed. In fact, David Gastfriend, MD, told a National Conference on Addiction Disorders (NCAD) audience Aug. 3 that the initiative known as “SBIRT” is backwards.
Rather than a progression from Screening, to Brief Intervention, to Referral, to Treatment, the new paradigm should list treatment first, leading to the new and opposite acronym T-RIBS, said Gastfriend, who currently serves as scientific adviser to the Treatment Research Institute (TRI) after stepping down as the organization's CEO at the end of June.
In other words, if health systems can identify hospitalized patients with significant substance use treatment needs, and specialty addiction providers can demonstrate effective care for them, generalist physicians will come to believe that the screening of many more individuals for substance use problems is warranted. Rather than approaching hundreds of thousands of patients with SBIRT, the new T-RIBS model would focus on fewer patients who are likely to benefit from treatment.
“If you start by showing that you can take care of a sick patient, the physician will remember that case,” Gastfriend said in his morning plenary talk. Do that many times over, he said, and hospitals will want to partner with specialty providers, “because hospitals are becoming accountable care organizations.”
The Affordable Care Act (ACA) is imposing penalties for preventable readmissions, a huge problem that accounted for an estimated $800 million in Medicaid costs in New York state alone in 2007. Gastfriend warned that under the ACA, the federal parity law, and the Health Information Technology Act, the tying of funding to accountability will reach the addiction treatment arena as well.
“The wave hasn't crashed on us yet, but it's coming,” Gastfriend said. “Get your surfboards ready.”
Under the new integration paradigm that Gastfriend envisions, a computer algorithm could use patient histories and current health markers to identify the most at-risk patients, who then could be introduced to a specialty provider while still in the hospital. At that time, “You could also have the counselor meet with the family,” he said.
Turn up the quality
In his talk titled “Precise Data for Imprecise Behavior: Why National Standards Make a Difference,” Gastfriend bemoaned a lack of outcome and program quality data that plagues the addiction treatment field vis-à-vis other branches of healthcare. Comparatively, “We look like we're some cult—we need to fix that,” he said.
He discussed numerous initiatives that he and the Philadelphia-based TRI have been involved in to give providers and consumers more tools for sound treatment matching and the identification of effective programs. TRI drafted a consumer guide focusing on adolescent treatment, listing key elements of high-quality care for youths.
Gastfriend was instrumental in the establishment of software to guide providers through the important but complex ASAM Criteria for patient placement, to assist an assessment process that he said up to this point has been “a sorry state of affairs,” adding, “It is not good enough for modern medicine.”
And this fall, the Kennedy Forum (established by former U.S. Rep. Patrick Kennedy) and TRI plan to release an online appeals guide designed to give consumers and families one common format for challenging inappropriate managed care denials. Gastfriend said these challenges, including at the court level, often have to be pursued in the early years of a new legislative mandate.
He also pointed out that more widespread use of standardized assessment and treatment protocols will inevitably lead to a better reception from managed care, or at least a fairer one. “Managed care [utilization review] will be more equitable; we'll be discriminated against like medical/surgical” Gastfriend said with a grin.