1. HOW TO PITCH SBIRT TO PAYORSPRESENTED BY:THE BIG INITIATIVE, NATIONAL SBIRT ATTC, NORC, and NAADAC May 8, 2014

2. HOW TO PITCH SBIRT TO PAYORSPRESENTED BY:THE BIG INITIATIVE, NATIONAL SBIRT ATTC, NORC, and NAADAC May 8, 2014

3. Webinar Facilitator and Presenter Eric Goplerud Senior Vice President Director, Substance Abuse, Mental Health and Criminal Justice Studies goplerud-eric@norc.org 301-634-9525

4. Produced in Partnership…

5. 2014 SBIRT Webinar Series • Archived - ACA and Addiction Treatment: Implications, Policy and Practice Issues • Archived - Overview of SBIRT: A Nursing Response to the Full Spectrum of Substance Use • Archived - SBIRT in the Criminal Justice System • Archived - Reducing Opioid Risk with SBIRT • Today – How to Pitch SBIRT to Payors • 5/14/14 - Treatment of Tobacco Dependence in the Healthcare Setting: Current Best Practices • 6/11/14 - Applying SBIRT to Depression, Prescription Medication Abuse, Tobacco Use, Trauma & Other Concerns • 7/9/14 - Training Integrated Behavioral Health in Social Work • 8/6/14 - Why Integrative Care? • hospitalsbirt.webs.com/webinars.htm

6. Access Materials • PowerPoint Slides • CE Quiz • Recording hospitalsbirt.webs.com/pitchingsbirt.htm

7. Ask Questions Ask questions through the “Questions” Pane Will be answered live at the end

8. Technical Facilitator Misti Storie, MS, NCC Director of Training & Professional Development NAADAC, the Association for Addiction Professionals misti@naadac.org

9. HOW TO PITCH SBIRT TO PAYORS

10. Alcohol as a cause or contributor to more than 70 diseases and injuries Under 35 Yrs Over 35 yrs Footer Information Here

11. Top 10 Leading Causes of Death in the United States for 2005 (CDC)

12. 8% 92% Estimated Percentage of Adolescents and Adults with a Substance Use Disorder (primarily alcohol use disorders) Recent estimates suggest that almost 8% of the US adults has a diagnosable substance use disorder (NSDUH, 2011)

13. How Many Get Identified? <0.8%of commercial health plan members, 1.2% Medicaid plan members are diagnosed (NCQA, 2010)

14. Substance use screening and treatment in health care: Adding burdens or solving problems : Guwande’sHandwashing and Anaesthetics

15. Where are the patients? Settings where Unhealthy or Dependent Use is common

16. Hotspot 1: Hospitals

17. Screening and Treating Acutely Ill and Injured Patients with Comorbid Substance Use Cochrane Collaboration review (McQueen et al, 2011) 14 RCTs, adults and adolescents Outcomes favor BI over non-treatment controls Significant drop in 6 month alcohol consumption Significant drop in alcohol consumption at 9 months Self Report at 1 year favor BI Significantly fewer deaths at 6 months and 1 year

18. Alcohol Disease Management Utilization and Costs to a Health Insurance Plan Rehabilitation facilities days decreased 67% BH inpatient days decreased 68% Medical inpatient days decreased 4% ER visits decreased 24% Partial Hospital and IOP visits decreased 69% Psychiatrist visits increased 44% Therapist visits increased 35% AUDIT score decrease 80% Net total medical cost savings (ROI 2:1) 34% Trauma Centers: 60% injured have substance use disorders 18 (N = 358, 12 month continuous enrollment prior and post enrollment)

19. Trauma Recidivism - Statewide injury recurrence days follow-up

20. Changes in Alcohol Intake (p = 0.01) 6 month follow-up 12 month follow-up

21. Net cost savings -- $89/patient screened, or $330/patient offered a brief intervention Savings of $3.81/$1 spent Potential savings if universal trauma center SBI -- $1.82 billion annually (2000 $)

22. 9 NNT to reduce 1 DUI arrest ~2000 DUI incidents/arrestee

23. Screening and Brief Interventions in Hospital Emergency Departments Systematic review of ED SBI 12 RCTs with pre- and post-BI results 11 or 12 observed significant effects on alcohol intake, risky drinking practices, alcohol related negative consequences, injury frequency Nilsen et al, J Sub Ab Treat. 2008

24. Consequences that matter to hospitalsUnstable discharges, rehospitalization risk

25. Hospital Accreditation and Performance Metrics CMS Inpatient Psych Incentive 2014 SUB-1 American College of Surgeons-Committee on Trauma Accreditation Requirements Joint Commission SBIRT Metrics

26. Practical Examples of Hospital SBIRT Falmouth Hospital (MA) Denver General Hospital (CO) Gunderson Lutheran Hospital (WI) Oregon Health Sciences University (OR) Christiana Hospital (DE) Salina Regional Hospital (KS) Temple University Hospital (PA)

27. 100 Bed Med-Surg Hospital; 50 Bed Addiction Treatment Center Courteous but Distant Neighbors since 1982 Mutually Necessary but not Collaborative Gosnold “a place to send ‘those’ people” SO WHAT CHANGED??? Collaborations between Substance Use Programs and Hospitals: Gosnold-Falmouth Hospital

28. ICU Transfers -- Pre & Post Project PRE POST Cost per day Med-Surg Floor vs. ICU 30%-40% LOWER IN MED-SURG

29. Average Length of Stay Before Collaboration 14.6 Days After Collaboration 6.2 Days

30. Project Engage at Christiana (DE) Hospital Targeting hospitalized substance users at withdrawal risk, significant comorbid addiction Bedside Peer-to-Peer intervention using Motivational Interviewing Addictions Community Social Worker to assist in removing barriers to transition to care and help with integration into the hospital milieu

31. Preliminary Claims Analysis Modified from Wright, Delaware Physicians Care Inc, 2010

32. Claims From Next 2 Cohorts Modified from Wright, Delaware Physicians Care Inc, 2010

33. Salina Regional Health Center Outcomes • 199 Bed Acute Care Regional Health Center-Level III Trauma Center • 27,000 ED presentations per year • Alcohol/Drug DRG was 2nd most frequent re-admission • Services provided • 24-7 coverage of ED • Full time SUD staff on medical and surgical floors • Warm hand off provided to all SUD/MH services • Universal Screening and SBI beginning in 2013 • Re-admission DRG moved from 2nd to 13th • 70% of alcohol/drug withdrawal LOS were 3 days or less • 83% of SUD patients triaged in ED were not admitted • 58% of patients recommended for further intervention attended first two appointments (warm hand off) • Adverse patient and staff incidents decreased by 60%. • CKF detox admissions increased 450% in first year • 300% increase in commercial insurance reimbursement

34. Hotspot 2: Prenatal Screening and Case Management

35. Kaiser-Permanente Northern California’s Early Start:A transformational program that is cost beneficial • Universal Screening of ALL pregnant women • Screening questionnaire • Urine toxicology (with consent) • Place a licensed mental health provider in the department of OB/GYN • Link the Early Start appointments with routine prenatal care appointments • Educate all women and providers

36. Rate of Preterm Delivery (<37 Weeks) Note: The rate of Preterm Delivery is 2.1 times higher in S group than SAF (Early Start patients)

37. RATE OF NEONATAL ASSISTED VENTILATION The rate of the babies needing a ventilator is 2.2 times higher in the S group that the SAF and 3.1 times higher than the controls.

38. RATE OF INTRAUTERINE FETAL DEMISE (stillborn) Stillborns (IUFDs) were 14.2 times more likely in the S group than the SAF or C groups

39. Maternal and Infant Mean Costs Comparison Positive Screen, No SA Treatment

40. Hotspot 3: Youth and Young Adult High Risk Users

41. Data were pooled from 16,915 adolescents from 148 local CSAT-funded programs and followed quarterly for 6 to 12 months In 2009 dollars, adolescents averaged $3,908 in costs to taxpayers in the 90 days before intake ($15,633 in the year before intake). This would be $3.9 Million per 1,000 adolescents served. Within 12 months, the cost of treatment was offset by reductions in other costs producing a net benefit to taxpayers of $4,592 per adolescent. Teen and Young Adult School Health and Ambulatory Health SUD Treatment

42. Hotspot 4: Ambulatory Primary Care SBIRT

43. Screening and Brief Substance Use Treatment Reduces Healthcare Costs

44. Impact of SBI on Utilization in an Employment-Based Health Plan • BH inpatient days decreased 63% • Medical inpatient days decreased 51% • ER visits decreased 20% • Partial Hospital and IOP visits increased 81% • Psychiatrist visits increased 31% • Therapist visits increased 22% • Net total medical cost savings 15% (N = 247, 12 month continuous enrollment prior and post SBI)

45. Hotspot 5: Treatment of SUDs with Medications

46. Baser O, Chalk M, Fielin DA, Gastfriend DR. Cost and utilization outcomes of opioid-dependence treatments. Am J Managed Care, 2011:17(6);S235-248.

47. Baser O, Chalk M, Fielin DA, Gastfriend DR. Cost and utilization outcomes of opioid-dependence treatments. Am J Managed Care, 2011:17(6);S235-248.

48. Baser O, Chalk M, Fielin DA, Gastfriend DR. Cost and utilization outcomes of opioid-dependence treatments. Am J Managed Care, 2011:17(6);S235-248.

49. Comparison of Massachusetts Medicaid Treatment Alternatives: 2003-2007 Clark RE, Samnaliev M, Baxter JD, Leung GY. The evidence doesn’t justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine. Health Affairs. 2011:30(8);1425-1433.

50. Baser O, Chalk M, Fiellin DA, Gastfriend DR. Alcohol dependence treatments: comprehensive healthcare costs, utilization outcomes, and pharmacotherapy persistence. Am J Manag Care. 2011:17(8);S222-234.