Okay.  Good.



I want to chime in as well.  This is Monica.  We here, at Great Lakes ATTC, we also provide workshops on trauma-informed care and actually have projects.  Next week, we’ll be at the Michigan Substance Abuse Disorder Conference, and we’re actually having a workshop on strength-based approach towards common treatment and recovery support for women.

So, if you’re interested, I can send you more information, and I’ll make an announcement.  I’ll send some information through e-mail as well where you can get some of our resources.  If you’re interested in any of our workshops in our four state region, I can send you that, and then, I can also provide national contacts for those who are not in our four state region.



Okay, fine.  That will be on your website, right?






Okay, very good.



Thanks for adding that, Monica.  Now, to address the second part of your question which was, “Where do evil capitalist fit into this situation?”  I would say it depends on what opportunity they see.  There’s going to be the potential for tremendous expansion in capacity of care for medical care, for substance abuse, and for mental health care created by this insuring of people who haven’t been insured before.

The studies that have been done by the National Association of State Alcohol and Drug Abuse Doctors looked at the impact of substance abuse care, the expansion of coverage for low income people in Massachusetts, Vermont, and Maine.  They saw quite a range, but in Massachusetts, there was a 20% expansion in demand for substance abuse treatment.  The other states were quite a bit larger.  A single state agency director from Massachusetts always reminds me that they already had a pretty high level of insurance coverage in Massachusetts before they did their health care reform.  So, that 20%, if it is applied to a state like Illinois, is going to be much larger.

So, there’s going to be a lot of need for new players, new partners, and so, this is the time for people who are serious about providing good care to think about who you want to be serving in the next three to five years.  In a state like Illinois, there’s also going to be a great expansion in Medicaid managed care.  The state legislature passed the law.  The governor signed it in January.  It is going to happen.  So, there is a big expansion in the insurance world as well.  So, I’m not sure who you were thinking about, but that’s in terms of…



Well, it seems to be that it’s going to be more focused towards fee for service versus block grant, which is the way the private insurance market works currently.



Yes, that is very likely.



Alright.  I think I understand.  I’ve got it.



The only thing I would add to that is not necessarily only fee for service because there’s a lot of discussion about capitation, bundle payment.  There are a lot of initiatives through the Center for Medicaid Medicated Services on payment bundling, accountable care organization, and we’re going to see a lot more of that. I know we’re going to see a lot more of that in Illinois.  I’m not as familiar with the path that the states of Ohio, Indiana, and Michigan are taking, but we’re all facing the same pressures.



Okay.  Thank you.



You’re very welcome.

I’m going to move into some of what will change.  The person who just asked that question previewed a lot of that for you because we’re looking at a lot of changes for funding and billing mechanisms.  Medicaid will be the dominant payer for people whose economic situation is below 133% of the federal poverty level.  Insurance companies who are operating products on the exchanges, the health insurance exchanges, and those premiums being subsidized by the federal government on a sliding scale, those will be the dominant payers for people above 133% of the poverty level to the extent that Medicaid managed care expansion.  That will be the expansion of companies into the below 133% population.

Particularly for the lowest income population, which tends to be very much affected by the criminal justice system, we’re looking at Medicaid as a dominant payer, and their funding rules will govern how substance abuse and mental health is structured, reviewed, and approved on an aggregate level and on an individual case level.  The state Medicaid authority will be the primary funder and overseer of the rules around them.  Providers will have to be and currently are in the process of implementing or upgrading their Medicaid-compatible fee for service billing structures.  Also, thinking about how they’ve been in decapitated care arrangements, which is a way to help manage the risks, the potential upside and downside, states are very much interested on who can participate in those arrangements.

There are specific Medicaid certificate requirements.  They vary by state agency departments and also the capacity to participate in health information exchange, health information technology, and sharing of electronic information and health records.  These are all things that will be required in a new environment.  States have different timelines for implementing them, and providers are in the process of figuring out how they’ll comply with those.

The providers who are used to receiving block grants that provides a majority of their funding will definitely by shifting funding sources.  We actually don’t know what state general revenues will look like in the future for substance abuse treatment to the extent that the federal block grant, how that will be used.  The National Association of State Alcohol and Drug Abuse Doctors has really done some good advocacy on having the federal block grants continue to be available to cover some very important services that Medicaid will likely not cover and also to cover some people who come into treatment uninsured.

I’m not familiar with the same advocacy on the mental health side, but there is a National Association of State Mental Health Directors.  They’re also very active in this area.  So, I need to look into that, but the potential loss of block grants and state revenue dollars, which providers currently have as majority of their funding, is what’s going to initiate this big shift.  We find that some providers are already there.  They’re already working extensive with Medicaid and insurance.  There are providers that have it, but it is not their primary funding.  So, there’s a big shift involved and some who are really starting at the beginning.

So, what we’ve been suggesting to people in the criminal justice system is to start talking to the providers now.  There’s no reason to wait until 2014.  They have a long list of things they need to do to be ready to expand services to meet the demands starting in 2014, and it’s very helpful for them.  They think of you as their customers.  So, it’s very helpful for them to hear from you that this is important because if they’re having resistance from their board or from staff who don’t want to do it, it helps them overcome some of that resistance and just get focused on doing what they need to do.

The second change I’m going to mention is reimbursement based on medical necessity. Medicaid billing requires authorization based on medical necessity, and each state Medicaid authority and state laws put into plays processes for that determination and the guidance for those determinations.  A lot of those determinations are made by managed care, whether it’s the Medicaid or the insurance side, and substance abuse and mental health providers will need to understand these provisions and do advocacy because around how they’re categorized.

The criminal justice system will also need to be thinking about this.  Just to give a couple of examples of what we’re dealing with here.  When you think about someone who’s been in jail or prison, incarceration generally has the effect of suppressing use, and while substance dependence is chronic and this true whether someone has a primary mental health condition along with their substance abuse or not, their symptoms may disappear temporarily, meaning their use, and are likely to reappear after their release.  So, there’s disconnect with how medical necessity is traditionally determined and what this means in a justice setting.

So, clinical treatment is still necessary to prevent return to use and build recovery, but we’re going to have to figure out how that’s actually worked through in a medically necessary treatment context.  We had some success in Illinois.  The state adopted a law that was the implementation of a mental health and substance abuse charity rule that put the American Society for Addiction for Medicine criteria in place as the criteria for determining medical necessity.  We don’t know yet how that ball is going to play out, but we saw that as a very helpful sign.

We definitely see increased demand for people needing substance abuse and mental health services.  I gave these statistics earlier in terms of utilization expansion in those three states, and there’s a real need to build a community treatment capacity to accommodate this increase in demand.  Joint planning between community substance abuse and mental health service providers and criminal justice systems can help the providers to accurately anticipate and build some certainty around how much capacity should be built.  We’re not just talking about building a building but building the capacity to provide the outpatient groups how many more counselors, the qualifications of these counselors so that it can be drawn from the Medicaid dollars.  There’s a lot of planning that needs to go into this.  So, it’s really not too early to start.

We may see a shift in the supply of services.  Again, the supply of services will be dictated by what will be covered in Medicaid and by the federal essential benefits.  The determination, we’re expecting to see that sometime in the next year.  We may see a situation wherein the depth of care is somewhat reduced.  The forces at work that I’ve described already may organize to push this away from more of an acute care to model to a long term recovery support model which fundamentally is a good thing but may result in less utilization of residential treatment.  Part of the reason that I mention it is because residential treatment is a particularly attractive thing for the criminal justice system to refer patients to if there’s a sense that it’s more structured, it’s safer, that person has more supervision even though it’s not a locked facility.  We want to be able to help the criminal justice system make this transition and also start to advocate, but what are we talking about?  We’re talking about long term recovery support.

Again, this is a very fertile area for providers in the community and the criminal justice system to talk about.  We may see some expansion of services that are less expensive than residential treatments.  Brief interventions, which are for people who are not substance use dependent and expansion of outpatient treatment, day treatment, partial hospitalization, and possibly medication-assisted treatment as well for the community where there are medications indicated that are useful.

There is also a focus on the integration of substance abuse and mental health with primary care, and that integration of care is designed to both improve access and improve coordination and result in fewer acute care episodes.  So, one of the big players in communities when we’re looking at the low income population will be federally-qualified community health centers.  It’s worthwhile to get acquainted with those folks if you don’t work with them now.  They are likely to become important as parts of your networks of care.  This is true for both substance abuse and mental health treatment providers and the criminal justice system.

Some of the things that would be incredibly productive in the integration process if we could plan successfully would be the transfer of prescriptions between corrections health care providers and community providers so basically we’re not starting over once they go to a community system.  That would expedite and provide for far less gaps in care.  The integration of electronic health records would be enormously helpful so that the correctional health care records could follow a person into the community.  Again, less gaps, less starting over.

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