see the video: http://vimeo.com/28067585

Matt:

Today’s topic is “Filing for Medical Insurance for Oral Appliance Therapy”.  We’re very excited to have all our attendees here as well as our presenter Dr. Sam Cress from Sugar Land, Texas.  He’ll be discussing this important topic and help you see the benefits of adding this to your practice.  Dr. Cress, the time is yours.

 

Dr. Cress:

Good morning.  Thanks, everybody for attending. I’d like to take this opportunity to thank Arrowhead.  I will tell you I’ve been with Arrowhead for about 18 years, and I’ve had great success with them.  I did a webinar series the last couple of months that has been presented that have been phenomenal.  So, I encourage everyone who’s listening in the future to listen to the webinars.  It’s a great, great opportunity for your staff to listen in and get some continuing education, and it’s very economical, just gathering around the office.  Tap into their webinars.  It’s really awesome.

Let me tell you about who I am.  I am a general dentist in Sugar Land, Texas, which is a suburb of Houston, and I have been in practice for about 18 years. In the past year, year and a half, I really have gotten turned on to dental sleep medicine, craniofacial dentistry and dental sleep medicine.  It’s been a phenomenal ride.

I just completed my residency in dental sleep in Tuft this past spring, and I am eligible for certification.  So, I am working on all my patient requirements and criteria in order to present and take the boards in June.  Then, I’ll become a diplomat in dental sleep medicine.  I just highly encourage anyone who’s interested in that area, field of dentistry to really pursue it.  It’s been a great ride.  It’s been exciting and so forth.

Today’s topic that we’re going to be talking about is “Filing for Medical Insurance for Oral Appliance Therapy for Obstructive Sleep Apnea”.  Now, I’m going to go out on a limb a little bit and make the assumption that you guys are already doing some type of dental sleep medicine or at least know a little bit about sleep medicine because a lot of the terms I’m going to be using, for example AHI, this is not really the format to discuss what those sorts of things are.

I would encourage you to contact Arrowhead and sign up for one of their sleep seminars, and, again, I’ll be presenting there as well.  We can go into details about sleep and the different indices and criteria for sleep.  We’re just going to be focusing on getting reimbursed.  It’s great to have all this knowledge and share this knowledge and be able to integrate this into your practice, but if you don’t get compensated for it, it really is kind of a moot point.  So, I’m just going to make an assumption.

Now, let me tell you a little quick story about insurance in general.  My wife is a psychiatrist, and we own our own building.  I’m on the first floor, and she’s on the second.  When we built the building, she was director of the mood disorder clinic in Baylor. When she was coming out, the first thing she said was, “How do I get on these insurance plans?”

I told her.  I said, “Listen, here’s the deal:  If you sign up for insurance plans, I’m going to file for divorce.”  That was 18 plus years ago.  We’ve been married for 22 years.  She did not sign up for any insurances at all.  She came in, and within 90 days, she was solid-booked.  So, today, if you call her office to see her as a new patient, you’re first available appointment is in October.

The reason I shared that information with you is because I encouraged her and really did support her in the fact that she does not need to be married or handed down, handcuffed to insurances.  When we did the dental sleep medicine component of our practice this past fall, the lady who’s been working with me on insurances for a long time, she and I went up to a presentation in Dallas.  We talked all the way to Dallas and all the way back, and we committed that we would not be married to insurances.

So, what we decided to do for sleep apnea was to collect up front, do a case-fee presentation, everything conclusive, collect up front, and courtesy bill for the patient.  It’s been incredibly successful for us.  We’ve had no issues whatsoever, but we’ve learned a lot of things about medical insurance and how different they are from dental insurance through the process.

So, my number one encouragement is for you to get that mindset that hey, I need to do a case-fee courtesy bill and collect the money up front and let the insurance ride, if you will.  You’ll see when I start presenting a lot of things to you, you’re going to get a little overwhelmed, and probably in about 10 or 15 minutes, you’re going to start tuning out.  You’ll see why when you see the volume of information that you have to do in order to get medical reimbursements for insurances.

So, anyway, get a pen and paper.  I’m going to throw you a lifeline at the very end of this presentation with some information that, to me, is very crucial to put all this together for you and kind of helps you through the process.  So, make sure you have a pencil and pen ready.  So, let’s get going here.

So, basically, when we file for dental sleep medicine, reimbursement for OSA.  You can do a couple of things.  First of all, you can bill on behalf of your patients, which is a nice way to do it.  It’s kind of the internal marketing procedure as well.  You can assist your patients to bill themselves.  Now, here’s the problem with that.  We already have a big, hardship trying to understand medical insurances and dental insurances as it is, but if you can imagine that turning over to the patients, they will be in your office everyday with tons of questions.  So, you can do that, but that’s going to be very challenging and very time-consuming on your part.

You can easily outsource your medical billing to companies.  There are several companies that are out there from coast-to-coast in your area that will actually do a medical bill for you.  They’ll submit everything for you, and they take a percentage of what they collect.  Then, you do fee-for-service only, which is what we do.  We do fee-for-service, and we do courtesy bill.

Here’s the key to any type of medical insurance when you get ready to bill.  I’ll look at it as trying to be the old Perry Mason if you would, trying to be the attorney.  You have to prove to medical insurances that there’s medical necessity.  They’re not going to hand those checks over very easily.  So, here’s how we’re going to do this.

First of all, understand medical insurances.  Working with insurance companies to obtain information about patient’s benefits.  You guys probably already do this in your practices, especially with dental insurances.  The only thing difference with medical insurances and dental insurances is dental insurance will give you no information except the patient is within or with no network.  So, they’re not going give you specific fees.

With medical insurances, we have learned are a little bit more open and will communicate with you a little bit more as far as the information in order to determine the benefits for their patients, but you need to learn to interpret each patient’s insurance policy because they’re all different.  Every single company has multiple policies and multiple sub-policies within that.

You also have to know a whole new type of nomenclature which is the Diagnosis Codes, ICD-9 codes, Procedural and DME codes as well as CPT and HCPCS codes and modifiers.  Then you have to fill out the CMS1500 form.  Now, we’ll talk about this in a little bit and how to do that.  Then, you’re going to submit all the documents that go with it. Now, guess what?  You’ve got to do the follow-ups and appeals as well.

Now, let’s look at the different types of insurances that are available and some of these guys you already know.  You have the PPOs, which are the in-network of physicians or hospitals that provide services.  The patients can choose to go out or in.  It depends on how much they want do and if they want to stick with their providers.

Then, you have Blue Cross Blue Shield.  Now, they’re a little bit of a tricky plan.  You may not have experiences on your personal side or with your patients.  They have the fully insured plans which are purchased and managed through Blue Cross Blue Shield.  Then, they have the self-funded which are underwritten by the company, but they’re managed by Blue Cross Blue Shield.

Then, we all know about HMOs.  I will tell you this.  Every patient that comes in with an HMO and you want to do oral therapy for them, you really need to find someone in their network to do that if you’re not a provider because you will get absolutely zero reimbursement.  The patient will get zero reimbursement.  Now, if the patient is on HMO and wants to pay cash up front, that’s okay as well.

Point of Service Plan.  The benefits are determined when the patient decides whether they want to be out-of-network or not, and, of course, our absolute favorite are the indemnity.  Now, those are very few and far between.  I’ve been practicing for 18 years, and I’ve only had one patient who has full indemnity.  If he came in today and did a full-mouth reconstruction, his insurance pays 100%.  He’s a little mucky-muck high-end individual when it comes, but those are very few and far in between.

Now, I’m not really sure what the demographics are, but for those individuals that are in the military, there are military insurances as well.  Now, where I’m located, we don’t have military bases, but basically, there’s TRICARE or TRICARE for life.  That’s for active duty and retired military personnel.  There’s two different kinds:  There’s TRICARE Prime, and that’s for all active duty.  There’s no co-pays and no deductibles. They can go to a non-military provider, but they need a referral in order to do that.  Then, there’s TRICARE Standard, which you’re probably going to see a little bit more of, and that’s fee-for-services.  Co-pays, deductibles apply.  Referrals are required, it’s much easier for that.

Let’s now talk about sleep apnea for just a second and prevalence with age, and it plays a very important role when it comes to insurance.  Now, there’s the orthodontist on the panel on the discussion here.  I’m not going to try to offend them in any way, but orthodontists, we in dentistry can create a lot of apnics by removing bicuspids, moving everything back, shutting everything down.

As we become older, and I can say it that way because I’m one of those patients, we see a little bit more higher prevalence of sleep apnea at this age.  We also see a lot of dentition and a lot of other things as well plus as the generation is getting older, we are learning more and more about apnea and sleep apnea.  So, you’re going to see a lot more prevalence with individuals with sleep apnea in the older age.

So, guess what?  We have to look at Medicare.  Now, Medicare is for 65+.  Now, I will tell you there is a gentleman who is very, very successful in Idaho, a colleague, a friend of mine who probably does about 80% Medicare for oral implants and sleep apnea.  The reason he’s so successful is because he understands and really gets in bed with Medicare and really knows how to work the system based on the rules.  They have a very set standard of rules, and you have to follow them to the tee for reimbursement.

Then, we have some key stakeholders that have some different goals and incentives, and one of the previous questions brought up to participate and also role.  So, just a quick review of those.  For behavioral health and medical care providers, expanding capacity, integrating primary care and specialty care, integrating community care with justice-based services, expanding their own capacity to enroll clients in Medicaid and insurance because certainly there are going to people who come not enrolled, improving treatment through the use of evidence-based practices, and then cultivating partnerships with new stakeholders.

County government officials, we were talking about their incentives to minimize cost and litigation risk is related to health care issues in jails.  Their option is to maximize diversion and effective re-entry services to reduce future demands for incarceration and reduce current demands for incarceration.  That’s the diversion side. It important I think for them to assess the potential risks and benefits.  They have the capacity to convene local planning processes to develop local action plans and also to help work the questions of the governmental food chain to bring the Medicaid folks to the table, to bring the insurance folks to the table, to bring the bring the Department of Public Health folks to the table, and to investigate reallocation of funding from county corrections to community health services if that’s something they want to pursue.

For state Medicaid directors, the criminal justice system presents a great opportunity to enroll a lot of people in a timely and efficient manner.  It does require some modification, possibly of how they’re thinking about doing it right now, but the numbers of people in the criminal justice system who are going to be a part of the newly eligible group are going to be so large that you’re going to get their attention if you bring the numbers to them.

So, collaborating with criminal justice and behavioral health and medical treatment providers to reduce coverage barriers, expediting enrollment, and also to facilitate strategic planning of the capacity expansion and again with special attention to rural or underserved communities.

State insurance directors are going to be operating health insurance exchanges, and there are going to be people most likely on probation who are, through family income or some job they hold, may not be eligible, may not be below that 133% poverty level but will be eligible for insurance subsidy through the exchange.  So, we want there to be continuity of access, continuity of coverage plans so, for example, one of my clients who, today, makes no legitimate income but gets a job once they’re in recovery, I don’t want them to be suddenly priced out of ongoing substance abuse care and our services.

So, that’s the value of establishing this continuity from my perspective.  I think from the criminal justice system perspective it’s just that writ across many hundreds of thousands of people want.  Also, proper integration of this population into managed care.

For criminal justice officials in jails, corrections, probation, and parole, partnering in systems integration efforts is really important, maximizing Medicaid and insurance enrollment is important, and partnering in diversion efforts will also make a big difference.

I don’t know if we have any judges on the phone, but judges, in particular, have a very strong role in convening groups of different stakeholders to try to bring this conversation into focus.  We work a lot with our judges to try to do this thing. They create a neutral framework, and they create some clarity about what the stakes are what’s needed. It can be very helpful.  So, we certainly encourage them to be involved.

That was the slide in the presentation.  Here are some resources that you may want to take a look at.  The links may not appear so well on the slide, but you’ll be able to see them more clearly when the presentation is available.

There was a national conference, the Community-oriented Correctional Health Services Conference Coaches.  We submitted a paper for that conference.  It was sponsored by the Robert Wood Foundation, and all of those conference papers may be of some interest to you.  There was a presentation form the Substance Abuse and Mental Health Services Administration thinking about this from the provider and treatment center perspective that was just given in July.  It was excellent. I encourage you to look at that.  The Council for State Governments also has a frequently asked questions document on health care reform.

So, those are the three things I wanted to suggest for folks who want to dig a little deeper into this.  Certainly, I’m available for e-mail and phone if want to talk further about this.  We’re doing a lot of national and local advocacy planning, and the whole thing’s unfolding day by day.  So, it’s a very interesting time.

So, Monica, we have a few more minutes if people want to ask more question.

 

Monica:

Okay, I have a question here from Herb.  Let me put unmute your line.  I can’t unmute his line.  Let me unmute Colleen’s line.  Okay, Colleen?

 

Colleen:

Can you hear me?

 

Monica:

Yeah.

 

Colleen:

Yes.  Hello, my question has to do with, I’m aware of the shortage of clinicians especially chemical dependency professionals, but are there any incentives coming down the pike with regards to raising the rate of pay or anything like that?  I know quite a lot of people who would like to be in the field, but they’ve done the research to find out the rates of pay overtime and have really chosen not to go into the field because of it.  Is there anything that we’re looking at as far as that goes?

 

Maureen:

Well, that is certainly a persistent problem in our field, and it’s trying to take grant dollars and make them stretch as far as you possibly can, I think, is one of the mechanisms by which pay rates for services and pay rates for people have been suppressed in that one.  So, I think that the natural market mechanism of demand will have an impact or raising prices in the more capitalist way.  The other way this will get worked out in terms of rates for services is it’s going to be all negotiated at the state level.  So, I would encourage you or through your provider organization to really take a look at how you all can influence that conversation.

We’re not quite there yet, but it’s a good time to start asking questions about when and where those decisions are going to be made and how to influence them.

 

Colleen:

Okay.  It just seems that some of these folks in this planet are being taken care of by some of those who get some of the lower rates of pay in the human services industry.  So, just curious about that.

 

Maureen:

Yeah.  I have about 299 colleagues in this agency who couldn’t agree with you more.

 

Colleen:

Yeah.  Thank you for that.

 

Monica:

We’ll go to our last question, and let’s see.  Herb?

 

Herb:

Yeah, hi.  Thanks for taking my call.  Do you hear my now?  Okay.  I guess I was just wondering and I left a couple of times.  I had a couple of things I had to attend to.  So, forgive me if you covered this, but is there any return on investment information on any of this in terms of primary prevention or prevention in terms of insuring that our clients and their family as well might be in better shape healthwise.

 

Maureen:

Yes.

 

Herb:

What I’m thinking is this.  For instance, I walk outside, and there’s always a handful or more of our clients smoking cigarettes.  We’re all paying for this high price, and I’m wondering is there anything down to that specificity on programs that might work and what the return on investment might be, something like that or other specific ways.

 

Maureen:

Well, the work that I’m familiar with on a more aggregate level is when you expand substance abuse and mental health service benefits, and this research has been done in both Medicaid and in private insurance.  What you see in terms of the reduction in health cost in the same program year and let alone down the road, that data is very encouraging, and it comes from the reduction of emergency room visits and a reduction in accidents, all those things we all see our clients go through and that stuff stops when somebody stops using or at least is significantly reduced.

So, there is actual read data that supports that, and if you want to send me a follow up e-mail, I’ll send you the annotated bibliography I have on that that I got from [01:52:36].

 

Herb:

What is it?  What is your e-mail?

 

Maureen:

I put it on the presentation.  You’ll get it on the presentation.

 

Herb:
Oh, okay.  Fine.  One other thing.  One of the things that I think is really troubling is not just that my clients and our clients here have significant substance abuse issues, but a significant number of them, while they’re out of control with drugs and alcohol and are trying to get it together, end up getting pregnant and having a child.  Then, there’s the whole thing with custody.  Is there a safe environment in their home or not?  Is there anything being done to try to stem what I think is almost like a tide because you just multiple the problems with economic problems as well as with other types of problems when folks are out of control themselves and then they can’t be expected, when they’re out of control, to provide a healthy and safe household in which to be raised.

 

Maureen:

You’re exactly right on the one really big benefit of this broad scale effort to deal with untreated addiction and psychiatric disorders is the impact on families and the impact on community.  I think you’re absolutely right that we pay in so many ways and our clients pay in so many ways and their children pay in so many ways, whether it’s children of people who are incarcerated and everything that they go through or whether it’s children who have an active drug or alcohol using parents.

So, our ability to intervene with that much more comprehensively, think has more of huge payoff for children, and I think it would be interesting to think about what would be a model intervention within a substance abuse treatment program that helps prevent that and intervene more thoughtfully and more directly with that issue.

Also, I think there will be a benefit from the much broader access, and we have a program where we work with parents who have lost custody of their children and are involved in the child welfare system because of their substance abuse.  A lot of those folks don’t get their children back, but we are able to get them sober.  Then, their subsequent children are born drug-free.  So, that’s actually one of our goals in that program is how many drug and alcohol-free births do we have even if reunification is impossible?

So, I really do see what you’re talking about, and I think we need to think about how to take advantage of these expansion of resources to create that kind of outcome for families and for children.

 

Herb:

Okay.  Great.

 

Monica:

That’ll be the last question.  For those of you who have your hands up, I will provide Maureen’s e-mail on the follow-up e-mail I’ll be sending out.

I just want to thank Maureen.  Thank you again for your presentation today. For all of you who participated today, I know two hours is a long time, but thank you so much for joining us.  I just want to make a mention that during the webinar Maureen mentioned several practices such as evidence-based practices, trauma-informed care, Medicaid assisted treatment.  Great Lakes ATTC will be hosting future webinars on those topics because we’re turning [01:56:23] into families, more on re-entry.

At the end of the month, we’re hosting two recovery-oriented systems of care, webinars on theory and practice.  I’ll send out that information, and we’re also hosting a two-day regional re-entry conference October 25^th and the 26^th.  Day one is in Chicago, and day two literally is in the correctional center.  If you’re interested in attending any workshops or stopping by at any of our exhibit tables at Large Conferences in the state of Illinois, Ohio, Michigan, and Indiana, you can contact me directly at monidela@uic.edu.

For those of you who are not in our four state region, I encourage you to visit our national website which is www.attcnetwork.org. I’ll also send this information, but thank you all.  Thank you, Maureen, and if you have any questions just let us know.

Thank you.
Maureen:

Thank you.  Thank you for hosting this, Monica.

 

Monica:

Oh, you’re welcome.  Okay. Buh bye.

 

Maureen:

Bye.

There’s going to be a need for greater public health education with this population.  These are folks who generally get their care in emergency rooms and jails if at all.  So, they’re not used to utilizing services, and we have to help them understand what their new rights and capacities are.  There’s also an interest particularly in substance abuse and mental health services conversation about actually physically integrating care so that substance abuse and mental health services and primary care are provided alongside each other.  There may lots of reasons why that’s a challenge, but it is a long term goal in terms of the health care system of the future.

We’re also going to see some new work force issues starting with this change particularly related to what services clinicians are credentialed to provide.  Are the clinicians that we’re used to working with in substance abuse and mental health systems today going to be able to get reimbursed for care in the future?  Lately, we’ve been hearing some very favorable conversations on the federal level about assuring how this happens.  That’s going to need to carry through at the state level.  We at TASC have the opinion that the behavioral health work force of the future needs to include layers of staffing on teams that can include a health care provider like a nurse, a licensed counselor, a certified substance abuse counselor, and recovery support specialist in different combinations for different populations.

So, for some states, that is reimbursable today, and for others, it’s not.  So, how we think this through together is important.  Many states have venues for this.  In Illinois, there’s a work force committee that is being led by the Illinois Department of Public Health.  My understanding is that hasn’t kicked off yet, but when it does, it’s going to be an important venue to have this conversation.

So, the last section of the webinar is talking about planning options.  So, why don’t I just take a last break here, Monica, and see if there’s anything that anybody wants to ask about.

 

Monica:

You know, we have two questions.  We may only have time for one.

 

Maureen:

I’ll let you be the screener then because I can’t see them.

 

Monica:

Right.  Carlo, your hand is still raised.  Hello?

 

Carlo:

Hello.

 

Monica:

Do you have a question?

 

Carlo:

Yes, I have a question.  This is going back to the potential impact of the broad re-entry program, that hypothetical jail model.  There was a statistic on there about a 10% reduction in jail days would yield over $1 million in savings.  I wanted to expand on that.  Is that presupposing that jails might want to reduce that time?  Is there a vested interest?  I ask that because there’s revenues from fines, court costs, fees, the fees mandated pictures such as a substance abuse assessment, victim impact panels, urine drops. So, people are getting charged for each and everything.  It’s a big source of revenue.  So, I question, really, if there’s a motivation to reduce those number of days or inmates in jail.

 

Maureen:

I think that’s a very perceptive question, and there are a lot of market influences that would reinforce what you’re saying.  I don’t know that, on their own, the sheriffs and jail administrators whose funding comes from that would necessarily go there.  There are certainly a lot of folks who run correction institutes who do have a strong commitment to re-entry services.  So, I think it’s a mix. I do think that the person in your community who has the biggest interest are the people who manage the county budget, and so, it may be a question of having the conversation with the right folks.

I know that we’re very concerned about if there’s a substantial reduction in incarceration and what you do with those jobs.  There’s a number of issues related to that, but we think that there’s a lot of potential for those jobs for community supervision. As part of this alternative, you have to rethink how you’re going to use your work force in a different way.  So, certainly, these are sensitive issues and controversial issues, and there’s a lot of both economics and politics at play, but I think the communities who are determined to take advantage of this situation really can.

Ten percent reduction may not be politically [01:32:50].  So, that’s why I didn’t say, “What’s a 25% reduction?”  We started with 10% because we thought it was more palatable for the stakeholders.

 

Carlo:

Okay.  Thank you.

 

Maureen:

Sure.

 

Monica:

Okay.  We can continue, and I have the names of the other people who had their hands raised so we can probably take that at the end of the webinar.

 

Maureen:

Okay, great.  Thank you for being the producer.  Alright, good.

The first opportunity and I’ve talked extensively about different aspects of this but just to pull it together, the first opportunity is earlier interventions and sustained services identified by broad based screening, screening everyone who comes into the system, intervening before conditions become deeply entrenched and chronic.  In the progression of a chronic disease like diabetes, the earlier you start to intervene, the less the complications are going to be and the less expensive it’s going to be and the better the outcome is going to be.

The same is true for substance abuse and mental health care as well.  So, the sooner that we can get the people, the better.  The more overall expansion certainly the more it incorporates practices that we know produce reliable results, the better results are going to be.

Opportunity number two is implement protocols for screening, and this is inside the justice system.  So, the justice system is determining to what extent you want to employ screening tools to determine eligibility.  Eligibility is not the right word here but screening tools to determine need for the kind of services that now the care’s is going to be extended for and also implementing the enrollment.

There should be a process to assess clinical need and public safety risk, and there are an increasing number of tools even very short tools that can give some guidance about that.  In a busy jail, when you want to be able to determine who it is a good idea for me send for treatment in the community instead of being here, you want to take that into account.  It’s actually important.  There are some good tools that can be used both for the screening and the public safety assessment.  I guess I would add on National Institute of Corrections on here, which I will do for the next time I give this.  An early screening also informs what participation people can make in many treatment alternatives.

The third opportunity is the justice system as a Medicaid enrollment partner.  The more streamline the state’s process for enrollment is on eligibility verification is, the easier it’s going to be to enroll people in jail.  Most people, when they get arrested, don’t have a lot of identification and documentation on them.  Their ongoing use and/or psychiatric disorders may make it difficult for them to go through an extended application process and just a lack of familiarity.

So, state Medicaid directors and insurance directors, because it’s usually the two together who are doing this work, play an important role in establishing procedures.  So, in Illinois, we’ve gone to these folks and said, “Look at the number of people we’re talking about here when you take into account all the people in jails, all the people on probation, all the people coming out of prison.  This is a significant group of your likely new enrollees, and we need to have smart systems that really help create the kind of health outcomes and cost reduction outcomes you’re looking for because if these folks continue to show up in emergency rooms and get really very expensive care, this isn’t the best situation for anybody.”

There’s been a little bit of work done on this by the Kaiser Family Foundation not specific to incarceration but specific to outreach to newly eligible populations, and they’ve identified what some of the barriers are.  Again, I mentioned electronic medical records earlier, but the capacity for people to leave with medical information and leave with valid Medicaid cards, that’s an incredible change in the system.

The fourth opportunity is really balancing clinical intervention and public safety at each point.  We’ve talked about how these resources can provide the basis for very broad expansion of diversion and re-entry and community supervision, which requires that people participate in substance abuse and mental health treatment virtually all the way across the criminal justice system.  Some of the things that need to be done preferably by the criminal justice system in combination with the community treatment providers is developing legal eligibility criteria for diversion or specialty supervision programs, developing the community supervision requirements, using both to inform the scope and scale of likely population demands for services for providers, using validated risk tools and evidence-based practices, and also avoiding net widening.  That’s the caution here is we don’t want to make any of the requirements at the risk that a lot of people wind up getting incarcerated as a result of participating.

There is an interesting thing that people need to be aware of which is a requirement in Medicaid for patient choice of providers.  It may seem a little apathetical in the criminal justice system where you’re used to saying, “You’re going to treatment, and it’s at this provider.  Here’s intake date.  Go,” and what Medicaid requires is a choice among appropriate service providers.

So, one of the things that we did was an access to recovery initiative here in Illinois.  We piloted this.  So, what we did was we did the enrollment and referrals to treatment.  We said to people, “You have to go to this level of care because this is what’s warranted based on your symptomatology, your history, everything, but here are the providers you can choose from who are in your area,” and if they didn’t want any of this, “Here are the ones outside your area.”

We found that there was quite a positive response.  People were absolutely overwhelmed that they got to choose their provider.  They got their preference to result in better engagement.  They were very pleased with how that turned out.  So, it may seem like it couldn’t work, but it actually worked really well.

A little bit more on net widening in this slide just to specify the issues we want to avoid, additional technical violations we want to avoid, lower risk offenders placed into more intensive supervision just to get access to care.  We want to have a good partnership between providers and criminal justice professionals on this issue.

In terms of planning, I mentioned a few times the process of planning process we’re doing in Illinois.  Different states, because of the relationship of their state to the national health care reform law, may be in different spots on this.  Illinois is very supportive and going right down this road.  Other states are holding back, and that’s every prerogative to make their decision.

In states where it’s possible, this can be done at the state level, but it can also be done at the community level.  So, this is to think about your local politics and how things fall out, but if your criminal justice system is already engaged in behavioral health treatment and your community health providers work with the criminal justice system, you have the building blocks.  There’s just some additional partners like Medicaid and insurance that needs to be brought into the conversation.

So, in terms of recommendation, we certainly recommend that you take a systems approach, incorporating the essential elements that are required to build recovery, balance the sanctions and rewards process in the criminal justice system to promote engagement, promoting client recovery from substance abuse and mental health conditions, and involving the community where offenders come from and almost all of them will be returning to.

Some of the components of care continuity for justice populations are on this slide:  Screening, comprehensive clinical assessment, placement in community substance abuse and mental health services, ongoing care management to support engagement and retention, and to report regularly on compliance to the criminal justice system.

Important elements of the infrastructure that try to get the whole focus to shift from an acute, episodic treatment to sustained, chronic disease management and support long term, durable recovery not just the cessation of use.

Often today, we only have access to enough treatments or get people to managing that acute use, but really there’s a much larger goal here.  Building community recovery capacity is also valuable. It will probably not be funded by the Medicaid expansion, but it is definitely something to take up in the context of all this planning, good planning that we’re going to do anyway.