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.

For San Diego dentist Dr. Daniel Vinograd, focusing on both the big picture and the small one is essential. This commitment to details and to overall health is why many consider him the best holistic dentist San Diego has.

Attention To Detail

For a dentist, details are essential. Fillings must not be too shallow or built up too much. Crowns must fit exactly. Dentures and dental implants must align properly or the patient will experience pain, problems eating and never be completely satisfied.

While a mouth may be generally healthy, a single tooth can need careful attention. Just for a moment, then, all efforts and attention must turn toward restoring that single tooth so that complete health and wholeness is possible. And a biocompatible dentist makes sure everything used for every restoration is okay for usage in the mouth.

The Bigger Picture

But a holistic dentist like Dr. Vinograd is concerned with much more than just teeth and oral health. A good holistic dentist understands that oral health and the overall health of the patient are intertwined. The bacteria that decays teeth can also cause heart disease. An acid mouth means an acidic body, and there are health implications from that. An infection in the mouth can spread, and ill health elsewhere in the body can lead to a decline in oral health.

It simply isn’t possible to treat the mouth without considering the whole body. That’s how Dr. Vinograd has established a reputation as the dentist San Diego residents trust above all others: he treats every patient as a whole person, not just a mouth.

In fact, that’s what holistic dentistry is: a focus on a healthy body and its connection to a healthy mouth. Doesn’t that seem like a smart approach to dentistry?

If you want the best toothpaste for your money and for your family’s health, you’ll have to look beyond the most common brands to smaller, less-well-known brands that are more careful what they put in their products.

You can find Sodium Lauryl Sulfate, Carrageean and Sorbitol in some brands. And most brands include Sodium Saccharin, a questionable artificial sweetener that’s the same thing as those pink packets some people once used in their tea or coffee before better alternatives were available.

Worst of all the chemicals found in big-name toothpastes is Sodium Fluoride and the other forms or Fluoride. While this was once considered essential to healthy teeth, there are better choices now that are non-toxic and don’t have the side effects. If you want the best toothpaste available, you want a fluoride-free toothpaste.

So which brands can be trusted? You need to carefully read the label of any product you’re considering, but you can trust some products from Tom’s of Maine, now made by Colgate, Jason and Kiss My Face.

Other brands you may be able to trust are:

• Dr. Ken’s
• The Natural Dentist
• Tea Tree Therapy
• Vicco
• Desert Essence
• Weleda, and
• Spry.

Reading labels and staying vigilant is as essential when choosing a toothpaste as it is when choosing vegetables, packaged foods and other products for your family. It’s so important to choose the right toothpaste because it goes into your mouth every day, is absorbed through your gums and some of it is inevitably swallowed, especially by children who don’t know any better.

Remember that even trusted makers change their formulas all the time, so a product that’s acceptable one week could be bad for you the next. Remember also that some products from trusted makers are better than others. Not every choice is a fluoride-free toothpaste that deserves to be called the best toothpaste for your precious family.

If you are willing to put in the time, here is a health homemade toothpaste recipe.

Doug:

Okay.  Good.

Monica:

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.

Doug:

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

Monica:

Yeah.

Doug:

Okay, very good.

Maureen:

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…

Doug:

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.

Maureen:

Yes, that is very likely.

Doug:

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

Maureen:

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.

Doug:

Okay.  Thank you.

Maureen:

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.

Now, we’re going to talk about specific opportunities for probation, and the biggest opportunity in probation is reduction in probation violations that are due to untreated substance use and psychiatric disorders.  We know that people who are continuing to use have both violations for new cases as well as many, many technical violations, and that has a big impact on how probation officers have to spend their time.  Many of those people wind up incarcerated as a result of repeated violation.

So, being able address what is, today, untreated substance abuse and psychiatric disorders can have a big impact for probation officers and probation departments.  It’ll be possible to gain these results across all probationers not just in smaller demonstration programs or specialty supervision units or specialty courts.  Then, for the specialty courts, specifically, they’ll certainly have better access to timely treatments.

A lot of specialty courts do their best to leverage existing resources.  They may have small amounts of grant dollars that pay for treatment. They may have the county dollars that they are able to use, but straightforward across the board access for everyone will make it much more manageable and hopefully much more timely manner to get into treatment.  There’s also an opportunity to focus on the high risk, high need probationers in the specialty court if everyone who’s on probation supervision is referred to treatment that specialty courts can be used to prioritize the people who need the more structured supervision, which we talked about earlier, Doug Marlow’s research.  This is a one way to apply it in this new environment starting in 2014.

A lot of the things that are needed to gain these results are similar to what’s needed in the jails, but’s a different twist because probation supervision provides different opportunities.  Timely enrollment in Medicaid and insurance is definitely very important.  A number of people who come into probation have spent time in jail.  So, if they get enrolled there, then that burden doesn’t shift to probation officers, but if probation officers can facilitate that timely enrollment, that’s great.  It could also be done by community substance abuse and mental health providers in partnership with probation departments.

Universal screening early in the criminal justice process will help determine who needs what because we know that the epidemiological information is all of this, substance abuse and mental health issues, are everywhere, but everyone has it in a different combination and in a different history.  So, everyone’s treatment plan is a little different.  So, universal screening could figure out what each person needs to expedite getting to everybody in a different way than we do today.

Certainly matching to appropriate services is very important.  There are people, the low risk, low need people you want to send to drug education programs and to early intervention programs, not necessarily to structured treatment services.  Intensive outpatient residential treatment are certainly for substance abuse side, which has very extensive needs.  The continuum on the mental health side, also will expand to [01:02:19].  I’m not as familiar with all the gradations along the way, but, certainly, it’s a high end community treatment services.  At the lower end, outpatient counseling that does a great deal of what it does in substance abuse treatment and everything in between.

So, there may be new modalities like an expansion of partial hospitalization.  That becomes available, and we’ll have to see how that plays out.  Certainly, the funding will come on board, and the providers need to get in planning the capacity, how much, how many, who, where, when.  Our suggestion is to do that planning in concert with the criminal justice system so that the providers are creating the capacity that the criminal justice system wants to use, and the criminal justice system will know which providers do what.  This whole system can be much more broad and robust and dynamic than is possible for it to be now.

It’s almost very important when you think about this kind of expanded act and expanded referral that we think about what universal reporting and sanctions process should look like.  We don’t want to generate an unmanageable burden for probation officers.  We don’t want to have a sanctions process that’s so aggressive that it actually results in more people violating and going to prison.  That’s the reverse of what we’re trying to make happen here.  So, we need to be really thoughtful about that, and the phrase for that in the criminal justice literature is net widening, when you set up a program and it’s intended consequence is that actually more people go to prison.  That’s widening of the net or more people are intensively involved in criminal justice supervision than you would expect.  So, we definitely want to avoid that.

Moving on to opportunities for parole.  There are, again, similarities and differences.  So, the opportunity in parole is to develop structured re-entry services for parolees who have had treatment inside correctional centers.  There’s many, many years of research that demonstrates that pre- and post-release treatment together have the greatest impact and subsequent reductions in recidivism.

There’s also the opportunity to reduce parole violations even for people who haven’t had treatment in an incarcerated setting to reduce violation due to untreated substance abuse and psychiatric disorders.  Increased access to treatment.  Increased ready-access to treatment as an alternative to re-incarceration when someone is about to be evaluated; is it a big deal for the criminal justice system?  Also, the expansion of routine access to treatment created that in a process of an interview, a parolee mentioned, “I used to have this problem.  I’m concerned about starting again/ I have started again.  I don’t want it to get worse.”

An easy access to the system in the community will make it much more viable for a parole officer to write that instead of waiting for the problem to get worse.  It may also make it easier for a parolee just to walk into treatment on their own, but I think we’re looking at a population that often needs a little encouragement.  So, this is helpful.

Also, there’s also a possibility of gaining these results across all parolees not just as earlier in the smaller demonstration programs or specialty supervision units.  The key is the creation of universal access to substance abuse and mental health services on release.

So, what’s needed for parole officers?  Again, timely enrollment in Medicaid and insurance.  We’re doing a planning process here in Illinois for connecting the criminal justice system and the substance abuse and alcohol treatment providers and Medicaid, which will be the big funder for our population in 2014 in planning how you would do this.  How can you facilitate timely enrollment prior to release from prison, prior to release from jail?  Looking at a number of technical options as well as how this would be staffed, workload expectations, and so forth, but I think we’re going to get there.  I think we’re going to see a good penetration of enrollment in an incarcerated setting.

As with probationers and people in jail, universal screening early in the justice process so you know who needs what.  Matching to appropriate services and expanding capacities and the same issues with avoiding net widening in the sanctions process and the reporting process.  The last thing we want to do is make this treatment expansion and significantly increase the number of people who are imprisoned or jailed as a result.

I’m going to take another pause here, and Monica, if you want to look if there’s any hands up.  The next section is going to be about the changes in the substance abuse and mental health treatment systems that are coming in health care reform and what the criminal justice system needs to know about that.

Monica:

Alright.  If we do someone raise your hand.  Okay, Taz?

Taz:

Hi.  I just had a question about a brief note about real jails and the correctional facilities and how they’re becoming the default settings for mental health and abuse health needs that are available in those communities. I was wondering if you meant that those are those only places where it’s available, or are there people who aren’t incarcerated who are actually attempting to access those?

Maureen:

That’s a really great question, and I’m glad you asked for clarification there.  What I meant was not that people are trying to get into jail to get services although once in a while you do hear an anecdotal story like that.  Really, it’s more than because there isn’t the capacity to provide treatment in the community for mental health and substance abuses, you got people with lots of untreated addictions. Their behavior gets them the attention of the criminal justice system, whether it’s because they’re arrested for possession or they’re arrested for a crime that they used to gain the resources to continue using or sometimes trespassing or disorderly conduct or a number of misdemeanor charges that people with serious mental health issues often brings them to the attention of the criminal justice system.

So, it’s certainly isn’t an intentional situation.  It’s just that the criminal justice system and the emergency room are two no decline systems, and that’s where the current situation is brought up.  Does that make sense?

Taz:

Yeah.  It does.  Thank you.

Maureen:

Sure, no problem.

Monica:
Okay, we have another question from Doug.

Doug:

Yeah, hi.  I have two questions actually.  You put out a term there that I haven’t seen before.  Trauma-informed care in one category, if you could explain that.  Then, the next question would be where and how do private agencies fit into the overall scheme treatment providers?

Maureen:

When you say private agencies are you thinking about private non-profits or private for profits or a combination?

Doug:

Abled capitalist.

Maureen:

Okay.  Let me take these questions one at a time, then.  In terms of trauma-informed care, that is a term that’s become more common in the substance abuse and mental health world in the last five to eight years I would say, and there’s some really good work being done on what this means in substance abuse treatment, what this means in mental health treatment, and what this means in the criminal justice setting.

So, the broadest notion of trauma-informed care is that, especially in any of those setting because the resource suggested is nearly universal, you assume that the people in front of you have had some significant issues, whether it’s domestic violence, being beaten up, sexual abuse in childhood.  There’s a long list of the kinds of things that create this response in the nervous system that suggests accelerated fight-or-flight response.

So, if you approach someone with a serious trauma history in a particular way and you get a very unexpected reaction from them, you know it’s active.  You know you need to deal with.  So, trauma-informed care practices, the research I’ve seen on this in criminal justice settings where they’ve done this systematically, they did a lot of this in Maryland in the prisons and the jails, has reduced the officer injuries.  It’s increased safety rates.  It’s had a lot of good effects for officers as well because we’re just a little bit more informed about who’s in front of us and how to handle them.

On the treatment side, how do you get out these issues in a way that’s appropriate for the setting?  So, you don’t want to push somebody into dealing with a level of their trauma history that they’re not ready for.  Yet, at the same time, you want to bring it to their awareness that they can start to integrate that into their thinking about why they’re using because, often, the heavier the use, the more likely use of opiates is a very high sign that there’s something going on because they’re using heavy pain killers.  It kills emotional pain or decreases emotional pain.

Doug:

Right.  Okay.

Maureen:

Okay.  So, good.  So, there’s a lot of work out on this.  If you Google trauma-informed care, you’ll start to find that there’s some good models for treatment like [01:13:00].  There’s a bunch of stuff out there.

The evidence-based practice has evolved.  There has been a lot of focus lately on trauma-informed care.  We know that there’s a lot of both childhood and current life trauma that’s common in the justice population, and those trauma are associated with very high rates of psychiatric and substance use disorders.  This may be part of the mechanism that we’re seeing in this population that we now have the opportunity to intervene with.  We certainly know that unaddressed trauma impedes treatment and recovery.

We have, just in our own clients, we link them to treatment.  We ask them to stop using and then what happens. All their trauma that they’ve been self-medicating with their heavy drug and alcohol use comes up, and because of the funding situation, we’re not able to send them directly to care for that.  Individual or group treatment psychotherapy is a horrible situation.  So, this is one of the big changes I think we can see once we have the funding in place.

I was speaking with a man who’s a coordinator for the Brooklyn Drug Court, which is a very mature program, one of the earliest developed programs.  They have about 500 people under supervision at any one time, and because New York has expanded their Medicaid coverage to cover single adults, they’re able to access substance abuse and mental health services much more extensively that, for example, we are here in Illinois.  They routinely send people for trauma interventions, and it was a very inspiring conversation for me and underlines the sadness of the current situation.  Again, this is a way that we can expand bills and strengthen the system of care.  Really, 2014 isn’t as far away as it sounds.

When you’re thinking about evidence-based practices, you want to think about aligning with the target population, where they are in their justice involvement meaning you would do something with a probationer than you would do with somebody who’s just getting out of jail without further criminal justice supervision, what their health needs are and certainly what risks they have, public safety risk and criminogenic risk.

Aligning the evidence-based practice with the overall goals of the health system with the program, you’re thinking of reducing costs, what kind of supervision is available on the correction side, what’s the goal in terms of reducing symptoms and improving their clinical status, and establishing a stable, durable recovery.  Then, aligning the evidence-based practice with the system capacity and design of the programs that you’re looking at.  So, evidence-based practices aren’t to fill the bullet.  They’re just practices that we know have proven reliably to demonstrate a consistent effect across setting, and, depending on the kind of research that was done, that is extremely valuable knowledge.

So, when we look at the Affordable Care Act and its potential to reduce costs in the criminal justice system, we’re looking at a board expansion of funding, more opportunities for diversion and intervention at every point in the justice system, the expansion of access that’s needed in the community substance abuse and mental health system that’s needed in order to meet this previously unmet demand from the justice system, bringing to scale programs that are already in place that show great results but don’t have the funding basis to expand and incorporating the proven models, which is the evidence-based practices.

So, what happens when one state gets this?  Washington State, in the beginning part of the last decade, made a major shift of resources from their correction system to funding substance abuse services particularly in the community.  They have some of the best data.  We just all really want to have this kind of data in Illinois, but we don’t have it because we don’t have a way to collect it and a process for it.

In Washing State, they established a public policy institute to do a lot of research at the time of the state policy shift.  So, they were able to document consistently that there was a 33% reduction in arrest after people went to substance abuse treatment, and that was without any criminal justice leverage at it.  They didn’t really do anything different on the criminal justice side to more strongly encourage people in treatment, to require that they participate in treatment, and to have a graduated sanction process, which we know improves participation and attention.

So, that’s just participation and treatment.  So, we think there is a potentially much greater reduction in recidivism possible when you combine the criminal justice leverage with the treatment. In fact, there are many other programs in the country that have demonstrated a more powerful reduction, including projects like the Sheridan Correctional Project that I mentioned earlier.

So, now we’re going to talk a little bit about the different opportunities in the criminal justice system.  I’m going to talk about for sheriffs, jail administrators.  I’m going to talk about probation officers, for probation and parole departments. That’s certainly now everybody along the full continuum, but it is where the large volumes of people tend to reside.  If people have questions about other parts of the criminal justice system, I’d be happy to take those.

So, first, in terms of specific opportunities for sheriffs and jail administrators, there are a lot of people who repeatedly appear in jail due to their substance use and their psychiatric disorders.  They are often called “frequent fliers” or “frequent users”.  They often use a lot of resources at high levels.  They need emergency room resources, especially for people with mental disorders.  They’re using homeless shelters a lot and cycling through those.  So, we’re spending an awful lot of money on them but not really moving them forward while we’re doing it.

So, there’s an opportunity to reduce this frequent flier situation by providing appropriate treatment both in jail but especially in the community and also to reduce health care expenditure related to condition.  So, if there is a way to divert people in jail to treatment in the community that reduces the number of people who require that kind of health care expenditure.  Certainly, if people come in in better shape because they’re getting better treatment in the community, then, the jails aren’t going to be in the constant situation of dealing with a huge flare up with a chronic condition because it is extraordinarily expensive to deal with and much more expensive than it needs to be.

There’s also the potential opportunity to reduce incarceration through increased diversion.  So, that’s one of the mechanisms that sheriffs and jail administrators have.  What I left off this list is actually the opportunity to reduce rebounding through good re-entry services.  That’s the other opportunity.  It’s post-jail.  You’ve got pre-jail, diversion from jail, and then post-jail you’ve got re-entry services to help reduce the next number of people who come back the next time.

We took a little look at a hypothetical moderate-sized county jail to see what the impact of this could be.  This is our economic scenario for illustration purposes only, but you can certainly apply this kind of logic to your own situation.  If a jail has 500 beds and you assume an average length of stay of about two weeks, which includes people who are only there overnight, people who actually served time in the jail as a result of a misdemeanor offense, and everybody in between.  If you take that as the length of stay and apply it to the 500 bed jail, you get about 13,000 detainees who cycle through that jail every year.

Applying national statistics, two-thirds of them report using drugs regularly.  That’s over 8,500, and if a jail has a treatment program, they probably only have the capacity to treat several hundred people a year.  If you apply the 15.4% jail figure for people with psychiatric disorders, you get about 1,800, almost 1,900 people with psychiatric disorders cycling through that disorder in a year.  You may have more repeaters among that group in the psychiatric disorders, but still, that’s a really large number.  Most of them will benefit from treatment in jail and especially from treatment in the community.  So, we said what if you didn’t get to all those people, but what if you just had a 10% reduction in the number of detainees?  Even that would result in significant cost-saving.

We used the figure of $70 per day for jails.  Some jails are more.  Some jails are less expensive, but that’s an average national number.  A 10% reduction in number saves, based on the drug using and psychiatric disorder population, would yield over $1 million in savings every year.  There aren’t many counties that would turn a blind eye in a million dollar savings that could come to them, especially when the most expensive parts of it, the community-based treatment, don’t need to be paid for by the county.  They will be paid for in part by the federal government and in part by the state government through the Medicaid expansion.

So, there’s a big potential payoff here, and we’re definitely encouraging people who plan county budgets and county criminal justice and health services to take a look at this.  Jails are very expensive.  The $70 a day jail cost is just a cost of feeding the person, housing them.  The cost of the staff in the jail, the correctional officers, anybody who’s on a medication, that’s more.  A lot of the psychiatric medications are very expensive.  So, there’s very big cost incentives to get people treated in the community.  We know that people, in general, do better in the community, certainly, if they meet that low risk criteria.  That’s a good decision all-around.

So, what will be needed starting in 2014 to gain these results?  A number of things are needed, and different people will play different roles.  One thing that’s needed is enrollment in Medicaid or subsidized insurance during incarceration.  The reason that’s important is because we want people to be able to walk out of the jail and to walk into community treatment setting without a big gap.  We know that if there’s a gap between incarceration and treatment in the community, people return to use.  Their psychiatric symptoms accelerate.  Whatever is going on in their lives if they may have lost their housing or they may have lost a job if they had one, all these various destabilizing factors come into play and result in very serious consequences and not in what we’re looking for, which is establishing getting into treatment, establishing stable recovery.

So, while the Medicaid and insurance wouldn’t have impact until people are released because health care reform will not pay for treatment in an incarcerated setting through Medicaid and insurance expansion, but once those services are available in the community, we want that enrollment to take place before people will be in the incarcerated setting.  We also want to see universal screening in jail for substance abuse conditions, psychiatric disorders, and chronic medical conditions because these are folks who need to get into services.  There are a couple of good methods to do this.  We just got some funding to pilot in the courts and here in the jails here in Chicago, using an adaptation of the expert intervention, the screening brief intervention and referral to treatment modified for the criminal justice population and modified for the setting as a way to identify people, motivate them to participate in whatever treatment they need, and ideally, though we can’t do it today, enroll people right there all in one intervention.  So, we’re hopeful that something like that can become common practice around the country.

Another important thing that should be done as part of this expert intervention is matching people to their appropriate services.  So, even if they’re just leaving the jail with no community supervision as a follow-up, you can tell them, “This is where you need to go, and these are good places that are available to you that will take your insurance.  You can go.”  This is after 2014, of course, but those are the treatment that needs to happen in order to get there.  If the criminal justice system chooses to add some restructured re-entry support to that it will only make it more effective.  Sorry, I didn’t have that slide up, but it will be on the webinar on the website.

So, people have to be pretty extensively disabled in order to benefit.  Often, people in the criminal justice system are not quite that disabled.  So, there’s this gap where people can’t get access to care, and it creates the same kind of ongoing, untreated addiction and mental health issues that basically have us where we are today.

So, under the current justice and healthcare structures, there are multiple and interconnected barriers to providing coordinated and effective care.  This is especially pronounced with behavioral health issues, and there are some challenges related to divergent goals between the substance abuse and mental health and criminal justice system, insufficient or fragmented funding, lack of health insurance coverage, insufficient care because of the previous health issues, and the lack of coordination, which makes it hard to accomplish large overall goals across the system.

In terms of divergent goals, the way we tend to think about this is the primary responsibility of the justice system is public safety and reducing recidivism.  The primary responsibility in the health care system including behavioral health is to protect or improve in individual and community health. These things do align, but it’s not necessarily always obvious how to make them align.

There’s certainly a mutual objective in cost containment.  There’s certainly different costs, but at the place, people can align.  The justice system is definitely not designed to be a provider of health care but often obliged to assume that role as a default setting because the capacity in the community system that’s needed isn’t available.

In terms of insufficient and inadequate treatment, the demand for community-based substance abuse and mental health treatment in most states way exceeds it availability.  Justice-based treatment programs rarely reach all individuals who are legally eligible.  Just to give you an example from the mental health core program that I worked on building earlier in this decade here in Crook County, Chicago.

There are about 20,000 people on probation today in Crook County, and based on the epidemiological estimates we got, we think 10% of those folks have persistent mental illness.  Well, we built a mental health core program that started at 25 people and had an ambitious goal of getting to 100 people and an outrageous goal of getting to 250 people because we’re building this with grants and we were basically borrowing money to pay for these services like the patchwork of a quilt. Those of you who do this work know what I’m talking about.

So, in our most outrageous goal, we were going to get to about 10% or over 10% of the people we knew needed intervention.  So, that scenario is repeated over and over again. We are hopefully in a moment where that could change.  For now, we lack the resources to expand models that we know work.

For those who haven’t had the pleasure of learning about the financing of substance abuse and mental health treatments and intervention services, I just want to get a little bit of information about that by way of background to understand the current situation.  Public substance abuse and mental health services are supported largely be federal block grants and categorical Medicaid eligibility.  By that I mean in most states, not all states, Medicaid eligibility is a combination of low income and low assets and a particular category of disability.  For example, in most states, people who have significant mental illness who are significantly disabled by that condition are eligible for disability, which makes them eligible for Medicaid funds for their care.

So, that I very good for people who have that access, but they are often very difficult to get.  It’s because it’s difficult to meet those criteria.  The application process takes a long time, and most folks whose lives are significantly disordered because of serious mental condition aren’t going to get through that application process on their own.  So, it’s a big challenge.  The challenge is the same on the substance abuse side, and those limitations have been enduring for as long as I’ve been in this field.

There are some federal funds, the block-grant funds that fund demonstration programs, initiatives that help.  They can provide evaluation money in those projects that help us to provide evidence that what we’re doing works, and those are helpful but pretty small in terms of the dollar amount.  They’re time-limited as well.  The largest dollar amount that goes into funding substance abuse and mental health services are actually state and county level funding like the state general revenue funds, county funds.  In some states, communities at the county level have the opportunity to have additional and small additional sales tax or other property tax added on that can fund some services. That is by far the largest amount of money spent nationally, but, again, it varies state by state and is certainly not enough to meet the need.

So, the pursuing of grant funding requires long processes for a somewhat incremental outcomes.  It is a very worthwhile and a strategy that we use all, but it’s a very laboring task.  Further, the larger, uncoordinated funding creates isolated pockets of service and not seamless continuums of care.  So, those are some of the things we think can be made to happen beginning in 2014.

So, what’s the impact of all of that?  Substance abuse and mental health conditions are chronic conditions that require ongoing long-term treatment and management. We know that for substance abuse, the National Institute on Drug Abuse has established that at least three months in treatment is needed to stop or curtail use.  That does not have to be residential treatment, maybe a short period of residential then some intensive outpatient or outpatient care, but there needs to be a sustained period of about three months to get things started well.  Durable recovery, meaning something that can last a lifetime and keep the people on a very different track in their lives, requires multiple episodes of are over many years.

Acute care treatment in justice setting just really cannot address these chronic conditions sufficiently.  They’re very important building blocks to getting to durable recovery, but they’re not enough in themselves.  So, that’s the trick here.  We’re trying to figure out how to extend the care in the community.

I talked before about the lack of insurance in this population.  There are about 12 of the 50 states that have expanded their Medicaid coverage to include single adults who do not have otherwise qualify through disability or parenting status.  None of the states in this four-state region have done that although I know many have considered it as a way to try to address this specific issue.  So, basically, we’re left with the 2014 option.

I want to acknowledge this because the Midwestern states in the [38:36] Region certainly have very large rural areas, and the rural jail and correction system have also become default settings for health and social services that don’t exist in the community through the lack of insurance or other funding and, in a lot of ways, hit those jails even harder.  If you’re operating a 45-person jail and you have enormously big health claim that can wipe out the budget for the whole year, let alone the capacity to provide the ongoing, constitutionally required care at an appropriate level.  So, a big opportunity with this funding coming is to think about how to use the resources that people, then, have as part of the individual insurance to bolster the health care systems in rural communities.

So, health care reform won’t solve all these challenges, but just to sum up, there are some very unique opportunities that are created for change on a broad scale.  Health care reform will create nearly universal coverage, meaning it does not include anyone who’s undocumented, and this affects a lot of communities differently.  The last testament I’ve seen suggests that health care reform will get about 94% of people covered nationwide, and that’s up quite a bit from where we are right now.  So, when I talk about near universal coverage, that’s what I mean with that limitation.

Potentially eliminating waiting lists for care is care in the community becomes more available and service capacity is expanded to absorb people who are now coming without dollars attached to them to pay for their care.  We have the potential to address gaps in services and build more continuum systems in the community and between jails and prisons and communities because that’s often where there’s a big juncture of mobility that creates a tremendous public challenge and a public safety challenge, that release piece.  Hopefully, ending the piecemeal approach to public funding, hopefully we won’t have to have to write the same type of grant proposals we’ve been writing for years as well.

So, this is another place for a good pause, Monica, if you want to look to see if we have any hands raised.

Monica:

Let’s see.  We don’t have anyone raising their hands, and at the end of the webinar, if you want to ask a question, we can provide Maureen’s e-mail.

Maureen:

Sure, and we’ll have time for questions at the end, too.

Monica:

Okay.  You can continue.

Maureen:

Okay.  Then, I’m going to continue.

So, now we’re going to shift to talking about thinking about health care reform in 2014 and its expansion of coverage in applying what works, applying what we know from 30 years of research from this field actually makes a difference in reducing recidivism, improving public safety, and building recovery.  So, rather than outline a number of specific practices, I wanted to talk about the frames of reference and the frames of research where all this stuff has been gathered.  All this stuff is easily available on the internet at the different national agencies.

So, the National Institute of Drug Abuse has “Principles of Drug Abuse Treatment for Criminal Justice Populations.  It’s very helpful and very helpful in thinking through what the system of care should be built around.  They definitely emphasize the matter of continuity between incarcerated situations and community treatment as a high priority with this group.

SAMHSA has a number of useful things including a more recent TIP, “Treatment Improvement Protocol 44:  Substance Abuse Treatment for Adults in the Criminal Justice System”.  That addresses both criminal justice system issues and also clinical issues.  So, it can be very helpful.  SAMHSA also has a National Registry of Evidence-based Programs and Practices.  SAMHSA is National or Federal Substance Abuse and Mental Health Services Administration.  So, they’re responsible for federal level funding of substance abuse and mental health treatment and prevention.

SAMHSA also has an organization called the GAINS Center that they’ve funded extensively that they’ve funded through the last 10 to 15 years, and they’ve identified six evidence-based practice treatments in mental health treatment that should be adopted in justice settings.  They have a great website.  If you Google the Gains Center Mental Health, you’ll find them, and they have really great sources available for all kinds of planning issues from screen to subsequent treatment into treatment in the community and continuity of care as well.

The National Institute of Corrections has published a number of documents and guidelines on evidence-based practice that should reduce recidivism, which includes substance abuse and mental health treatment but aren’t restricted to that.  They also have guidelines for implementing evidence-based practices in community corrections.

So, depending on who you are and where you work, different pieces of this might be of most interest to you, but they are all quite valuable.  They summarize the last 30 years of research because we really do know what words.

The challenge there is because of the limited funding for substance abuse and mental health treatments for people who otherwise don’t have health insurance, we aren’t getting to a very high percentage of the population.  On the last estimate that I saw nationally was that drug courts get to about 1% of people on probation. They do very good work with those folks, but we’re not getting to jail.  It’s healthcare reform that gives us an opportunity to take these interventions to scale.

We also look a look at the parole populations.  Obviously, the number of people on parole are significantly smaller, but they are substantial.  In Illinois in 2009, we had about 33,000 people on parole.  In Indiana, it was about 10,000.  In Michigan, 22,000, and Ohio with about 19,000.  Much like for probation, there’s special parole supervision initiatives.  Individual officers make a lot of referrals.  There has also been other interesting initiatives in our region.  Ohio, recently, passed a reform legislation that will focus on putting more people on the street than the community.  Then, there are projects in Illinois where we have in Sheridan, Southwestern Illinois correctional center programs, which is on its way to becoming a jail because they’re a large institution.  There are, in both cases, I think 1,000 inmates, and most are treatment prisons.

So, most are medium-security prisons for people with substance disorders.  They get treatments there, and there are a lot employment programs to that initiative and also, post-release, treatment and case management in the community.  So, those are efforts that have shown benefits and recidivism among the parole population.  Given how expensive it is to put people back in prison, we pay a lot of attention to that here in Illinois, especially the last couple of years.  So, these are the kinds of things that when there is more availability of treatment in the community, they’ll be easier to expand these kinds of positive initiatives.

I’m going to shift now to talking about some of the current challenges and latest thinking on evidence-based practices, and Monica, if we want to take questions about what I presented.  Let’s give the people a chance to raise their hands.  We could do that. On your screen there, you have an option of raising your hand.  Right now I see Jimmy whose hand is up on this line.  Jimmy?

Jimmy:

Hi.  My question is more like will this presentation be available after the conclusion.

Monica:

Yeah.  For those of you would like to have a copy of the webinar, I’m actually recording the webinar, and we’ll be posting the webinar on our website.  I’ll make that announcement.

Maureen:

Will the slides also be available, Monica?

Monica:

Yeah.  The slides will also be available.

Maureen:

Okay.  Thank you for the question.

Monica:

Does anyone have any more questions? Are there any more hands raised?  We don’t, but we’ll have another opportunity to ask questions.

Maureen:

Okay.  Alright, good.  So, we’re going to go on to talking about the current challenges in both providing care and funding care for justice populations.  First of all, this slide may be a little bit hard to see on your screen, easier when you have the PowerPoint and you can blow it up much larger.  This is a chart that we use to talk about the criminal justice system and all of its on-ramps and off-ramps and the intervention opportunities that exist along the continuum, and when we’re talking about being able to take the intervention scale, we are really talking about the whole length and breadth of the national justice system.

So, there are opportunities for diversion to community days, mental health and substance abuse treatment and arrest on the mental health site.  The crisis intervention, you can see CIT is an intervention that’s been gaining a lot of popularity, and I definitely encourage people to pay more attention to that in the future.  There are opportunities for similar community-based supervision at the time when people are arraigned, but before I get into that, people who are held in jail and whose charges are dropped or dismissed, there’s an opportunity to do good re-entry services with them as well.  They just have to be short and quick and very effective.  So, there’s some models I’ll talk about a little bit later on that.

In terms of interventions and arraignment or sentencing, there are lots of opportunities to divert people to community-based substance abuse and mental health treatment.  With community supervision with the support of a community-based infrastructure that links support and the community, as well, to tighten up the supervision part of that so the court and the community could have confidence that people are supervised.  What this does is it allows us to have people supervised in the community and going to treatment in the community, which we know is very effective, rather than incarcerated and pulled out of the community for a period of time and, then, just face all of those issues, again, when they come out.

For people on probation, I talked a little bit earlier about specialty courts like mental health courts and drug courts. The opportunities to link people to substance abuse and mental health services once they’re more widely available exists all along throughout probation and parole.  We certainly, in the future after 2014, we should be considering every person in front of us as a person who could potentially be referred to the services that they need.  We’re not able to think that way now.  We’ll talk a little more about the reasons why now.  It is very frustrating, but it is a good thing that it may change.

So, this slide is borrowed from a presentation that Doug Marlow gave.  If you don’t know Doug’s work, he is the research director for the National Association of the Drug Court Professionals and a university professor, and he does very good work on thinking about how you use graduated sanctions in drug court to influence behavior, what the timing is on these kinds of things.

This slide is from a different perspective.  He wrote a great paper called “Evidence-based Sentencing Practices”, and he talked about the continuum of risk and need.  Risk, in this situation, is public safety risk, and need is need for a clinical intervention; so, mental health and substance abuse treatment.  In particular, when you look at people who are in the low risk, low needs in the bottom right box, they aren’t posing much threat to public safety.  They don’t have very high need for formal, structured substance abuse and mental health treatment, but they’re doing some stuff that’s getting them through the attention of the criminal justice system.

So, what do they need?  He talks about that as prevention.  We might, in the substance abuse treatment field, we might talk about it as early as intervention.  So, motivational intervention structured like an expert, screening, brief intervention, and referral to treatment project, which is a strong methodology that’s been demonstrated on the public health side and in the substance abuse treatment side to make a difference, as well as what kind of life skills interventions and good supervision that are offered through community safety officers.

So, then, if we go up to the next, high need, low risk box, this is the classic box for low-level drug offenders who’s continuing involvement with the criminal justice system is driven by their alcohol and drug use.  They have a very high need for good structured intervention, but because they pose low risk to the community, they don’t need a very high level of supervision from probation and parole officers.  They could conceivably be good candidates for diversion programs at the far end of the criminal justice system as well.

Then, when we look at the high risk column, we are really dealing with a different profile of offenders.  Also, if this box represented offenders in the criminal justice system, the high risk column would be much narrower and smaller and the row risk column would be much larger.  The high risk, high need folks are people who, and Doug has come to talk about these folks.  These are the folks that need the resources of a drug court and a mental health court.  They need to be very accountable on short timeline for whom treatment compliance is absolutely essential, and also, a lot of habilitation is needed.

So, when you think about the previous slide of the continuum of intervention, we just don’t want to spend our resources willy-nilly.  We want to prioritize where our somewhat limited resources go, and so, focusing the highest intensity of resources on the high risk, high needs people makes a certain amount of sense.

Then, the last box is the high risk, low need people.  These are people who are less likely to be impacted positively by mental health and substance abuse treatment and for whom accountability and habilitative services are the priority.

So, that’s how he broke out this thinking, and it’s a helpful way.  There’s a lot of talk in probation these days about evidence-based probation strategies, and triaging and spending resources where they’re most needed is obviously a budgetary reality as well as a professional reality.  So, this is the kind of thinking that helps us figure out what to do.

So, just a minute.  For folks who aren’t familiar with mental health and substance abuse treatment, I’m just going to say a few things about what treatment actually is.  High quality treatment is used as evidence-based strategy.  Different kinds of treatment modalities that we know have been proven over the years to actually make a difference in people’s subsequent behavior, their arrest behavior, their work behavior, their continued use or not continuing use, which is the goal.

In substance abuse treatment in particular, behavioral therapies are used.  We use counseling.  We use cognitive therapies like DVT and MRT.  We use psychotherapy as well in various combinations.  You may become more familiar with hearing terms like residential treatment, inpatient treatment, outpatient treatment, and basically, we call those modalities and their levels of intensity and also structure and also determine whether housing is a part of that intervention strategy or not.  What goes on in these settings is the same general activity.  We just relate it to what the setting is in which the person will most benefit.

Physician-prescribed medications are increasingly a part of substance abuse treatment.  Methadone has been around for many years.  There are a number of new medications that have come to prominence in the last decade.  Many of them have been around for a long time but not applied to addiction in this particular way.

There’s buprenorphine, which also goes by the name Suboxone®.  There’s Vivitrol®.  That’s the trade name for a medication that’s been promoted for treating alcoholism as well as opiate addiction.  Buprenorphine is a treatment for opiate addiction, and the good news about all these medications is that they really help people who, otherwise, don’t really stand a great chance of being able to control their own craving and get through the first part of establishing early recovery without some assistance.

What we hear from our treatment partner is folks who are using these kinds of medications actually stay in treatment, and they’re to benefit from the psychosocial rehab and the counseling and the other things that the person has to do to get their life together.  If they’re not able to stay in treatment, they can’t manage their cravings, and they feel overwhelming urgency to go back and use and we’re not getting anywhere.  So, that’s increasingly the value we see in medication-assisted treatment.  Treatment is often a combination of one or more therapies.  They’re not mutually exclusive, and people are stepped up and stepped down in different levels of care based on their progress.

Now, mental health is often organized in a different way, and community mental health centers do a great deal of work around the country.  There’s also a certain amount of this work that’s done in community health centers where physicians are prescribing medications and doing some counseling with people.  In our experience, at least in Illinois, the challenge for the mental health system, even before the budget cuts that have hit since 2008, is that they’re really restricted to working with the most disabled people and a pretty limited number at that because the money will only go so far.