Time To Change The Way We Fish

Greg Williams Blog

The Federal Government recently released the annual data showing some modest changes in substance use and the prevalence of substance use disorders. However, one number continues to stick with me every single year – nearly a 90% addiction treatment gap in America continues to persist.

That means of the over 20 million Americans who meet medical criteria for substance use disorder, only approximately 10% or just over 2 million people actually get any specialty medical care at all for what is now the leading cause of death for those under 50.

This addiction treatment gap ratio hasn’t changed in any substantial way in decades and has persisted even after allocating billions in new government resources toward it in recent years, mandating insurance coverage (parity), and expanding access to health insurance. While the death toll from a preventable and treatable condition continues to rise in spite of the existence of a more than $35 billion industry attempting specialty care today.

Perhaps we’ve been looking for fish in the wrong pond? Approaching the problem from the wrong direction? By continuing to invest in an acute care specialty system, that operates in isolation and isn’t well-matched to succeed against a massive persistent chronic health problem, it is no wonder we haven’t been getting positive outcomes. The landmark Surgeon General’s Report on Alcohol, Drugs, and Health, Facing Addiction In America, synthesizes decades of research and clear protocols about what works in intervention, treatment, and recovery support. The report also includes a robust call-to-action to integrate and coordinate addiction health services across a long-term continuum of care similar to other chronic disease models.  

Our approach has been to drop the bobber into the water, sit back, and wait for the fish to come to us. Then, when someone doesn’t seek out care for their addiction or they don’t sustain recovery after receiving treatment for their chronic health problem in an infectious-disease modeled system, we blame the individual.

“They weren’t ready yet to change their life,” or “they need to hit a bottom.” As we let ourselves continue to believe this lie, we simply keep fishing for the same 10% of people who might check all the boxes to fit well into our existing acute addiction treatment infrastructure rather than taking a hard look at perhaps changing the way we fish.

The truth is harder to look at and to solve for. The truth is the system we have in place just failed the 18.2 million Americans who couldn’t get or didn’t seek care for their substance use disorder in 2017. 18 million people didn’t fail. How could they? The health system in place for their problem isn’t designed, well-matched, or aligned to produce wellness for the illness they have.

System change isn’t easy, and as Facing Addiction with NCADD’s reach has grown in all 50 states across the United States there is a shared complaint no matter how urban or rural, conservative or progressive a community is. Nobody in our network is satisfied that their community’s health care entities are responding adequately to alcohol and other drug problems. How could they if a 90% treatment gap has persisted for decades?

The time has come for us to demand a systemic overhaul of how we engage, treat, and support people on a person-centered pathway to recovery (of their choice) in America. What if we started learning how others in the chronic healthcare management field fish and really went hard at closing the addiction treatment gap in America from another direction? What would that look like?

For one, it would require business as usual to end. No longer can we only have specialty providers who sit back and wait for their phones to ring or their internet marketing tactics to pay off after a Google search. We have to stop incentivizing a system that fishes in a catch and release mentality. There are 18 million people falling through the cracks and we have to figure out how to urgently fill these cracks.

If we are going to think differently about how to serve the 18 million people in need who are falling through the cracks, my big questions to you are:

  • In your community what happens when an individual presents with an alcohol or other drug problem in the local ER, or a family member walks into the pediatrician or primary care office worried about their loved one, or when the police pick up someone for a DUI or public intoxication?
  • Are they assertively engaged, connected, and embraced by the health providers in the community the same way a patient with heart disease is? Or does your community catch and release?

The rest of our health care system doesn’t catch and release for other chronic conditions. They provide years of assertive engagement, education, training, and multiple doorways of entry to wellness. Part of the reason they can do this is that mainstream health systems are directly involved and serve that condition. Your local hospital or health system most likely has an entire cardiology team, an entire floor, and a network of outpatient providers in your community that is interconnected with the primary care providers in the community. They probably have a full NFL-style team focused on endocrinology with different providers playing different positions, perhaps even with a quarterback to navigate patients throughout the system and levels of care an individual might need depending on the severity of their illness.

Does your community have a team or entire floor dedicated addiction at your local hospital? Why not? It’s more prevalent than 1.5 times all cancers combined.

The reason is actually astonishingly simple in my mind. They haven’t been incentivized to do so. Insurance companies, patients, and policymakers have never come together to demand and provide the resources for health systems to get involved in addiction before. But we can’t afford to allow the status quo to persist any longer.

Let’s come together and start asking the hard questions to your local health system executives:

  • Are you collecting data for how many people passed away from overdoses in our community within 90 days of interacting with your health care system?
  • Are you collecting data for what percentage of ER visits are related to alcohol and other drugs? What percent of these patients were discharged with a robust treatment and recovery plan?
  • Are you collecting data on the percentage of patients your primary care providers identified with a substance use disorder last year? Were any of these patients engaged in person-centered treatment and recovery plans?

If they aren’t collecting these data points then it is hard to address the specific system problems related to those who are falling through the cracks. It’s time for us to demand they start looking to diagnose the specific system problems for people facing addiction in their community. To not accept a catch and release mentality any longer.

The good news is for the first time in the history of addiction treatment and recovery the payers are starting to embrace a willingness to think and act differently. I can tell you from first-hand experience they are not only at the table, but some are actually setting the table.

In August 2017, Leavitt Partners and Facing Addiction with NCADD convened a group of 40 healthcare thought leaders. This group was comprised of senior representatives of various health care organizations ranging from health insurers, hospital systems, behavioral health experts, employers, and others.

The purpose of this meeting was to begin a discussion about solving systemic issues for addiction health services. The group set out to determine if the conditions were right to explore the creation of alternative payment and delivery pathways for long-term treatment and recovery. In the months that followed, this group organized the Alliance for Recovery-Centered Addiction Health Services to develop and promote an innovative approach to payment and delivery of addiction treatment and recovery services.

The Alliance published the first draft of The Addiction Recovery Medical Home Alternative Payment Model (ARMH-APM) on September 7th during the Summit for Addiction Recovery Payment Reform. The ARMH-APM is a consensus learning model representing an attempt to establish a structure that promotes the type of integration and patient care capable of producing improved outcomes for patients, payers, and health systems by aligning all incentives. This Alliance is committed to further promoting the approach, pilot it in various markets, evaluate outcomes, and refine the model over time, but we need your help.

Individuals and families in communities drive market demand for the availability of local healthcare resources. The time has come to teach our health systems to start fishing for the 18 million people falling through the cracks. We need you to stand with this Alliance and demand that your community health system stop catching and releasing and start incentivizing long-term recovery! You can tell your local health system executives that for the first time ever the payers are ready to meet them wherever they are, whether it is the full ARMH-APM or just a few recovery coaches in the ER or training their primary care doctors — sweeping change won’t come easy or fast. But I know for sure it won’t come unless we demand it. The size and scope of the problem hasn’t moved the health system for decades, so now the time has come to see if our stories, passion, and collective vision for a better future for the next generation can.