The many people with substance abuse problems may find few to treat them

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The number of people with insurance coverage for alcohol and drug abuse disorders is about to explode at a time there’s already a severe shortage of trained behavioral health professionals in many states.

Until now, there’s been no data on just how severe the shortage is and where it’s most dire.  Jeff Zornitsky of the health care consulting firm Advocates for Human Potential (AHP) has developed the first measurement of how many behavioral health professionals are available to treat millions of adults with a substance use disorder, or SUD, in all 50 states.

Zornitsky’s “provider availability index” – the number of psychiatrists, psychologists, counselors and social workers available to treat every 1,000 people with SUD – ranges from a high of 70 in Vermont to a low of 11 in Nevada. Nationally, the average is 32 behavioral health specialists for every 1,000 people afflicted with the disorder.  No one has determined what the ideal number of providers should be, but experts agree the current workforce is inadequate in most parts of the country.

“Right now we’re in a severe workforce crisis,” said Becky Vaughn, addictions director for the industry organization National Council for Behavioral Health.  The shortage has consequences, she said. “When people need help for addictions, they need it right away. There’s no such thing as a waiting list. If you put someone on a waiting list, you won’t be able to find them the next day.”

The shortage of specialists threatens to stall a national movement to bring the prevention and treatment of SUD into the mainstream of American medicine at a time when millions of people with addictions have a greater ability to pay for treatment thanks to insurance.

Two Federal Laws
The Affordable Care Act for the first time requires all insurers, including Medicaid, to cover the treatment of drug and alcohol addiction.  In the past, Medicaid covered only pregnant women and adolescents in most states. Private insurance either didn’t pay for treatments or paid so little that most people could not afford to make up the difference.

For anyone with insurance coverage, the Mental Health Parity and Addiction Equity Act ensures that the duration and dollar amount of coverage for substance use disorders is comparable to coverage for medical and surgical care. Together, the two federal laws are expected to make billions of dollars available to the behavioral health care market.

Of the estimated 18 million adults potentially eligible for Medicaid in all 50 states, at least 2.5 million have substance use disorders. Of the 19 million uninsured adults with slightly higher incomes who are eligible for subsidized exchange insurance, an estimated 2.8 million struggle with substance abuse, according to the most recent national survey by the U.S. Substance Abuse and Mental Health Services Administration.

Although the federal government has acknowledged the scarcity of treatment specialists, it has failed to quantify and assess it. Other fields of health care, including mental health and primary care, are tracked by the U.S. Health Resources and Services Administration to determine which communities are “underserved.”  Without this information, it is hard to know where more behavioral health specialists are needed and when the supply of providers is expanding or shrinking in any given region.

That’s where AHP’s Zornitsky steps in. Using data from the U.S. Department of Labor’s Bureau of Labor Statistics on the current size of the labor force and its projected growth, plus Department of Health and Human Services data on the prevalence of SUD among adults, he approximates the relative adequacy of the addiction treatment workforce in each state.

“It is not perfect,” Zornitsky said of the index, “but it’s a consistent, state-based measure that allows for comparisons and tracking over time.”

Poor Pay
According to a 2013 report to Congress from the Substance Abuse and Mental Health Services Administration, the “growing workforce crisis in the addictions field” is due to a variety of factors, including stigma, an aging workforce and inadequate compensation.

The U.S. spent $24 billion on treatment of drug and alcohol disorders in 2009, the most recent year for which comprehensive data are available, according to a new study by the Pew Charitable Trusts (Pew also funds Stateline).  Sixty-nine percent of the spending came from public sources such as state and local governments, Medicaid, Medicare and federal grants. Private sources, including commercial insurance and out-of-pocket spending, made up the balance, according to the report.

Historically, reimbursement rates and consequently salaries for physicians, psychologists, social workers and counselors in the addiction field have been well below salaries for comparable professionals in other health care specialties that require the same level of education and training.

For example, the average salary for social workers in the addiction field is $38,600, compared to $47,230 in the rest of the health care industry, according to the Bureau of Labor Statistics.

As a result, too few health care workers are going into the field and too many are switching to more lucrative specialties. And because the average age of addiction specialists is higher than in other professions, demographers predict a behavioral health retirement boom in the next five years.

Between now and 2020, the addiction services field will need to fill more than 330,000 jobs to keep pace with demand, of which more than half are the result of people retiring and switching to other occupations.

Low Treatment Rates
Of the roughly 23 million Americans who suffer from drug and alcohol disorders, only 11 percent receive treatment at a specialty facility, according to the most recent National Survey on Drug Use and Health.

That compares to U.S. treatment rates as high as 80 percent for diseases such as diabetes and hypertension. Part of the reason for lack of treatment has been inability to pay. With billions in private insurance and Medicaid dollars becoming available, that is expected to change.

But questions remain about how the existing addiction services industry will manage the expansion, whether new businesses will enter the market and how many providers will take Medicaid patients. Today, only 55 percent of addiction practitioners accept Medicaid reimbursements, which tend to be lower than private insurance.

Another reason many substance abusers go without treatment is the social stigma connected with addictions and mental illness. To avoid being labeled, many hide their drug or alcohol use, and refuse to admit they have a problem. With more money available for treatment and increased public concern over the nation’s rising death toll from drug addictions, experts are hopeful the stigma will dissipate and more health care professionals will be drawn to the field.

The Affordable Care Act eventually should spur more competitive salaries for behavioral health professionals. But for now, it is complicating matters, Vaughn said. Both Medicaid and private insurers require levels of professional licensing and credentialing that were not needed when addiction services were funded primarily by federal grants. In addition, many of the mostly small providers in the industry have no business experience negotiating contracts with Medicaid managed care organizations or filing claims for Medicaid and private insurance.

It will be largely up to states to make the changes needed to develop an adequate addiction treatment workforce. The federal government has offered model licensing guidelines that define a so-called “scope of practice” for each job title in the behavioral health profession, but states will have to create licensing laws and regulations. States could also encourage more people to go into the profession by offering to repay student loans and funding local colleges.

In addition, state Medicaid agencies will need to reach out to the existing addiction industry and provide business training to enable them to file claims for the billions in new funding for drug and alcohol treatments. Most important, Vaughn said, Medicaid rates for addiction services need to be raised to provide a reimbursement benchmark that is closer to the fees paid to practitioners in other health care professions.

Becoming evidence-based: A step-by-step approach webinar

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Do you believe your program is effective? What does it take to get on an “effective program list”? In this webinar, we will discuss the process of becoming evidence-based, with a focus on child and youth-serving organizations. What steps must your program go through to reach the point at which independent evaluations can be done to assess whether the program works? How do you make sure it can produce sustainable results over time?

Experts from Child Trends – Kristin Moore, Martha Beltz, and Vanessa Sacks – will explain the process, and Dominique Bernardo will illustrate with real-life examples from Congreso de Latinos Unidos. The panel will walk through assessing needs and selecting or developing an appropriate intervention, program implementation and ongoing performance management, and external evaluations. We will address questions like:

  • What are the steps in the process of becoming evidence-based? 
  • What are appropriate and realistic outcomes for child and youth-serving agencies? 
  • What is the role of ongoing performance management in program implementation? 
  • When is the right time to bring in external evaluators for an independent study? 

Join Child Trends to explore a positive and cost-effective path to evidence-based programming. For those familiar with the “Performance Imperative,” this event offers an in-depth look at pillars #6 (internal monitoring for continuous improvement) and #7 (external evaluation for mission effectiveness). The speakers will take questions from the audience.

National Wraparound Initiative looking for examples of excellence

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The National Wraparound Initiative is looking for videos of actual Wraparound practice for a new study on Wraparound facilitator skills. From this research, they hope to establish an online video library that facilitators can access for training purposes. Right now, they are in need of videos of one-to-one meetings between facilitators and family members.

Let's help them out, Network faithful!

Treating First Episode Psychosis

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Psychiatrist John Kane, M.D., discusses treating first episode psychosis using coordinated specialty care. Dr. Kane, of The Zucker Hillside Hospital and Hofstra North Shore-LIJ School of Medicine, is one of two lead investigators on the Recovery After Initial Schizophrenia Episode (RAISE) research project. Designed to reduce the likelihood of long-term disability that people with schizophrenia often experience, RAISE is funded by the National Institute of Mental Health (NIMH).

Feds pay for drug fraud: 92 percent of foster care, poor kids prescribed antipsychotics get them for unaccepted uses

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Art Levine, Huff Post, 4-30-15

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The release in late March of an alarming new report by federal investigators has confirmed in shocking new detail what has been known for years: Poor and foster care kids covered by Medicaid are being prescribed too many dangerous antipsychotic drugs at young ages for far too long -- mostly without any medical justification at all. The report by the U.S. Department of Health and Human Services (HHS) Inspector General examined in depth nearly 700 claims filed in 2011 in five of the biggest prescribing states -- California, Florida, Illinois, Texas and New York -- and discovered that two thirds of all the prescribing with these popular and costly "second generation antipsychotics" (SGAs) raised high-risk "quality of care" concerns.

The new report noted several disturbing examples, just a few months after an overmedicated teen in foster care, Steven Unangst, died in Antioch, California. The report cited a 10-old-year with ADHD given an antipsychotic -- without any medical documentation -- mixed in with other psych drugs; a 4-year-old on four psychotropic drugs, including two antipsychotics; and a 16-year-old with bipolar disorder on six psychiatric medications, including variously three antipsychotics. Among the side effects of this polypharmacy assault: "This child experienced paranoia, hostility, unstable mood, hallucinations, and suicidal thoughts. This child also experienced significant side effects potentially resulting from the prescribed drugs, including a 22-pound weight gain, insomnia, and edema (swelling) of hands and feet."

Perhaps even more damning, the report found, 92 percent of all kids on Medicaid receiving antipsychotics don't have any of the limited "medically accepted pediatric conditions" supposedly justifying their use. These "accepted conditions" include the authority to use antipsychotics even for autistic children as young as 5 for such dubious FDA-approved conditions as "irritability."

So just how far outside the bounds of sensible prescribing must a doctor be that government approval to provide antipsychotics to a 5-year-old child is somehow considered too limiting? Yet that's precisely the sort of free-fire-zone prescribing underway now for 92 percent of those kids receiving antipsychotics in foster care and the broader Medicaid program.

The Inspector General's report also noted that over half of kids receiving antipsychotics are victimized by "poor monitoring" of the drugs' risky health side effects -- which can include breast growth in boys, cardiac arrest, extreme weight gain and diabetes.

But the report and most of the few mainstream media accounts ignored altogether an even more fundamental example of failed oversight: the federal government's lax monitoring of state Medicaid programs dispensing these potentially life-threatening medications to children.

*   *   *   *   *   *    *   *   *

artlevineArt Levine is a contributing editor of The Washington Monthly, and a former Fellow with the Progressive Policy Insititute. He has also written for The American Prospect, The New Republic, The Atlantic, Slate, Salon and numerous other publications. He is the author of 2005's PPI report, Parity-Plus: A Third Way Approach to Fix America's Mental Health System, and is currently researching a book on mental health issues.

Note: Please be sure to leave comments on the Huffington Post website to help ensure continued visibility of this post.

Representative Murphy and Matsui introduce bipartisan resolution recognizing May as Mental Health Month

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WASHINGTON, DC – Reps Tim Murphy (PA-18) and Doris Matsui (CA-6) have introduced a bipartisan congressional resolution declaring “May as Mental Health Month.” H. Res. 244, seeks to “remove the stigma associated with mental illness and place emphasis on scientific findings regarding mental health recovery.” And, “promote public awareness of mental health and providing critical information and support to the people and families affected by mental illness.”

Since 1949, May has been observed as National Mental Health Awareness Month to draw attention to the mental health issues impacting nearly 20 percent of the U.S. population.

“For too long, mental illness has been a topic saved for the shadows, often going unmentioned. By designating May as Mental Health Month, we bring stories of courage and recovery out of the shadows and into the bright light of day. During May is Mental Health Month, we strive to inspire thoughtful examination and discussion across the country on our nation's mental health challenges and opportunities,” said Congressman Murphy.

“Mental health care has been ignored for far too long in this country.  I am co-leading this Resolution with Representative Murphy to recognize the importance of mental health and the critical need to reduce its stigma,” said Representative Matsui.   

To read the text of Congressman Murphy’s Mental Health Awareness Month resolution, please click here.

Assisted Outpatient Treatment recognized as evidence-based intervention

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The Substance Abuse and Mental Health Services Administration (SAMHSA) last week added the practice commonly known as assisted outpatient treatment (AOT) to the National Registry of Evidence-Based Programs and Practices (NREPP).

AOT has been at the center of CMHNetwork dialogues over the past year. One of our dialogue participants, Brian Stettin, led a successful effort on behalf of the Treatment Advocacy Center to get AOT added to NREPP. With the addition of AOT to the national registry, the opportunity exists for researchers to help define the "T" in AOT. We will be watching and writing about how this newest addition to NREPP begins to take shape.

Harvard Center on Developing Child releases 3-part video series on resilience

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The science of resilience can help us understand why some children do well despite serious adversity. Resilience is a combination of protective factors that enable people to adapt in the face of serious hardship, and is essential to ensuring that children who experience adversity can still become healthy, productive citizens. Watch this video to learn about the fundamentals of resilience, which is built through interactions between children and their environments.

This InBrief video is part one of a three-part sequence about resilience. These videos provide an overview of Supportive Relationships and Active Skill-Building Strengthen the Foundations of Resilience, a working paper from the National Scientific Council on the Developing Child.

Advanced training in child protection offered by Kempe Center

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The Kempe Center is launching a Summer Institute on Child Protection from July 6-24, 2015 in Denver, CO. The Institute is for individuals interested in advancing their knowledge and skills in research, clinical practice, leadership and policy related to child abuse and neglect and family violence. The short course, highly interactive format will provide ample opportunity to network with faculty, other participants, and special guests. 

This looks like an excellent opportunity, Network faithful!

Sesame Street in Communities

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It’s the Month of the Young Child, and the Sesame Street pals are celebrating with videos designed to help little ones grow smarter, stronger, and kinder.

Sesame Street in Communities brings free video content of everyone's favorite, furry Muppet friends as they help children and the adults in their lives reach their highest potential. Grover and the gang will tackle a variety of topics that face children in the areas of health and well-being, school readiness, and emotional well-being. Some of the content and topics presented are more sensitive, so you should preview these videos before sharing with a child. For free resources and tips, follow Sesame Street in Communities on facebook.

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