A year has passed since the United States Congress enacted sweeping legislation to address deficiencies in our national behavioral health service infrastructure. The Comprehensive Addiction and Recovery Act (CARA) and 21st Century Cures Act, both passed by the 114th Congress in 2016, authorized a variety of initiatives to support individuals with serious mental illness (SMI) and substance use disorders (SUDs). The 21st Century Cures Act also authorized the appointment of an Assistant Secretary for Mental Health and Substance Use within the Substance Abuse and Mental Health Services Administration (SAMHSA) and the establishment of an Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC). The ISMICC, operating under the authority of the newly-appointed Assistant Secretary, is charged to enhance coordination across federal agencies that serve individuals with SMI. These initiatives, although surely imperfect and prone to the bureaucratic malaise that afflicts other governmental actions, constitute a welcome recognition of the inextricable link between SMI and SUD and the need for a correspondingly integrated response to them.
The ISMICC recently released its first report to Congress, and it underscored both the prevalence of co-occurring mental health and substance use disorders and our failure to deliver integrated and evidenced-based care necessary to ameliorate them. Of the 10.4 million American adults diagnosed with SMI, 2.6 million (approximately 25%) are dually diagnosed with a SUD. Although two-thirds (63.2%) of this cohort received mental health care in 2016, only 14.3% received specialized care for substance use (Interdepartmental Serious Mental Illness Coordinating Committee, 2017). Thus, approximately 2.2 million adults with co-occurring SMI and SUD conditions did not receive specialized substance use treatment in 2016. In addition, individuals with SMI and SUD are exceptionally prone to physical health conditions that further compromise their overall health and lead to adverse outcomes including potentially preventable hospital readmissions and premature mortality. One study found individuals with serious behavioral health conditions incurred substantially greater medical expenses for physical health concerns than did individuals without behavioral health conditions (Melek, Norris & Paulus, 2014). This finding applied to all payers under review including public (e.g., Medicaid and Medicare) and commercial. A survey of New York State Medicaid expenditures revealed a similar finding via analyses of hospital readmission rates among individuals with and without behavioral health diagnoses. Individuals with behavioral health conditions incurred more than twice the cost in hospital readmissions ($395 million) than did those without behavioral health conditions ($149 million) (National Council for Behavioral Health, 2007). Recent developments, most notably the scourge of opiate drug abuse that has ravaged communities across the nation, have only exacerbated the plight of those with behavioral health disorders. Although individuals with mental health conditions comprise less than one-fifth (17.9%) of the overall population, they received more than half of opiate prescriptions (51.4%) written during a survey period (Davis, Lin, Liu, & Sites, 2017). The foregoing findings appear to confirm the anecdotal accounts of many behavioral health service professionals. In short, individuals with co-occurring SMI and SUD are highly susceptible to the myriad health risks that afflict the general population and their comorbid behavioral and physical health conditions often result in adverse or tragic outcomes.
Healthcare reform efforts presently underway must address the needs of this vulnerable population in order to achieve desired improvements, and this must begin with a sober recognition of some enduring obstacles to reform. For instance, individuals with co-occurring disorders continue to have limited access to evidenced-based, integrated care essential to treating the unique manifestations of their conditions. In 2016, only 10% of those with co-occurring disorders received such treatment (Interdepartmental Serious Mental Illness Coordinating Committee, 2017). Thus, a substantial majority of individuals with co-occurring disorders must rely on “conventional” treatment modalities that target discrete symptoms of mental illness or substance use, as if the parts of their experience could be managed independently of the whole. These approaches are surely helpful to some, but they often fail to address the particularly complex experiences of individuals with both SMI and SUD. Moreover, these modalities remain deeply embedded within longstanding fiscal, regulatory, cultural and philosophical frameworks that frequently impede integration. For example, providers that deliver substance use treatment are subject to guidelines promulgated by the federal government and New York State Office of Alcoholism and Substance Abuse Services (OASAS). Their fiscal viability depends on a byzantine network of reimbursement standards that vary considerably by payer. Some providers promote treatment predicated on abstinence from any and all substances and this may even preclude the use of psychotropic medication or Medication Assisted Treatment (MAT), whereas others embrace nuanced approaches that employ principles of Harm Reduction and multiple pathways to recovery. Such differential approaches to treatment often betray deep philosophical underpinnings that may not accommodate new or contradictory evidence. They are simply unnavigable for many individuals with SMI, so it is unsurprising that only 14% of them access such treatment as affirmed by the ISMICC report.
The application of appropriately integrated and evidenced-based care for individuals with co-occurring disorders is necessary but insufficient to achieve the outcomes envisioned by the pioneers of healthcare reform. Like members of other vulnerable populations, individuals with SMI and SUD frequently have limited access to Social Determinants of Health (SDH) essential to optimal health and stability. The Centers for Disease Control and Prevention (CDC) defines SDH as “conditions in the places where people live, learn, work and play,” and it suggests these conditions exert considerable influence on individuals’ overall health and wellness (Centers for Disease Control and Prevention, 2017). An emerging body of evidence suggests healthcare plays a relatively minor role in overall population health, whereas social conditions, behavioral patterns and genetic predispositions are far more determinative of long-term outcomes (Schroeder, 2007). These findings confirm what intuition and anecdote have taught us for many years. Simply put, individuals with serious mental illness, substance use disorders or comorbid medical conditions cannot be expected to achieve lasting recovery without safe and stable housing, fulfilling personal relationships, income supports and avenues for personal growth via employment or other meaningful activity. Unfortunately, current social and economic policies fail to acknowledge the prominence of SDH in the healthcare equation as evidenced by marked discrepancies in spending for healthcare and social support services. The United States spends considerably more of its GDP on healthcare and less on social services than other developed nations, but its outsized investment in healthcare yields comparatively poor outcomes (Butler, Matthew, & Cabello, 2017). New York has generally mirrored this imbalance, especially within its Medicaid program. Until recently, New York boasted the largest Medicaid budget in the nation for which it enjoyed only mediocre (and in some respects dismal) results. This prompted Governor Cuomo to appoint a Medicaid Redesign Team shortly after he took office in order to enact much needed reforms.
The path toward integrated and holistic support for individuals with co-occurring disorders remains fraught with obstacles, but recent developments suggest a promising trajectory. A host of reform efforts presently underway (operating under a veritable alphabet soup of acronyms) aim to replace costly modes of institutional care with community-based alternatives, and many of these include new investments in SDH and other supports essential to individuals’ enduring stability. The New York State Office of Health Insurance Programs recently established a Bureau of Social Determinants of Health in order to ensure SDH are addressed in value-based reimbursement arrangements between providers and payers. Key stakeholders and constituents operating under the auspices of Clinical Advisory Groups, Regional Planning Consortiums and similar forums have been charged to identify various recovery-oriented services and supports (including SDH) for inclusion in future service contracts. These stakeholders must identify specific services and the metrics through which their impact will be monitored and assessed. This is surely a tall order, but there is nearly universal recognition of its importance. The overarching goals of healthcare reform, as encapsulated in the vaunted “Triple Aim,” will continue to elude us unless we employ a holistic and multifaceted approach to the treatment of individuals with co-occurring disorders. If we hope to reduce the cost of care, improve healthcare outcomes and enhance overall population health we must not neglect the unique needs of this population.
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