Sep 11, 2016

Fighting heroin in Cincinnati with money we already have and volunteers who are ready to start

A huge crisis. A new treatment paradigm. Now what do we do?

I live in Cincinnati, where over 300 people have overdosed this past week. People have been calling this a “bad batch” of heroin, but overdoses have also ramped up across southern Ohio, West Virginia, Kentucky, and in Ohio’s other big cities. This is not a “bad batch.” It’s a product evolution, and it is coming to your town soon.

Fortunately, our community response systems have reached a tipping point on policy. Police here are offering immunity to people who turn in their drugs and ask for treatment. Medication assisted treatment is supported as the norm. Earlier this week, I spoke at a Cincinnati City Council committee meeting to offer my take on what might help. I used to be an outlier on policy, advocating for harm reduction and medication treatment in a community that favored nonmedical 12-step approaches and abstinence based care. This week, people were nodding their heads as I spoke, and I was nodding in agreement as treatment program leaders spoke.

To put it bluntly, we have reached a Kumbaya moment on addiction policy. Naloxone, medication assisted treatment, and community support programs are mainstream concepts now. People agree that we need a system that provides these things. What we need now is action. This creates new issues — implementation issues. How fast can we implement a new systems paradigm? Where will the money come from? Where will workers come from?

Fortunately, in Ohio, the money and protocols are already in the system. Certain reforms that have already been worked out must be implemented several months sooner than planned. Ohio has been in the midst of a behavioral health finance redesign for several years. These reforms are scheduled to kick off in mid-2017. The redesign process will move the state’s behavioral health system much closer to a “pay-for-performance” finance model. It also adds coverage for some new services, including peer support. Given the overdose emergency we are facing today, it should be possible to pilot the new payment system immediately in the places where overdoses are raging. In practice, this means training up existing staff, and upgrading payment systems to use new billing codes. It won’t cost more to implement reforms early. Because every dollar invested in medication assisted treatment saves around $5 in other healthcare system costs, the question is not “how much more we need to spend.” The real questions are “how much do we want to save?” and “how fast can we start?”

Who is going to do the work? Cincinnati already has the human resources to implement reforms at scale. We have about 1250 primary care physicians in Hamilton County, where the City of Cincinnati is located. If just ten percent of them took on 30 medication assisted treatment patients each, they could stabilize 3,750 people this year. Next year, federal regulations will allow each of these doctors to expand their caseloads, and serve 100 patients each, for a total of 12,500 people. That is the entire population that needs treatment in Hamilton County today, stabilized in just two years.

Our region is fortunate to have sufficient healthcare infrastructure to implement the new paradigm. We have four large hospital systems, a dozen or more Federally Qualified Health Centers, and several networks of behavioral health providers. These provider systems already negotiate rates and treatment protocols with public and private insurance systems. If provider systems step up their game, they can work together to create what are called Accountable Care Organizations (ACOs) and Special Needs Plans (SNPs). These are legal structures and insurance arrangements that support collaboration and help finance the work. It takes leadership and some technical skill to put this together, but the models to accomplish this exist.

Like other communities in America, Cincinnati has no shortage of willing volunteers. Church groups and community organizations are looking for ways to address the social needs of people in recovery. Our hospital systems at the center of the new treatment paradigm already manage volunteers. The missing ingredient is action.

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