An estimated 12% of adult Medicaid beneficiaries suffer from substance abuse disorder, according to 2011 government data. People with this disorder also often experience physical health problems that include liver disease, pancreatitis, and chronic pain. (View the report at: http://bit.ly/2PKPN9b.)

About one out of every eight people who visit an ED present with substance abuse or mental health needs. These data suggest the need for care coordination initiatives. (For more information, visit: http://bit.ly/2S5D8zv.)

Case management for substance abuse patients can help coordinate their health and social services, according to a new report by The Association for Community Affiliated Plans (ACAP). Four ACAP-member Safety Net Health Plans are building case management strategies for fighting addiction.

The association has focused on the opioid epidemic for about five years, says Margaret A. Murray, MPA, chief executive officer of ACAP in Washington, DC. ACAP, a trade association of 63 Safety Net Health Plans, serves more than 21 million people in 29 states.

The association promotes a change in federal rules protecting confidentiality of substance abuse records, 42 CFR Part 2, because these are more stringent than rules under the HIPAA Privacy Rule and they hinder coordinated care for patients with substance abuse disorder.

“Substance abuse providers are subject to higher rules about privacy than people on the physical health side,” Murray says. “This limits communication between substance abuse providers and physical health providers.”

Because of 42 CFR Part 2, a patient’s doctor might not know about the patient’s treatment for substance abuse. Advocates for a change thought an opioid bill, called the SUPPORT for Patients and Communities Act, signed by President Trump on Oct. 24, would change this requirement. It could have made it easier for providers to communicate about patients’ substance abuse treatment, but the bill’s final version did not change privacy requirements.
(The text of the bill is available at: http://bit.ly/2Pkb2lw.)

“We felt like this should have been changed in the opioid bill, but it wasn’t,” Murray notes. “Many of us think privacy rules related to substance abuse should be similar to those about mental health, similar to HIPAA rules.”

ACAP’s work also includes helping healthcare professionals to be mindful with prescribing pain medication and assisting patients with substance abuse disorder.

“We have done a couple of reports where we’re talking about how the plans work with providers to change their prescribing patterns,” she says. “All of these changes have to be supported by an improvement in care management, an understanding of what people are facing.”

The reports also include strategies for prescribing medication-assisted therapy and supporting case management.

For instance, one plan involves embedding case managers in clinics to provide substance abuse assistance, Murray says.

Using a team approach, case managers work to get patients what they need and help clinicians understand the implications of substance abuse disorder from a behavioral health perspective, she explains.

“Some plans provide staff training to increase the number of providers who provide medication-assisted therapy,” Murray says.

Medication-assisted therapy reduces cravings and side effects — but, like methadone, does not give them a high. Patients can live on it the rest of their lives, Murray says.

“It is an effective way to treat substance abuse,” she says. “For a lot of people, the opioid addiction is too strong. This is a way to allow them to not have the behaviors of drug-seeking, but it reduces cravings, and they can live a normal life.”

Some providers are not comfortable with this approach, so it’s not available to everyone who would benefit from it, she says.

The following are some of the other benefits ACAP offers patients with substance abuse disorders:

Case managers help patients with nonmedical-covered benefits, such as offering them transportation to see their doctors. “A couple of our plans have bus passes or agreements with ride-sharing services,” Murray says.

“Our plans provide acupuncture and try to find pain management alternatives to opioids,” she says. “The care manager is involved in making sure people know what their alternatives are, including therapeutic massage, acupuncture, and behavioral therapies to deal with pain.”

These strategies can work for people who suffer from opioid addiction and for those who do not, she notes.

“We hope the report will be read widely so plans and care managers can learn what’s working, what they can improve to serve their beneficiaries better,” Murray says.