October 31, 2018
Of course, the goal promoted before, during and since President Trump’s legislation signing ceremony in the White House last Wednesday is to reduce opioid addiction and attendant deaths.
“Together, we are going to end the scourge of drug addiction in America,” said the president, before hedging his bet by adding, “We are going to end it or we are going to at least make an extremely big dent in this terrible, terrible problem.”
One can hope he’s right about the impact of the SUPPORT for Patients and Communities Act, regardless of expectation. Drug overdoses overall took more than 70,000 American lives in 2017 with opioids responsible for almost 50,000 of those. By any measure, opioids have ravaged American society in recent years and serve as a placeholder for the desperation that seems, for many, to define American life.
But while cautious optimism is appropriate following successful efforts to do something about opioids, questions are also appropriate. In fact, if we are to realize the president’s stated objective of ending “the scourge of drug addiction in America,” questions are essential.
Perhaps we can start with this one: What other goals must we work toward to truly address both addiction and the many behavioral health challenges of which drug dependency is a comparatively minor subset?
Computers are necessary, but insufficient.
It’s not just about the direct monetary attention paid to opioids in the legislation, which passed both houses of Congress with near unanimity, a feat in these polarized times akin to convincing Yankee fans to root for the Red Sox. The SUPPORT bill also contains provisions meant to incentivize EHR purchases by mental health providers—from psychiatric hospitals through to clinical social workers.
How will those incentives work? This remains to be seen. The bill tasks CMS’s Center for Medicare and Medicaid Innovation (CMMI) with developing a pilot program to see what works. This is no small task. Where acute care is a more structured landscape of large, medium, small and critical access hospitals, behavioral health is a patchwork of providers. Some are large and institutionalized, but a sizeable percentage of the industry is single therapists working from home or near-home offices.
If we can create a scenario where most, if not all, healthcare providers use electronic tools, we must also identify data exchange standards.
To a certain extent, that challenge seems to be resolving itself. In early October, the Office of the National Coordinator (ONC) released an assessment showing that HL-7’s Fast Healthcare Interoperability Resources (FHIR©) standard has proliferated with the expectation of continued growth.
“New analysis shows that the United States might be at a turning point when it comes to the adoption and implementation of (FHIR),” said the ONC report. “Overall, of the hospitals and Merit-based Incentive Payment System (MIPS) eligible clinicians that use certified products, we find that almost 87 percent of hospitals and 69 percent of MIPS eligible clinicians are served by health IT developers with product(s) certified to any FHIR version.”
The adoption of a single standard is great for acute care, and it’s essential that behavioral health also be in the mix. Primary and emergency care providers will find it hard to give appropriate treatment without knowing of co-morbidities, including addictions and mental challenges. In many cases, they don’t have the data to know what they’re dealing with, which solutions related to FHIR will hopefully one day change.
It’s also worth asking whether there should be an incentive for the adoption of telehealth solutions. Currently, telehealth is a key player in a handful of ideas that, combined, may keep rural hospitals from closing. It is also the only approach for many in rural areas who can’t find in-person behavioral health care. Like EHRs and a communications standard, telehealth seems like a must.
The gap between 6 and 100 is large.
The SUPPORT legislation President Trump signed allocates $6 billion for the effort and expands Medicaid funds available to some treatment centers. Hopefully this initial commitment is just a down payment, because more is needed.
How much more? Judging by the comments of industry experts, a lot.
“It’s a very good starting point. But I call it wave one, and I hope there will be wave two,” said Daniel Ciccarone, a UC San Francisco professor.
“I certainly think it’s moving in the right direction, but I do think it’s woefully underfunded,” added Albert Einstein College of Medicine professor Chinazo Cunningham.
Senator Elizabeth Warren and Representative Elijah Cummings have suggested $100 billion over 10 years, and even that would probably prove insufficient simply because we’re now allocating dollars without an understanding of exactly what the task is.
Think about it. Prescribing fewer opioids is one challenge and replacing them with other forms of pain management is another. Acknowledging the incarcerated mentally ill is one challenge and getting them necessary treatment is another. Identifying the interconnected causes of addiction and desperation is several challenges and trying to fix them is a bunch more.
The root causes of addiction are numerous. It will take time and consistent funding to dig them up.
Are we treating symptom or disease?
The opioid crisis is just one symptom of a fractured society. While it would be a mistake to try and tackle various symptoms at once, it would also be wrong to ignore cross-currents. How do we realistically expect to reduce the number of homeless, for example, without trying to manage PTSD before it gets out of control or working to make sure affordable housing exists?
In an era of ever-shorter attention spans, the opioid epidemic requires a consistent, steady focus, mostly at the local level. Our national support for cities, towns, neighborhoods and families must be enduring. What form that support takes—more rehab centers and drug courts, community policing programs, additional police—will vary from place to place, but what can’t vary is the commitment to a solution.
And the solution to the opioid problem is on shaky ground if not couched in the broader issues of mental illness, homelessness and poverty.
The best way the federal government can show commitment now is to provide more funding over a longer term. Those dollars then trickle down to local programs that have enough confidence in financial support to invest in the process of effectively changing lives.
All presidents are concerned about their legacy, as are members of Congress. Now that this laudable first step toward resolving America’s opioid crisis is past the conceptual stage, it’s time to consider when the next payment on a healthier America will be made.