Commentary: Affordable Care Act Could Benefit Treatment of Co-Occurring Disorders

As this country moves into a new era of how we approach the treatment, prevention and administration of illness, we must keep the rubric of co-occurring disorders at the forefront. One would be hard pressed to find a higher rate of co-occurring disorders than in the field of behavioral health, where more than 70 percent of those treated for substance abuse also have a mental health disorder.

There is no shortage of data pertaining to the dangers of co-occurring disorders. Those with such a condition die an average of eight years earlier than those with only one behavioral health disorder. High rates of tobacco use are also prevalent in co-occurring patients. For those with co-occurring disorders, physical safety and overall health risks are great and the chances for successful treatment are small. Yet co-occurring disorders are not the exception—they are the norm.

It is estimated that 8.9 million adults have co-occurring disorders—that is they have both a mental and substance use disorder. Unfortunately, fewer than eight percent of individuals receive treatment for both conditions, with 55.8 percent receiving no treatment at all. The consequences of undiagnosed, untreated or under-treated co-occurring disorders can be severe. They include homelessness, incarceration, suicide and early mortality.

Patients with addiction or mental health-related problems accounted for 12.5 percent of all hospital emergency room visits by adults in 2007, according to a report from the U.S. Agency for Healthcare Research and Quality. Alcohol dependence is four times more likely to occur among adults with mental illness than among adults with no mental illness (9.6 percent versus 2.2 percent) based on a nationwide survey conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA). The report also shows that the rate of alcohol dependency increases as the severity of the mental illness increases.

According to SAMHSA, integrated treatment or treatment that addresses mental and substance use conditions at the same time is associated with lower costs and better outcomes such as reduced substance use, improved psychiatric symptoms and functioning, decreased hospitalization, increased housing stability, fewer arrests and improved quality of life.

Clearly, there is no shortage of data on the subject. There has been great progress in recent years on the treatment of co-occurring disorders, both on the substantive and procedural fronts. One example comes from Connecticut. The state’s Co-Occurring Capable Guidelines and Co-Occurring Enhanced Program Guidelines, developed as part of their Co-Occurring State Incentive Grant (COSIG) from SAMHSA, have been recognized as models by a workgroup of COSIG states and other experts convened by SAMHSA’s Co-Occurring Disorders Integration and Innovation in 2010.

Connecticut had a platform to build from, with a vision for recovery-oriented services, articulated by the state’s Department of Mental Health and Addiction Services in its Practice Guidelines for Recovery-Oriented Behavioral Health Care. With a focus on providing direction, rather than being laid out as a regimen, each set of guidelines was developed by a diverse group of treatment practitioners and informed by the latest research, models and tools for delivering and monitoring progress in co-occurring service delivery. The program guidelines directly address complex issues such as minimum staff, the use of pharmacological interventions and peer support. These enhanced guidelines were also used to create an Integrated Care Policy for the state’s Medicaid Enhanced Care Clinics. Now, 17 programs across 11 service agencies in Connecticut meet the guidelines in their Intensive Outpatient Programs and were designated as Co-Occurring Enhanced Programs.

Many are anxious to see how the Affordable Care Act (ACA) will impact, and hopefully improve, the delivery of services for the treatment of co-occurring disorders. The design of the ACA has the potential to benefit these consumers in a few ways by providing:

• improved coverage of physical health care, which is important  to those with co-occurring disorders because they are highly likely to have co-occurring chronic physical disorders;

• improved coverage of mental health conditions;

• improved coverage of medications under Medicare Part D, including psychiatric medications; and

• financial incentives for providers to enhance health and mental health services integration.

The ACA also has the potential to benefit patients by emphasizing preventive interventions, emphasizing services in the home and community instead of in institutions, and calling for enhancements of long-term care coverage and service quality.

As the ACA continues to evolve, and states continue to define their respective essential health benefits, advocates should keep a careful eye on how those benefits will impact the treatment of co-occurring disorders.

Andrew D. Kessler is IC&RC’s Federal Policy Liaison and Founder of Slingshot Solutions, LLC.