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Parity and the medicalization of addiction treatment.

Addiction is a widespread condition, often beginning in adolescence, with new-onset cases possible at virtually all points along the lifespan. It has been estimated that 20% to 30% of our nation's total health care costs are devoted to treatment of the medical, surgical and psychiatric complications of substance use and addiction, whereas around 1% of America's healthcare dollar is spent on treatment of the primary illness of addiction itself. Most addiction care is delivered by counselors, not physicians, and the degree of supervision of that care by physicians varies widely, as does the knowledge, skill base, and quality of the physicians providing that supervision. When persons with addiction do receive care, 80% of the time it is care delivered in or paid for by the public sector: America's private sector health delivery system, the most technologically advanced (and expensive) in the world by far and the mainstream of American medical care, devotes surprisingly little attention to addiction as a primary illness. Most addiction care in America is delivered in a specialty delivery system in geographic locations separate from locations and facilities where other medical care services are provided. In sum, the care patients receive when they have addiction is not on a par with the care they receive for cardiologic, orthopedic, obstetric, or even psychiatric conditions. And the third party payment and utilization review systems associated with addiction care have clearly been separate but not equal when compared to private sector third-party payment, care management, and utilization reviews associated with other medical care.

OPPOSING DISEASE DISCRIMINATION

The idea that health insurance coverage and other resources for the treatment of addiction should be on a par with insurance coverage for the treatment of other medical illnesses is not new. Ever since the AMA identified alcoholism as a disease in 1956, the logical position taken by recovery advocates is that there is no reason for alcoholism and other chemical dependencies to receive different levels of benefits or fewer available resources than do other diseases. Those of us who were privileged to promote this idea in the early twenty-first century are humbled to recognize how we stand on the shoulders of giants, starting with Marty Mann, the founder of NCADD, and her advocacy predecessors based in the Oxford Movement. Efforts to legislate equality in the availability of effective treatment for addiction began early in the Nixon Administration with testimony before a U.S. Senate panel chaired by Sen. Harold Hughes (D-IA). William Wilson (Bill W.) testified as a cofounder of Alcoholics Anonymous. Marty Mann, the first woman to achieve recovery through the fellowship of AA, and several other AA members testified, not as members of the fellowship but as people with alcoholism and in recovery, to a U.S. Senate panel, the Special Subcommittee on Alcoholism and Narcotics of the Senate Committee on Labor and Public Welfare, on July 24, 1969.

The year 1970 saw the enacting of PL 91-513, through passage of the Comprehensive Drug Abuse Prevention and Control Act. This act is best known for establishing a format for "scheduling" of controlled substances, but it also amended the Harrison Act of 1914 and allowed physicians to use a medication (methadone) to treat opioid addiction and opioid withdrawal (the Harrison Act had made it a criminal act for a physician to prescribe any opioid to a patient with such a condition; the Harrison Act was further amended by the Drug Addiction Treatment Act of 2000, which allowed physicians to use sublingual buprenorphine to treat opioid addiction and opioid withdrawal). The same year (1970) also saw the adoption of the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act. Authored by Sen. Hughes, a person with a personal history of addiction who was very open about his recovery. It established Public Law 91-616, through which The National Center for the Prevention and Control of Alcohol Problems of the National Institute of Mental Health became the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The NIAAA was granted the authority to develop and conduct comprehensive health, education, training, research, and planning programs for the prevention and treatment of alcohol abuse and alcoholism. Only four years later, the National Institute on Drug Abuse (NIDA) was established to direct research, treatment, prevention, training, and clinical services for addictions other than alcohol addiction.

Parity is a natural extension of this recognition that addiction is a medical condition, a disease of the brain. William Silkworth, a New York City psychiatrist, had presented the medical perspective in the 1939 book, Alcoholics Anonymous, describing alcoholism as a medical condition in which the individual had intrinsic deficits in self-management of drinking. The AMA followed its declaration of alcoholism as a disease with its declaration in 1987 of drug addiction as a disease. These concepts are reflected in the sequence of legislative recognitions that addictions are disease states and not desired conditions.

Initial efforts at achieving parity via federal legislation were partially successful. Through the leadership of Senators Pete Domenici (R-NM) and Paul Wellstone (D-MN), the Mental Health Parity Act (MHPA) of 1996 (which became Public Law 104-204) decreed that insurers could not set lifetime dollar limits and annual dollar limits on mental health benefits at a more restrictive level than lifetime or annual limits on medical or surgical benefits. This law fell short in that it did not mandate that coverage for mental health conditions be present in insurance policies. It did not address limits on prescription drug coverage, the number of inpatient days or outpatient visits per year for mental health care, or the kinds of copays and deductibles that insurers could assign to mental health care. Also, it did not address discriminations in the structure of benefits for treatment of substance-related disorders (alcohol/drug withdrawal or addiction) at all: such conditions were within the scope of the legislation until a last-minute maneuver prior to the Senate's vote, which dropped substance use disorders from the list of covered diseases in the bill. In a feature that was recapitulated in the 2008 parity bill passed by Congress, the 1996 MHPA allowed for employers offering employment-based health insurance benefits to "opt out" of complying with provisions of the law if they could demonstrate that compliance with the law would result in premium increases of more than 1% per year.

A far more complete parity bill, one that does include addiction as well as mental health conditions, was enacted by the 110th Congress. In the U.S. Senate, a parity bill (S.558) authored by Senators Kennedy and Domenici, and named the Mental Health Parity Act of 2007, was developed with input from business and health insurance industry advocates as well as advocates for mental health professionals, but with relatively little effective input from advocates for addiction treatment. In the U.S. House of Representatives, the Paul Wellstone Mental Health and Addiction Treatment Act (H.R. 1424) was introduced by two members of Congress who are themselves in recovery, Rep. Jim Ramstad (R-MN) and Rep. Patrick Kennedy (D-RI); the language of this bill was strongly influenced by addiction treatment advocates. Provisions from these bills were melded into the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), which passed both chambers on October 3, 2009, and was signed into law by President Bush later that day as Title V, Subtitle B of Public Law 110-343. (It is ironic that the MHPAEA, which carried a fiscal note of $10 billion over ten years, became a vehicle for the passage of the $700 billion dollar "bailout" bill for the nation's financial services system, the so-called Emergency Economic Stabilization Act (EESA) which created the Troubled Assets Relief Program; the EESA became Titles 1-3 of P.L. 110-343).

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires every insurance benefit package provided by employers with more than 50 employees, renewed on or subsequent to October 4, 2009, to provide coverage at parity for addiction and mental health, if coverage for these illnesses is provided at all. There is no requirement that coverage be provided for any mental health or addiction disorder; but if that coverage is provided, it has to be provided at parity. Specifically, plans could not provide those benefits in a more restricted way than other medical or surgical benefits provided by that plan.

EVOLUTION OF ADDICTION MEDICINE

During this active time in federal reforms to promote addiction and addiction treatment research, policy makers had the wisdom to recognize that expansion of the basic science and clinical knowledge of addiction was important, but that education of physicians about such advances was also necessary to improve the public health. A federal program to encourage academic leadership in developing the science and teaching of addiction medicine, the NIDA/NIAAA Career Teacher Program for medical school faculty, was authorized in 1971, establishing a strong core of 63 Career Teachers, scientists and physicians, most of whom were not themselves in recovery. This program provided training for medical students, residents, and junior faculty, and was one of the most significant advances in the development of the field of addiction medicine.

Parallel to these evolutions in medical science and medical education in the addictions in the governmental arena were changes within organized medicine. A group of Career Teachers, at an informal meeting at Georgetown University Medical School, hosted by William Flynn, a Career Teacher, agreed to form the Association for Medical Education and Research in Substance Abuse (AMERSA) in 1976. To form AMERSA, the Career Teachers joined with faculty from nursing, psychology, social work and other health professions. This seminal organization provided an opportunity for addiction professionals to network and to develop conferences and educational venues so that advances could be presented within the larger field. From the earliest days of addiction treatment, there has been an understanding among expert physicians and other specialty professionals that, given adequate resources, lives can be saved and families can be restored. Addiction, though a chronic disease, does not need to progress to disability or death.

Physicians who had developed an interest in the treatment of addiction, either from clinical experience and learning from the success of their patients or due to academic efforts, began to organize to further their interests. This began concurrently in New York, California and Georgia with the emergence of the American Medical Society on Alcoholism (AMSA), the California Society for the Treatment of Alcoholism and Other Drug Dependencies (CSTAODD), and the American Academy of Addictionology. These three organizations merged in 1986 to become the American Medical Society on Alcoholism and other Drug Dependencies (AMSAODD), which three years later renamed itself the American Society of Addiction Medicine (ASAM) and became a membership society of physicians with a broad spectrum of primary specialty backgrounds. A major accomplishment of AMSAODD was to accept the certification examination for physicians that had been established in California by the California Society for the Treatment of Alcoholism and make it a national examination. ASAM then became a more influential and robust national medical specialty society when it selected its first full-time Executive Director, James Callahan (who had served previously as a co-administrator, with Jeanne Trimble from NIAAA, of the NIDA/NIAAA Career Teacher Program).

The concept that the disease of addiction and the treatment of addiction needed to become more mainstream within medicine, and not the purview of social service systems and non-medically trained counselors, was promoted within the AMA House of Delegates by Jess Bromley, a member of the California Medical Association who was instrumental in ASAM being granted a voting seat in the AMA House. With the "War on Drugs" taking so much prominence in the media and in the public eye during the Reagan Administration, and with so much government funding devoted to criminal justice approaches and control of drug supplies, importation, distribution and the like, Dr. Bromley made the case that the proper approach wasn't the legalization of drugs but the "medicalization of addiction." Physician leaders from inside and outside ASAM recognized the wisdom of this approach. The movement toward the medicalization of addiction treatment required that, just as ASAM's national certification examination in addiction medicine recognizes physician expertise, physicians needed to be recognized for their expertise in addiction diagnosis and treatment by the entity that oversees physician specialty certification in the U.S.: the American Board of Medical Specialties (ABMS). Richard Frances, Sheldon Miller, and several other academic psychiatrists who specialized in addiction worked with the ABMS and its 24 member boards to establish a certification program in addiction that would be recognized by the ABMS. Regrettably, their efforts at that time to interest the American Board of Internal Medicine and other member boards of the ABMS in these initiatives were not embraced. These academicians were left to work with their own board, the American Board of Psychiatry and Neurology, to approach the ABMS for recognition. The result was the establishment of addiction psychiatry as a subspecialty of psychiatry. Soon thereafter, these same psychiatric leaders established a professional society to represent them, the American Academy of Addiction Psychiatry (AAAP). This is an organization of psychiatrists, most of whom obtained ABMS-recognized subspecialty certification in addiction psychiatry; the AAAP's first Executive Director was the aforementioned Jeanne Trimble from the by-then defunct Career Teacher Program.

Following somewhat separate paths, ASAM and AAAP promoted recognition of addiction medicine and addiction psychiatry within organized medicine. ASAM, having received a seat in the AMA House of Delegates several years prior to the creation of AAAP, still plays an active role within the AMA. This presence within organized medicine has led to recognition within medicine of the leadership of addiction medicine and addiction psychiatry in deliberations related to substance use disorders and the use of substances with the potential for abuse; both ASAM and AAAP were looked to for expertise by Congressional staffers and the authors of the Senate and House parity bills in 2008.

Since the first strategic plan developed by ASAM in 1998, the need for increased access to effective addiction treatment has been a major goal of the organization. The update of the ASAM Strategic Plan approved in 2006 included the following goal (among five other major goals) for the society: "There will be increased access to effective addiction treatment." To accomplish this, ASAM committed itself to ensuring that addiction services would be provided by addiction medicine specialists or other appropriately trained professionals, and that there would be parity in insurance coverage for addiction treatment. ASAM has devoted major resources to the realization of this goal, especially in the years leading to the passage of MHPAEA and its signing into law by President George W. Bush.

DEVELOPMENTS IN ADDICTION TREATMENT

A concurrent development from the 1970s into the 1990s was the recognition that physicians with addiction could be predictably treated, rehabilitated, and then return to the workplace. Physician health programs evolved that required effective treatment for physicians identified as having an addiction. Physician treatment programs clarified models of treatment that recognized addiction as a chronic disease, developing lengths of stay and reentry monitoring criteria and using laboratory testing as part of monitoring of the physician-patient's recovery over a span of years rather than weeks. Many of these physicians chose to use their medical training and the experience of their own recovery to help non-physician patients recover from addiction; they moved beyond their original specialties and began practicing addiction medicine part-time or full-time in the service of patients and families. Recovering physicians who practiced addiction medicine comprised the core of the American Academy of Addictionology prior to its merger into what became ASAM. In the 1980s, there was a large increase in the number of physicians who were interested in the treatment of addiction, supported by the reality that at that time there was also a large increase in the availability of opportunities for patients to receive such treatment with an expansion in the treatment industry. For many of these recovering physicians seeking positions as medical directors and staff physicians in residential programs, there was an incentive based on the scientific foundations of medical education to move beyond their personal experiences with recovery and become knowledgeable about the scientific progress in the field, and to put these progressive ideas into practice. For both recovering and non-recovering physicians, a few formal fellowships arose to provide intensive post-residency training. But most physicians prepared themselves for the ASAM examination and their careers in this new specialty through continuing medical education programs offered through ASAM and other organizations. Such CME provided the training needed for evidence-based practice, education sadly not available during the physician's medical school and residency years. Through such CME there emerged an expanding cadre of thought leaders and innovative clinical practitioners in addiction medicine who embraced the need for comprehensive, science-based and evidence-driven treatment.

What began as a unique interest among a small number of physicians who were impressed by life changes made by their alcoholic and drug addicted patients, by the science they studied and taught, or by their own recovery experiences, became the conviction that addiction could be identified and effectively treated. The clinical science was initially empirical and based on case studies and practical experience. But because of the massive economic impact of alcohol and drug use disorders on our society and the intrinsic fascination with the biological determinants of behavior, increasingly basic science research and larger, more scientifically significant clinical studies produced an expanding body of knowledge relative to the understanding and treatment of addiction. The idea emerged that, as addiction is a biological illness and best understood by physicians trained in the biological sciences, the treatment of addiction best includes and evolves from highly trained and specialized physicians, able to apply that science to the treatment of patients. There was a momentum for the development of increasingly effective and individualized treatment modalities for addiction in all of its presentations. But the better treatment became, the less available treatment became for most patients.

As ASAM and AAAP continued to grow and wield influence in the public policy arena, their members were practicing in an environment in which the expansion of managed care led to restrictions in access to care for patients and reductions in reimbursements for clinicians. Many experienced physicians left addiction treatment practices to return to their original specialty, and many experienced addiction nurses and therapists saw their positions eliminated as rehab centers and detox centers closed due to financial pressures. The absence of parity in insurance coverage was increasingly recognized as a barrier to access to treatment. What seemed obvious in the context of the recognition of alcoholism, nicotine dependence, and other addictions as disease states--that they should receive equal resources for treatment--became difficult to secure.

The persistence of moral thinking about the origin and perpetuation of addiction, the initial success of nonmedical models for some, and the visibility of those people with addiction who seemed to achieve long-term recovery without medical intervention, all served to discount the need for and marginalize the importance of medical training in the treatment of addiction. Opposing the trend reflected in legislative efforts that recognized addiction as a medical disorder, America saw addiction treatment in the early 1990s battered in the managed-care dominated private sector, and provided increasingly in public sector, non-medical modalities.

Recovery advocates have been aware of the importance of insurance resources to the possibility of recovery from addiction for decades. Recall that it was only in the final moments of negotiation and floor debate on the 1996 Mental Health Parity Act that addiction was dropped from the legislation. During the Clinton Administration, in the initial efforts to secure substantive healthcare reform, a great deal of effort on the part of ASAM and others went into assuring that addiction treatment be included in the compendium of available medical services, and at parity with other medical conditions. ASAM's public policy statement on the Core Benefit for Primary Care and Specialty Treatment and Prevention of Alcohol, Nicotine and Other Drug Abuse and Dependence clearly outlined the need to include addiction services in any standard benefit package. Actuaries had made clear that addiction must be treated effectively to prevent the medical, surgical and psychiatric complications of untreated addiction. And this was necessary to control costs in any system with universal access to services. So, while the Clinton efforts at overall health system reform failed, the inclusion of addiction services was embraced. A precedent was set. A core group of advocates grew out of these and previous parity efforts and these advocates relentlessly toiled to secure federal reforms in insurance laws and how private insurers would pay for addiction services. This group has been so focused and so persistent that the law of the land now is P.L. 110-343, the result of the passage in the 110th Congress of the MHPAEA!

IMPLEMENTING PARITY LEGISLATION

To implement this huge change in federal law, three federal departments were charged, in the MHPAEA, with developing the rules and regulations that would guide implementation of the legislation. The Departments of Health and Human Services, Labor and Treasury together published an Interim Final Rule in January of 2010. This is the set of clarifications, rules and regulations that will guide insured individuals, treatment providers, insurers and employers in the implementation of this law. Also in January of 2010, the Advocates for Human Potential (AHP) Consulting Group, part of the Parity Implementation Coalition, published an operational analysis of the interim final rule to sort out the meaning and implications to stakeholders.

These federal regulations call for oversight of health insurers and managed care plans, as well as penalties for non-compliance with the provisions of the law. If the plans restrict access to mental health and addiction care in ways that are more stringent than the way they restrict access to medical/surgical care, they will be held accountable. Advocacy groups such as the Parity Implementation Coalition, of which ASAM is a leading member, responded during the public comment period about the draft regulations, and stand poised to serve in a watchdog role to monitor how parity provisions actually get operationalized, and whether the non-discriminatory approaches envisioned by parity advocates really come to pass. Both ASAM and AAAP have encouraged their members to submit any examples of noncompliance with the new parity law so that these professional societies can collate data, identify trends, and submit reports to federal regulators of any gaps in "making parity real."

The rules leave several challenges and unanswered questions. The scope of services for addiction is not substantively addressed. It is unclear if plans are required to reimburse the full spectrum of services available, or if plans can limit services that are covered in such a way as to exclude part of the continuum (thus, not every level of care described in the ASAM Patient Placement Criteria, and not every level of care described in the ASAM Core Benefit statement, two documents largely held to be care standards in the field, may be covered by every insurer). The complexities of understanding the various insurers' benefit packages and applying those benefits to the treatment of addiction in patients, each of whom has a benefit package from a separate carrier and each of these originating in separate employer packages, will require significant development of expertise on the part of providers, such as information technology systems, that are not compensated by the law. Most importantly, the criteria for medical management are delegated to the various insurers and the requirement that these criteria meet generally acceptable medical standards is weak. Specifically, no insurer is required to follow the ASAM Patient Placement Criteria--though all are required to make their utilization management criteria public. But despite its limitations, there is huge opportunity in the 2008 MHPAEA legislation for the development of a momentum in the treatment of addiction that will provide a basis for further development of the concept of parity in emerging federal health care reform efforts.

MOVING FORWARD

Medicalization of addiction treatment has broader meaning than insurance parity, even though this is an important aspect. "Full parity" means equality in access to addiction services with access to other medical/surgical services for patients; equality in the quality of medical education and training opportunities for physicians who choose to specialize in addiction medicine; equality in compensation received for such services by physicians (and others); and equality in the recognition of physicians specializing in Addiction Medicine. The ASAM Strategic Plan has pointed not only to parity in insurance coverage, but parity in the way the American Board of Medical Specialties addresses special expertise among addiction medicine physicians. The establishment in 2007 of the American Board of Addiction Medicine, and the transfer to ABAM in 2008 of ASAM's national certification examination for physicians in addiction medicine, is part of the process of securing full parity in the recognition of addiction medicine among other specialties. And the membership of ASAM in the Council of Medical Specialty Societies, a status currently being pursued by ASAM, will more completely establish ASAM among other national medical specialty societies. A major plank in the realization of full parity will be creation of widely-available training programs in addiction medicine, accredited by the Accreditation Council on Graduate Medical Education (ACGME), so that physicians from all specialties, not only psychiatrists, can access high-quality graduate medical education to expand their knowledge and skills. The sister organization of the American Board of Addiction Medicine, the ABAM Foundation, is focusing all its energies and resources in the second decade of the twenty-first century on the establishment of available, accessible, high-quality training programs in addiction medicine, accredited by the ACGME and on a par with training programs in other areas of clinical medicine.

Addiction is the third leading cause of disability and premature death in the United States. Addiction is responsible for huge losses in our economy and a huge toll in human dysfunction. It may be argued that untreated addiction is responsible for many of the burdens of our society, and is the major driver of controllable health care costs. In a world of adequate resources for the treatment of addiction, and not just treatment of its complications, we can expect to see dramatic improvements in the welfare of our citizens in all areas of life. Just as we have seen lengthening of the life span with the development of medical expertise in the treatment of various potentially fatal illnesses, we can expect to see an increase in the quality of life (and in longevity) with the availability of effective, evidence-based, individualized treatment for addiction. The concept of parity actually extends beyond insurance payment for professional services rendered by physicians, counselors and others to patients in need: "true parity" would mean that treatment for addiction would be of equal quality to treatment for other conditions, and would be as available (in every community, in every hospital, within every primary care and multispecialty medical clinic) as treatment for other conditions, and that providing such treatment would be as well compensated and respected as is such care for other medical treatments. It would mean that the education and certification of professionals providing addiction care would be equal to the education and certification of professionals who treat other conditions. It would mean that such training would be available for physicians and other health professionals who want it, that training would have reliable and affordable funding streams to support it, and that viable career paths for professionals in addiction medicine would exist, making it no less attractive a field for young clinicians to enter as other medical and behavioral health specialties.

Post Deadline Addendum

President Obama has signed into law the Patient Protection and Affordable Care Act on March 30, 2010. The language of MHPAEA is preserved in insurance "exchanges" for individual and small business policies. Mental Health and Substance Use Disorders (MH/SUD) coverage is required in the "Essential Benefits Package" (state exchanges) and "Medical Homes" will have MH/SUD capability. This represents further progress in the direction of universal availability of treatment for addiction and intervention for harmful use of addicting substances. As is true for MHPAEA, the rulemaking process continues and will ultimately influence the availability and comprehensiveness of addiction treatment as well as the support for physician supervision and provision of those services.

([dagger]) The authors would like to thank Kevin B. Kuntz, M.D., M.P.H., President of ABAM and James F. Callahan, D.P.A., Executive Vice President of ABAM for contributions to the historical accuracy of this article and for editorial suggestions.

Ken Roy, M.D., Chair, Parity Action Group of the American Society of Addiction Medicine, Past Secretary of ASAM, and Co-Chair of the ASAM Legislative Advocacy Committee.

Michael Miller, M.D., Immediate Past President, American Society of Addiction Medicine, past Co-Chair of the ASAM Medical Specialty Action Group, past Chair of the ASAM Public Policy Committee, and Director of the American Board of Addiction Medicine and the ABAM Foundation.

Please address correspondence and reprint requests to Ken Roy, M.D., 4836 Wabash Street, Metairie, LA 70001 or preferably to: kenroymd@cox.net
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Title Annotation:American Board of Addiction Medicine
Author:Roy, Ken; Miller, Michael
Publication:Journal of Psychoactive Drugs
Date:Jun 1, 2010
Words:4845
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