How Can States Use Opioid Settlement Funds to Truly Transform Substance Use Disorder Treatment?

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Debbi Witham is a principal in the Health Management Associates behavioral health practice group. She shares her in depth understanding of the complexities of substance use disorder (SUD) treatment systems and highlights the critical need for quality measures and sustainable healthcare funding. Debbi emphasizes the importance of not throwing more money into systems that are not producing outcomes, and that states have an opportunity to course correct. The conversation explores topics such as the impact of reimbursement on care delivery, the urgency of addressing addiction within the larger healthcare ecosystem and provides insights into the necessary steps for coordinating a community response that improves outcomes.

Jennifer Colamonico: Welcome to HMA's vital viewpoints on health care, concise conversations with experts that identify practical solutions to make healthcare and human services work better. I'm your host, Jennifer Colamonico, and I'm thrilled to be your guide as we explore new ideas for solving challenges that confound our uniquely american systems. Charged with delivering health and health care in a world that has far too much information and far too little wisdom, we'll aim to keep it simple, frank conversations about what it really takes to reimagine these systems of health and health care. Our HMA experts know how things work and don't work, and they have viewpoints on both the problems and solutions that are born from that experience. Vital viewpoints on healthcare is not just another podcast, it's your window into the minds of those steering us toward a healthier future.

Jennifer Colamonico: Subscribe now and together we will explore the hard earned wisdom that could change the way you think about your professional challenges. Our guest today is Debbi Witham. Debbie is a principal in the HMA Washington, DC office and she is a Real leader in our work on substance use disorder. Debbie is the former managing director at The Commission on Accreditation of Rehabilitation Facilities otherwise known as Carf International, where she oversaw federal policy development and tracked issues impacting service delivery.

Jennifer Colamonico: She played a pivotal role in developing standards for opioid treatment programs, and that's the basis of the work that she does at HMA, working on program design, delivery system reforms, compliance, accreditation, quality improvement, workforce development, and value based payment models. Debbie brings her unique perspective as a licensed social worker with a law degree. So, Debbie, when we think about opioid settlement funds, you really are one of the best people to help explain what perhaps is obvious as an opportunity, but maybe also not so obvious as an opportunity for states that may be receiving these opioid settlement funds. So let's set the stage a little bit in terms of the opportunity. It looks like state and localities could yield about $50 billion. I think about half of that is one particular settlement that was awarded to 46 states. So it seems like there's a lot of one time money coming to states. How do you characterize this opportunity?

Debbi Witham: I think it's an opportunity for states to really pause and take a look at what their system needs.

Jennifer Colamonico: Right.

Debbi Witham: So I think traditionally the substance use disorder treatment system has been dramatically underfunded. A lot of it is through Medicaid. And the rate that providers receive is really based on, varies greatly from state to state. I think it's an opportunity to then to really take a look at what are the needs of the people that are living in our state? What are the points of entry into the system? So not just looking at this as far as what is a substance use disorder treatment system, but where are the points of entry where we might catch people who need treatment, right? So people entering into skilled nursing facility after an acute visit to the hospital for endocarditis, or people entering the justice system, right. Most frequently, people have some history of substance use disorder, actively intoxicated when they're entering incarceration. So making sure that we use all of those places as points of entry to get people into the system and to bring treatment into those systems if needed. I think the other opportunity really is to look and make sure recovery is not a linear process, right? So a person might need a different form of recovery at any point in their process. And so what we wanna make sure of is that people are really able to receive the right treatment in the right place at the right time, and that doesn't exist in most states and in most communities, because what happens is you tend to have, and it often tends to be like the service that's most highly reimbursed, and you have a lot of that service, and then a dearth of the other services that people may also need. And so making sure that if someone really struggles with their activities of daily living, they have access to residential where they're relearning those skills, but we're not also over treating them if they really would do well, and outpatient. And so really focusing on, and I think looking at it from the levels of care, from the American Society of Addiction Medicine, because it really provides a personalized approach to a person's level of functioning across all of the dimensions that make up what someone needs in a substance use disorder treatment. I think the other piece is to really take a look at the workforce. What is the workforce that we need, and what is the workforce that currently exists? Are they trained in evidence based practices? We still, unfortunately, within the treatment system, have a lot of providers who operate from a philosophical perspective as opposed to an evidence perspective. And you see that frequently, there's still many providers that don't believe in medication, medications for opioid use disorder and medications for alcohol use disorder. And they say it's not part of their philosophy. And so we really need to take a look at, we can't afford to do that anymore, right. We really need to make sure that we have providers that are using evidence based practices. And so this is an opportunity for states to say, what do we have and what do we need and how do we use this one time funding to really create that system in a way that's sustainable?

Jennifer Colamonico: So one time funding is tricky. Right. And anybody who's worked in government and programs. Right. You can't build a new program cause you can't sustain it. So the training provider training element is interesting and probably not what people would think about when we think about how to use the funds. What do you see in terms of states? Like how many states sort of get what you're talking about? I mean, is there a, I imagine there's a variety of response already. How are states kind of preparing for this? And are there any that you feel are going down that right path that you characterize?

Debbi Witham: One state that does come to mind that I think is really using this as an opportunity to think through their system is Minnesota. So they're creating kind of a community of practice that brings together all different members of the community. And that's not, so it's not just providers. It's not just people with lived experience. It's law enforcement, it's hospital systems. It's everyone who really has a stake in this and to really work through what are some of the critical issues and provide feedback on how the system should be structured. And I think that's something that really needs to happen because substance use is something that touches everyone in a community. And so we really need to understand what everyone's needs are. And in making a long term impact.

Jennifer Colamonico: It seems that there's an opportunity here. You know, there's the actual funding opportunity, of course, but there's also sort of that dialogue. I mean, just what you characterize, bringing together disparate parts of the community that are all impacted or impacting this, this epidemic. And even the way I'm using the word epidemic. Right. We've sort of, in the public, we're at this new level, and I guess maybe talk a little bit about what, what does that bring to the debate?

Jennifer Colamonico: Right.

Jennifer Colamonico: We've had addiction for a long time, but, you know, where are we kind of in this, in this moment? And what, what else does this opportunity of this funding bring to communities to sort of change how we think about this issue?

Debbi Witham: No, and I'm glad that you said that because you're right. We're constantly in a substance use disorder crisis in this country. Right. Like, it's something that's been going on. This isn't even the first opioid crisis. The language has changed to an epidemic at this point because, you know, there's longstanding disparities in how people who use drugs are treated in different communities. And that's something we're seeing here. And so because initially, this current epidemic impacted many suburban white people, we started to call an epidemic, whereas in the past, we've often treated as a criminal justice issue. And so I think we need to take a look at not just how we set up our opioid use disorder system, but how do we set up our substance use disorder system, because we're always going to be if we only focus on the opioid use disorder. And what you do see happening now is meth is coming back up, cocaine is coming back up. People are dying of opioid overdoses. They have no idea they're using opioid. They're using methamphetamines, they're using cocaine, and there's fentanyl. So we really need to be thinking about how do we create a system that addresses all substance use disorders? How do we also then create a system that is culturally appropriate, where we have a workforce that reflects the communities that they're serving, where we have a. Where we have services that are available that understand what addiction and mental health diseases mean within a certain. Within specific communities, what it means to seek treatment, what the stigmas are within a community so that you can really help people access and enter treatment and be successful. And then also, again, obviously, a workforce that's linguistically appropriate and well trained.

Jennifer Colamonico: Do you think this, you know, so I'm thinking about this notion of it affects everyone now, right? We've gone into, you know, everybody knows somebody who's affected by addiction in some way or perhaps has lost somebody to the disease. We're thinking about it differently. At the same time, we're really thinking about mental health differently. And this is obviously behavioral health issues broadly. You can't have a conversation in healthcare without talking about behavioral health right now. So do you think that, I guess.

Jennifer Colamonico: Are you optimistic that we're changing hearts and minds around stigma because that is.

Jennifer Colamonico: Still such an issue, right. We've shifted from sort of blaming the addict to understanding that, you know, they. They have a disease, even what I just said, right. Maybe not be universally accepted. Do you think that we're thinking differently about addiction? And does that give you hope?

Debbi Witham: I'm cautiously optimistic. So I will say that I do hear people having different conversations than in the past. I think people using different language than they did in the past, and really, you know, understanding that. That it is a chronic disease. Right. I think still many people do hold stigma and I think when we think about it in terms of the larger healthcare ecosystem, the leadership may not be saying that as much, but I think what's happening in certain instances, and you see this even in the treatment system. So, for instance, in the treatment system, you'll see people adopting medications into their business philosophy, into their business plan, but not necessarily their clinical philosophy. Right. So they may not really necessarily see it as and understand the true value that it's bringing. You also see that I believe within some, like, primary care and hospital settings where people are still treated horribly when they're going into the hospital, right, where people are still not necessarily wanting to, feeling like they might say we're the place for treatment, but you're not necessarily loving having people in your waiting room. And then the finally still within the treatment system, there's a lot of stigma. So, and this goes to the workforce issue. There's a lot of people that still kind of believe in a different philosophy than that. That really is where the science is showing us. And that includes not using medications and it includes really kind of using some treatment tactics that we're may understanding really did continue stigma even within a person and within the treatment system. So I think I'm cautiously optimistic because we're having conversations that I don't know that we would ever have had before. But I still think we need to, like, walk the walk a little bit better.

Jennifer Colamonico: What do you, when you think about this funding opportunity and these, you know, billions of dollars coming to states, what do you worry that they'll be wasted? I mean, what, like, how, how could you see this just being squandered? What's the kind of worst case scenario here?

Debbi Witham: I think reinvesting and what states just throwing more money into what they already have.

Jennifer Colamonico: Right.

Debbi Witham: So, like, okay, let's just build more residential. Let's build more, let's add more beds and add more seats and not really look at the quality of treatment. I think the thing that we always need to remember is sometimes having really poor quality treatment could be worse than no treatment. Right. And so I think throwing more money at what is already there and not looking at outcomes and not looking at quality and not really taking the time to measure to see what's working.

Jennifer Colamonico: Yeah. Well, and it's, you know, I'm just thinking about my own small town and you always hear not enough beds. Not enough beds. Right. So that beds has become a measurement of access. So you raise a really good point, and I sort of worry about that. Well, maybe I'll pose the question, you know who's out there ensuring that that doesn't happen.

Jennifer Colamonico: Right.

Jennifer Colamonico: Because I'm sure in my community if there were funding available, they'd build more beds because that's what people are asking for. Right. So how are we guiding states and localities to kind of focus more on quality than quantity at this point?

Debbi Witham: I think a lot of that is really going to go to who are the stakeholders that bring around the table to help make some of those decisions and making sure that you have not always just the usual players, right. Because they're going to be invested in the status quo, but making sure you have all of the other people that can talk to you about what they, what's needed from their perspective. And so I think that can be, that's obviously family members, that's people within the housing and homelessness system, people within the justice system, law enforcement, people in the larger healthcare ecosystem of primary care and hospital systems. To really help think through a child welfare system is incredibly important. Right. I think the more voices you have around the table, the more you're going to have less opportunities for one voice to be or one type of treatment or one group to have an overwhelming majority.

Jennifer Colamonico: So it sounds like in terms of the funding opportunity, it's more about enabling a better process, a redesign process, as opposed to immediately deploying funds into an existing system that is kind of not well serving many people with sudden.

Debbi Witham: Absolutely. And I mean, I think it goes to the major challenge that we have in behavioral health, right. Which is how do we measure quality and we still haven't decided on what are the right things that we're measuring and what really shows success. And so we don't know that a 30% completion rate and people remaining in recovery for six months, if that is the best, you know, if that is the best measure or what really is, it's never been decided. So, but we do need to kind of take a look at this is how these systems are performing and what they're doing for the people that they're serving and then figure out what's either pumping money to make that better or putting money into different types of treatment or different types of models that will, that would really work. And I think really, you know, it's an opportunity to think about providers have, and the Sud really in behavioral health have, have always been incentivized in the payment system to keep their beds full, to keep their seats full. You're not incentivized to get people better. When I worked in the treatment system, you would see people cycle through. They come to residential for nine months, leave for a few weeks, ends up in another residential, ends up in the criminal justice system, end up in the shelter system, and then end up back at another person's residential.

Jennifer Colamonico: Right.

Debbi Witham: So it's like how do we kind of stop that cycle? Really kind of looking at outcomes and thinking about payment systems to the point of sustainability. Right. Which is now we have, now we're looking at the ecosystem. Now we have to take some time. Medicaid needs to be at the table. Right. To be thinking about how we're funding these systems and how we're really incentivizing providers to get people well, not to keep them cycling through their systems.

Jennifer Colamonico: Yeah, that's, that's the theme in all of healthcare these days, but particularly here. So you mentioned earlier about, you know, resources sort of exist where the reimbursement is the highest. So just to be clear, that's residential right now it depends on the state.

Debbi Witham: So we've worked with some states where like this is reimbursed very highly. So every, you know, we have a lot of it, but that's been typically what we tend to see, which is that you have a lot of services where they're reimbursed well. And then, you know, some states have never really included much sud treatment into their, into their Medicaid state plans. And residential is new as far as a Medicaid service with IMD exclusion. So that looks very, very different.

Jennifer Colamonico: I think in every state you mentioned not exactly knowing what works the best. I mean, where are we in terms of measurement, in terms of outcomes? Like what is it that we're using today and where do you think that needs to evolve to better measure what works?

Debbi Witham: A lot of times we're really looking at in behavioral health measures around process so fall up after hospitalization, things like that. I think we really need to look at outcome. We need to really get focused on outcome measures and we really need to look at measures that show not just, you know, is this person no longer using, but measures that show their functioning. Right. And like are they, like how they're functioning in the community, that focus on recovery, that focus on the things that really matter to people. We often like, when we're talking about this, think about SAmHSA's definition of recovery and how do you kind of use that as a framework for what you want to see and measure about how people do when they're in your services?

Jennifer Colamonico: I was thinking about with a lot of physical issues, there's sort of that activities of daily living.

Debbi Witham: Right.

Jennifer Colamonico: There's kind of somewhat a consistent measurement of if you can maintain your activities of daily living, it's sort of a measure of wellness. Does there exist a similar set of, or a parallel set of measures for behavioral health or addiction?

Debbi Witham: And that hasn't really been developed yet. There really still this large focus on Hedis. But what is actually interesting is usually that person's participation in behavioral health treatment impacts all of those, impacts their functioning on the healthcare side, it just takes much longer to show the impact of cost on the behavioral health side.

Jennifer Colamonico: Right.

Debbi Witham: So they show physical improvement sooner than they're showing behavioral improvement and lower cost. So, but it's the participation behavioral health services, it's helping them to engage in healthcare that improves that functioning.

Jennifer Colamonico: So do you think that as we're, as we're sort of largely focused on behavioral health systems and integrating behavioral health and physical health, seems like addiction services have been separated from both of those systems. Right. So I mean, do you see, and we talked about, you know, you've done work in sort of integrated care delivery. Do you see addiction medicine, if you will, being pulled more into physical health or behavioral health or both? As we look to better integrate care.

Debbi Witham: I think hopefully, ideally we'll see it in both. Right. Because people need different, need care at all different levels. So some people, they're only really going, they will be fine getting at their primary care provider.

Jennifer Colamonico: Right.

Debbi Witham: So some training on that part and a basic level of services. But I also think, you know, having the certified community behavioral health clinic model really is driving a lot of that integration where you can have your su, because most people don't just have a mental health disorder or just a substance use disorder. Right. They have both. And so they can have all of that treated within one place in one setting and often have their primary care monitored as well. That is driving a lot of the integration. I think we're seeing it more in federally qualified health centers. Right. So making sure there's more mental health and sudden within those systems. And even, I think within the new ASAM criteria, they're really looking a lot more at like what are the medical services? What are the mental health services that can be provided? Everyone, every SUD provider is now expected to be co occurring capable. Right. So they're able to, they're expected to be able to provide some level of mental health treatment for people that are coming into, or mental health services for people that are coming into their, into their SUD program. So I think we're seeing a lot more expectation on it. I think there will be times there's going, it's going to take time for the workforce and for, you know, all of the providers to catch up, to really learn, to really learn how to do both well because we have had them siloed for so long. But I do think there's a lot of different things moving in the right direction that will be driving.

Jennifer Colamonico: So let me just ask you, if you, if you had a magic wand and you could fix one thing, we've talked about a lot of things that need fixing, clearly. But if there was one thing you could fix that you think would sort of create that ripple effect to really improve these systems of care, what would that one thing be?

Debbi Witham: Things that would be reimbursement. Because I think that providers in the system will follow the money and they will be able to. And I don't say that in a way that sounds, that makes, and I want to be clear that I'm not villainizing providers. They're doing what they need to do to continue to provide services. They're very, very invested in the people that they're treating. But you have to keep your doors open.

Jennifer Colamonico: Right.

Debbi Witham: And so I think the more that we drive care based on outcomes and the more that is well funded, we can have our workforce. Right. People are much more motivated to move people through a continuum, not to keep them in their care because that's how they'll be making their money. So I think reimbursement is really the one thing I would change. If I can only change one thing, that's good.

Jennifer Colamonico: Incentives matter for sure.

Jennifer Colamonico: Anything else you would add that perhaps people don't normally think about when they're trying to understand this issue and when they're reading the newspaper about these opioid settlements funds. Is there anything else you would add that people really need to understand?

Debbi Witham: I think it's just really driving home that the need to treat this as a bigger issue than just the opioid use disorder issue, that it's part of a larger healthcare ecosystem issue, behavioral health system issue, and that Sud doesn't exist in a vacuum and we need to address the entire system of care and, and really think about how we build community in order to have a lasting impact.

Jennifer Colamonico: Thank you so much for your time and your wisdom. We appreciate talking to you.

Debbi Witham: Thanks.

Jennifer Colamonico: This episode of vital viewpoints on healthcare is brought to you by HMA Grant prospector. Is your organization looking for behavioral health grant funding? HMA's grant prospector is your ultimate solution to streamline your grant search time and maximize your grant seeking success. Get started today and unlock your organization's potential. For more information on the grant prospector, visit Hmais dot Health management.com. Thank you for tuning in to another enlightening episode of HMA's vital viewpoints on healthcare. We hope today's discussion has sparked new insights and perspectives. To learn more about our esteemed guests, please be sure to visit healthmanagement.com podcast. Until next time, stay informed, stay curious, and keep searching for the wisdom that will help to transform our healthcare landscape. This podcast was produced by myself, Jennifer Colomanico, along with Tiffany McKenzie, in collaboration with our guests. The content is the property of Health Management Associates.

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Vital Viewpoints is hosted by HMA Director of Thought Leadership, Jennifer Colamonico.

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Debbi Witham

Debbi Witham

Washington, DC
Quality & Accreditation

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