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Non cash investing and financing transactions quizlet pharmacology forex euro

Non cash investing and financing transactions quizlet pharmacology

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The literature on the effectiveness of drug-focused brief intervention in primary care and emergency departments is less clear, with some studies finding no improvements among those receiving brief interventions. It is also important to emphasize that brief primary care-based interventions by themselves are likely not sufficient to address severe substance use disorders.

However, primary care providers can use other interventions with this population, including providing MAT, providing more robust monitoring and patient education, 49 , 50 and importantly, referring individuals to specialty substance use disorder treatment.

Effective referral arrangements that include motivating patients to accept the referral are critical elements to encourage individuals to engage in treatment for their substance use disorder. A number of strong arguments underpin the growing momentum to integrate substance use disorder services and mainstream health care. The main argument is that substance use disorders are medical conditions like any other—the overarching theme of much of this Report.

Recognition of that fact means it no longer makes sense to keep substance use disorders segregated from other health issues. A number of other realities support the need for integration: Physician prescribing patterns, patient drug diversion selling, sharing, or using medications prescribed for another person , and doctor shopping behaviors have all contributed to the ongoing opioid overdose epidemic. In March , the U. Department of Health and Human Services HHS made addressing the opioid misuse crisis a high priority, announcing a national opioid initiative focused on three priority areas: 1 providing training and educational resources, including updated prescriber guidelines, to assist health professionals in making informed prescribing decisions; 2 increasing use of the opioid overdose reversal drug naloxone; and 3 expanding the use of MAT.

Since then, HHS has initiated many efforts to help reduce prescription opioid misuse and use disorders. Improving prescribing practices is one of these important efforts. Rather, the guideline is meant to inform health care professionals about some of the consequences of treatment with opioids for chronic pain and to consider, when appropriate, tapering and changing prescribing practices, as well as considering alternative pain therapies. The same month, HHS also released the National Pain Strategy, which outlines the federal government's first coordinated plan for addressing chronic pain that affects so many Americans.

The National Heroin Task Force, which consisted of law enforcement, doctors, public health officials, and education experts, was convened to develop strategies to confront the heroin problem and decrease the escalating overdose epidemic and death rate. This included a multifaceted strategy of enforcement and prevention efforts, as well as increased access to substance use disorder treatment and recovery services.

Although only about 4 percent of those who misuse prescription opioids transition to using heroin, concern is growing that tightening restrictions on opioid prescribing could potentially have unintended consequences resulting in new populations using heroin. The concern about opioid overdoses has also triggered efforts by health systems to increase access to naloxone, an opioid antagonist that prevents overdose fatalities by rapidly restoring normal respiration to a person whose breathing has slowed or stopped as a result of opioid use.

Since , community-based organizations in many states have implemented overdose education and naloxone distribution programs for people who use heroin or misuse pharmaceutical opioids and efforts are underway to expand access to naloxone to patients who are prescribed opioids for pain. Expanded access to naloxone through large health systems could prevent overdose fatalities in broad populations of patients, including patients who may experience accidental overdose from misusing their medications.

Many individuals who come to mainstream health care settings, such as primary care, obstetrics and gynecology, emergency departments, and hospitals, also have a substance use disorder. In a study within one health plan, one third of the most common and costly medical conditions were markedly more prevalent among patients with substance use disorders than they were among similar health system members who did not have a substance use disorder.

Because substance use complicates many other medical conditions, early identification and management of substance misuse or use disorders presents an important opportunity to improve health outcomes and reduce health care costs. In addition to the health problems faced by individuals engaged in substance use mentioned above, substance use can adversely affect a developing fetus. In the United States, fetal alcohol spectrum disorders FASD remain highly prevalent and problematic, even though they are preventable.

Opioid pain reliever use among pregnant women has also become a major concern due to neonatal abstinence syndrome NAS , a treatable condition that newborns experience after exposure to drugs while in the mother's womb. Newborns with NAS are more likely than other babies to also have low birthweight and respiratory complications. The incidence of NAS has increased dramatically in the last decade along with increased opioid misuse.

Moreover, in , newborns with NAS stayed in the hospital an average of For women who are considering getting pregnant or are already pregnant, abstaining from all substances is recommended, since NAS is not exclusively caused by opioids. Adolescents with substance use disorders experience higher rates of other physical and mental illnesses, as well as diminished overall health and well-being.

In addition to the physical health problems described above, mental health problems are also over-represented among adolescents with substance use disorders, 92 , 93 particularly attention-deficit hyperactivity disorder, 94 - 98 conduct disorders, 99 anxiety disorders, and mood disorders.

Treatment of substance use disorders has historically been provided episodically, when a person experiences a crisis or a relapse occurs. In addition to chronic care management for severely affected individuals, coordinating services for those with mild or moderate problems is also important. Studies of various methods for integrating substance use services and general medical care have typically shown beneficial outcomes.

Care coordination is an essential part of quality in all health care. The Healthcare Effectiveness Data and Information Set HEDIS , The Joint Commission, and organizations such as the National Committee for Quality Assurance emphasize coordination and accountability and the use of evidence-based care and performance indicators to establish and monitor quality and value.

This approach to care delivery proceeds on the assumption that services for the range of substance use disorders should be fully integrated components of mainstream health care. Publicly available quality measurement information helps consumers, health care purchasers, and other groups make informed decisions when choosing services, providers, and care settings. Performance measurement has the dual purpose of accountability and quality improvement. A IOM study on Psychosocial Interventions for Mental and Substance Use Disorders recommended that the substance use disorder field develop approaches to measure quality, similar to approaches used for other diseases.

This includes the development of performance measures, use of health IT for standardized measurement, and utilization of these measures to support quality improvement. Many measures are being tested by public and private health plans, though most have not been adopted widely for quality improvement and accountability.

A measure of care continuity after emergency department use for substance use disorders is in process. Because substance use disorder treatment is currently not well integrated and services are often provided by multiple systems, it can be challenging to effectively measure treatment quality and related outcomes. The ability to track service delivery across these multiple environments will be critical for addressing this challenge.

For example, community monitoring systems to assess risk and protection for adolescents are being developed. Pay-for-performance is an approach for improving quality and for incentivizing programs or health care professionals to produce particular outcomes for example, treatment retention and treatment outcomes. It has been used more in general health care than in substance use disorder treatment.

However, Delaware and Maine have experimented with it in their public substance use disorder treatment systems, and several studies have found improvement in retention and outcomes. Although pay-for-performance is a promising approach, more research is needed to address these concerns. Several models of coordination have been described by researchers.

In one such model, coordination ranges from referral agreements to co-located substance use disorder, mental health, and other health care services. Onsite programs had the highest rates of treatment engagement. These models, as well as recovery-oriented systems of care, provide opportunities for substance use disorder services and mainstream health care to engage in various types of collaborative efforts to integrate their services at all stages: prevention, treatment, and recovery.

Importantly, the models all emphasize the relationship between person-centered, high-quality care and fully integrated models. Innovative financing mechanisms now being explored also allow for formal arrangements to implement some of the models discussed above, including linking to off-site health professionals in specialty substance use disorder treatment settings and vice versa when locating multiple services at one site is not feasible.

Integrating substance use services with general health care e. Prevalence of substance misuse and substance use disorders differs by race and ethnicity, sex, age, sexual orientation, gender identity, and disability, and these factors are also associated with differing rates of access to both health care and substance use disorder treatment.

These differences are often exacerbated by socioeconomic variables. A study of a large health system found that Black or African American women but not Latina or Asian American women were less likely to attend substance use disorder treatment, after controlling for other factors; there were no ethnicity differences for men. In addition, an analysis of longitudinal data from the National Epidemiologic Survey on Alcohol and Related Conditions showed that individuals from most racial and ethnic groups were less likely to receive an alcohol intervention than were White individuals over a 3 year period.

Differences within the various racial and ethnic groups by sex were not studied. A fundamental way to address disparities is to increase the number of people who have health coverage. The Affordable Care Act provides several mechanisms that broaden access to coverage. As a result, more low-income individuals with substance use disorders have gained health coverage, changed their perceptions about being able to obtain treatment services if needed, and increased their access to treatment.

Individuals whose incomes are too high to qualify for Medicaid but are not high enough to be eligible for qualified health plan premium tax credits also rarely have coverage for substance use disorder treatment. Because the new Medicaid population includes large numbers of young, single men—a group at much higher risk for alcohol and drug misuse—Medicaid enrollees needing treatment could more than double, from 1.

Notes: Totals may not sum to percent due to rounding. Ineligible for Financial Assistance share includes those ineligible due to offer of more Another way to address disparities is to ensure that substance misuse prevention, interventions, treatments, and recovery services are tailored and relevant to the populations receiving them.

Several interventions have been adapted explicitly to address differences in specific populations; they were either conducted within health care settings or are implementable in those settings. The list below provides examples of such programs that have been shown to be effective in diverse populations:.

In other words, it is expected that the number of people who seek treatment across all racial and ethnic groups will increase. Few studies have directly compared treatment populations by race and ethnicity. However, some studies have examined race and ethnicity as predictors of outcomes in analyses controlling for many other factors such as age, substance use disorder severity, mental health severity, social supports , and they showed that after accounting for these socioeconomic factors, outcomes did not differ by race and ethnicity.

This body of research has some key caveats. For example, studies have found that matching programs and providers by race or ethnicity may produce better results for Hispanics or Latinos than for other racial and ethnic groups. At the same time, offering programs that are tailored to patient characteristics or that incorporate health care professionals who share similarities with their patients in sex, age, or race or ethnicity may improve willingness to enter and engage in treatment.

It should also be noted that civil rights laws, such as Section of the Rehabilitation Act, the Americans with Disabilities Act ADA , and Section of the Affordable Care Act, protect many people with substance use disorders and impose requirements on substance use disorder treatment programs.

These laws require individual assessment of a person with a disability, identifying and implementing needed reasonable modifications of policies and practices when necessary to provide an equal opportunity for a person with a disability to participate in and benefit from treatment programs.

More generally, these laws prohibit programs from excluding individuals from treatment programs on the basis of a co-occurring disability, if the individual meets the qualifications for the program. Additionally, under Title VI of the Civil Rights Act and Section of the Affordable Care Act, providers who receive federal financial assistance must address the needs of people with limited English proficiency. The ADA and Section also apply to discriminatory zoning laws and decisions that operate as a barrier to providers seeking to open or expand substance use disorder treatment programs.

As the section on Electronic Health Records and Health Information Technology shows, health IT holds tremendous promise to provide culturally appropriate services in multiple languages and that incorporate health care professionals with characteristics similar to the target patients' population. With scarce resources and many social programs competing for limited funding, cost-effectiveness is a critical aspect of substance use-related services. Over the past 20 years, several comprehensive literature reviews have examined the economics of substance use disorder treatment.

Evaluations of Medicaid expenditures for substance use disorder treatment show that the costs of treating substance use disorders are more than offset by the accompanying savings to Medicaid in reduced health care costs, such as reductions in future substance use disorder-related hospitalizations and residential treatment costs. Costs associated with substance use disorders are not limited to health care.

The accumulated costs to the individual, the family, and the community are staggering and arise as a consequence of many direct and indirect effects, including compromised physical and mental health, loss of productivity, reduced quality of life, increased crime and violence, misuse and neglect of children, and health care costs. As described elsewhere in this Report , a substance use disorder is a substantial risk factor for committing a criminal offense.

Reduced crime is thus a key component of the net benefits associated with prevention and treatment interventions. Overall, within the criminal justice system, more than two thirds of jail detainees and half of prison inmates experience substance use disorders.

Substance use-related costs are also prominent within child welfare and related services. The estimated prevalence of substance use disorders among parents involved in the child welfare system varies across service populations, time, and place. One widely cited estimate is that between one-third and two-thirds of parents involved with the child welfare system experience some form of substance use problem.

The National Survey of Child and Adolescent Weil-Being found that caseworkers perceived substance misuse problems in 23 percent of cases, which was correlated with significantly higher probabilities of severe harm to children 24 percent , compared with parents with no such indication 5 percent.

Children of parents with substance use problems were more likely than others to require child protective services at younger ages, to experience repeated neglect and abuse from parents, and to otherwise require more intensive and intrusive services. Substance use disorders appear to account for a large proportion of child welfare, foster care, and related expenditures in the United States. It is one of the largest health care systems in the United States. The IOM conducted a comprehensive study of military prevention and treatment services for substance use disorders.

Further, service members and veterans suffer from high rates of co-occurring health problems that pose significant treatment challenges, including traumatic brain injury, post-traumatic stress disorder, depression, and anxiety. Along with other recommendations, the IOM report recommended conducting routine screening, integrating substance use treatment with other health care, and implementing evidence-based treatments.

These illustrative examples underscore that the costs associated with substance use disorders are incurred across diverse service systems that serve vulnerable populations. These expenditures might be reduced through more aggressive measures to address substance misuse problems and accompanying disorders.

Moreover, many substance use-related services provided through criminal justice, child welfare, or other systems seek to ameliorate serious harms that have already occurred, and that might have been prevented with greater impact or cost-effectiveness through the delivery of evidence-based prevention or early treatment interventions.

Different kinds of economic analyses can be particularly useful in helping health care systems, community leaders, and policymakers identify programs or policies that will bring the greatest value for addressing their needs. Two commonly used types of analyses are cost-effectiveness analysis and cost-benefit analysis. Both types of studies have been used to examine substance use disorder treatment and prevention programs. Studies have found a number of substance use disorder treatments, including outpatient methadone, alcohol use disorder medications, and buprenorphine, to be cost-effective compared with no treatment.

Treatment Settings and Approaches. A study estimating the cost-effectiveness of four different treatment modalities—inpatient, residential, outpatient methadone, and outpatient without MAT—found that the treatment of substance use disorders is cost-effective compared to other health interventions, with outpatient programs without MAT being the most cost-effective.

Methadone Maintenance versus Methadone Detoxification. Cost-effectiveness study. A comparative analysis of two or more interventions against their health and economic outcomes. These outcomes could be lives saved, illnesses prevented, or years of life gained. Cost-benefit study. A study that determines the economic worth of an intervention by quantifying its costs in monetary terms and comparing them with the benefits, also expressed in monetary terms.

Total benefits divided by total costs is called a cost-benefit ratio. If the ratio is greater than 1, the benefits outweigh the costs. Methadone Maintenance versus Maintenance with Other Medications. However, extended-release naltrexone is not off-patent, and therefore these cost findings will likely change when it becomes generic. A measure of the burden of disease used in economic evaluations of the value of health care interventions that accounts for both the years of life lived and the quality of life experienced during those years, relative to quality associated with perfect health.

Buprenorphine-Naloxone versus No Treatment. A study examined individuals with opioid use disorders who had completed 6 months of buprenorphine-naloxone treatment within a primary care setting. A review of cost-effectiveness studies for alcohol SBI in a primary care setting found considerable variability in the estimated cost-effectiveness ratios and cost savings across studies.

Using that comparison, alcohol misuse screening achieved a combined score similar to screening for colorectal cancer, hypertension, or vision for adults older than age 64 , and to influenza or pneumococcal immunization. Because current levels of SBI delivery are much lower than desired, this service deserves special attention by health care professionals and care delivery systems.

Interventions that prevent substance use disorders can yield an even greater economic return than the services that treat them. The Washington State Institute for Public Policy has used a standardized model to estimate the cost-benefit of diverse prevention, early intervention, and treatment programs.

In a literature review of the economics of substance use disorder treatment, one study highlighted the variability in cost estimates for substance use disorder treatment delivered in specialty settings. Costs were typically lower when activity-based costing assigning the cost and amount of each activity that is part of the intervention was employed and when the SBI occurred in a primary care setting or was performed by a provider who was not a physician.

Additionally, variation was attributed to the wage of the person conducting the screening and the amount of time the screening took. In recent years, use of MAT has increased. Recent studies have examined extended-release naltrexone, buprenorphine, and methadone for opioid use disorder treatment. While other treatments may be less costly, they are also somewhat less effective.

In , about three-quarters of all general health care purchased in the United States was paid for by private insurance, Medicare, or Medicaid. The rest was covered by consumers paying out-of-pocket, by other federal health grants, and by programs and other insurance provided by the DoD, Department of Veterans Affairs, and other state and local programs.

In , the largest share of substance use disorder treatment financing was from state non-Medicaid and local governments 29 percent. Coverage of substance use disorder services under private insurance has waxed and waned over the past 30 years. During the s, insurance benefits and specialty addiction providers expanded, , and from to , substance use disorder spending grew by 6.

This expansion was followed by managed care restrictions on reimbursement for substance use disorder treatment in inpatient settings, such as limitations on length of residential rehabilitation stays a common treatment regimen. Further, the share of substance use disorder financing from private insurance dropped dramatically between and , from 32 percent in to 13 percent in ; this was followed by an increase to 18 percent in , likely due to MHPAEA and qualified health plan coverage now being available through the Affordable Care Act.

Approximately 20 percent of people in the United States have health coverage through Medicaid, a joint federal and state health coverage program that provides medical assistance for children, families, and individuals with low income and limited resources; an estimated 12 percent of adult Medicaid beneficiaries have a substance use disorder. The federal government establishes basic requirements that states must follow in designing their Medicaid programs, including some mandated services that must be covered and guidance regarding payment rate-setting and contractual arrangements, eligibility and quality standards, and provision of optional services.

States can choose to cover or not cover specific treatments or to place restrictions on covered services. In the past, some states have not included certain critical substance use disorder treatment options in their benefit packages e. In many states, Medicaid also does not cover residential treatment, especially for adults. For those who are eligible and have substance use disorders, Medicaid is an extremely important program, as it can cover many services that such individuals may need, such as crisis services and many preventive services.

In addition, while Medicaid does not provide payments for housing e. In states that did not expand Medicaid, racial and ethnic minorities are disproportionately affected. In addition, in these states, young adult single males—a group with high rates of substance use disorders-are ineligible for Medicaid benefits. An estimated 14 to 15 percent of uninsured individuals nationwide who could be newly eligible for Medicaid coverage under the Affordable Care Act have a substance use disorder. Medicare covers almost all individuals aged 65 or over as well as those eligible because of disabilities.

Approximately Prescription drug treatment is generally covered for beneficiaries enrolled in Medicare Part D or a Medicare Advantage plan that includes drug coverage. Medicare does not cover outpatient use of oral methadone for substance use disorders, but Part D can include coverage for medications, such as disulfiram, naltrexone, acamprosate, and buprenorphine.

Although insurance coverage is critical to improving access to and integration of services for individuals with substance use disorders, it is unlikely to cover all the services that such individuals may need, such as crisis services e. Research has shown that uninsured individuals have higher unmet medical needs than do insured individuals, and those without insurance also have higher rates of substance use disorders than do individuals with insurance.

Funds from federal block grants to states for substance use disorder treatment services such as the SABG, which is often used for prevention activities and for maternal, child, and adolescent health services Title V of the Maternal and Child Health Services Block Grant may be used to fill the gaps in treatment services not covered by insurance.

These funds also finance treatment for people without insurance and support community prevention activities. In addition, federal funding for certain community prevention programs encourages public-private partnerships and community collaboration to improve health outcomes. Grants are used to increase screening, counseling, workplace wellness programs, and community prevention.

Although investments in prevention have repeatedly demonstrated favorable economic returns, primary prevention for all health conditions still accounts for less than 5 percent of overall health spending in the United States. Prevention should be seen as an appropriate health cost to be covered by insurance. Current funding options for community prevention, described below, include grants from hospital and health system foundations, hospital-based community benefit programs, tax earmarks, and targeted state programs.

Foundations formed from the conversion of tax-exempt non-profit hospitals and health systems into for-profit entities are required by federal law to invest in health-related activities within the community area served by that hospital. Beginning in , tax-exempt hospitals have been required to provide benefits to the community in return for not paying taxes. Tax-exempt hospitals must: 1 conduct a community health needs assessment at least once every 3 years; 2 involve public health experts and representatives of the community served by the facility in the needs assessment; 3 make the results of the assessment available to the public; 4 develop an implementation strategy to address each of the community health needs identified through the assessment; and 5 report yearly to the Internal Revenue Service.

Many states also have community benefit programs that must be synchronized with the requirements of the Affordable Care Act. In certain jurisdictions, direct funds from a local or state tax can be earmarked for substance misuse prevention in the same way as tobacco taxes are currently used for public health and health programming in many states. Jackson County, Missouri, first introduced a dedicated sales tax in to tackle drug use and drug-related crime.

The funds are used for a variety of prevention, treatment, and anti-drug and drug-related crime prevention programs. In addition, Florida and Indiana, among other states, earmark alcohol taxes for child and adolescent substance use-related services. The Massachusetts Legislature passed the first state-based prevention fund, called the Prevention and Wellness Trust Fund, in as part of a health cost control bill.

Grantees have a strong focus on extending care beyond clinical sites into the community. It is clear that integrating substance use disorder services with mainstream health care is beneficial for individuals and communities and that health reform is encouraging this trend. However, several key challenges must be addressed if integration is to be fully successful.

The Congressional Budget Office currently estimates that by , 24 million Americans who would otherwise be uninsured will obtain health insurance coverage as a result of the Affordable Care Act. However, the specialty care substance use disorder treatment system faces challenges along with these new opportunities.

Nationally representative data from the National Drug Abuse Treatment System Survey underscore the importance but also the difficulty of integrated care efforts. Fifty-five percent of addiction treatment patients in expansion states are receiving care in organizations that at least have contractual linkages to some medical or health home arrangement. Substance use disorder treatment organizations currently face significant challenges in engaging in care coordination with other types of providers.

Because these organizations have traditionally been organized and financed separately from general health care systems, the two systems have not routinely exchanged clinical information. In a survey of treatment programs to assess their readiness for health reform, 63 percent described their organizations' adoption of EHRs as having not yet begun, or only in the early stages.

For example, private, for-profit treatment facilities were significantly more likely to be early adopters of buprenorphine therapies than were their public or private non-profit peers. This offers promise for increasing adoption and use of health IT by behavioral health providers. Another challenge for effectively coordinating care relates to the need for specialty substance use disorder treatment programs to comply with substance abuse confidentiality regulations 42 CFR Part 2 and state privacy laws when implementing health IT systems.

In addition, substance use disorder treatment organizations face the challenge of communicating with non-health care personnel including those in social service, criminal justice, and educational facilities and even when EHRs are in place these systems lack interoperability the ability to effectively exchange digital health information from an EHR in a common format with the information systems used by social service organizations, hindering communication.

Medical homes are most likely to pursue contractual arrangements with large and technologically sophisticated organizations that are best equipped to meet their needs for timely clinical and administrative information. The move toward integrated care is therefore likely to accelerate consolidation of substance use disorder treatment programs, which may hasten the adoption of new technologies and processes among sophisticated providers.

Particularly in combination with expanded insurance coverage, this trend may attract new partnerships, for example between ACOs, which are integrated delivery systems, and more sophisticated specialty addiction providers. Yet, the same patterns may harm smaller providers, some of whom offer the only culturally competent services for particular patient groups, such as services tailored for specific racial and ethnic populations, sexual and gender minorities, or women in need of trauma-related residential services.

One key challenge for integrating substance use treatment and health care is that implementation of pharmacotherapies i. Research suggests that whether treatment programs offer MAT is influenced by a number of organizational and state-level factors, including differences in organizational size, whether the treatment program is in a hospital setting, whether psychiatric medications are prescribed, whether the program has access to prescribing staff, and whether state Medicaid policies support the use of generic drugs.

Another medication, extended-release injectable naltrexone, approved by the FDA for use in treating individuals with opioid use disorders, is underutilized by programs. For example, one study found that only three percent of United States treatment programs used it for opioid use disorders. One study found that between and , its use for detoxification in specialty opioid treatment programs OTPs increased from 36 percent of programs in the sample to 46 percent; its use for maintenance increased from 37 percent of programs in the sample to 53 percent.

A recent study found that raising this limit further, rather than increasing the number of specialty addiction programs or waivered physicians, may be the most effective way to increase buprenorphine use. Another key challenge is that primary care settings have not yet routinely implemented recommended preventive health and intervention services related to substance misuse.

Currently, the Affordable Care Act requires that all non-grandfathered health plans must cover, without cost-sharing, certain preventive health services recommended by the USPSTF, and women's preventive services and preventive services for infants, children, and adolescents in guidelines supported by HRSA As discussed earlier, the USPSTF recommends alcohol screening and counseling for adults.

The USPSTF currently considers the evidence to be insufficient to support screening or behavioral interventions for substance misuse problems in pediatrics. Hilton Foundation, are currently underway that could add to the evidence base. Major pediatric medical organizations, including the American Academy of Pediatrics, strongly recommend addressing these issues regularly at each well-adolescent visit and appropriate urgent care visits.

The Affordable Care Act requires health plans to cover, at no out-of-pocket cost to families, the preventive care services outlined in this schedule. Bright Futures discusses how to incorporate screening into the preventive services visit for these age groups. Screening and brief intervention for substance misuse is also consistent with the prevention activities recommended in the IOM report Preventing Mental, Emotional, and Behavioral Disorders Among Youth: Progress and Possibilities.

The Joint Commission Requirements mandate that hospitals offer inpatients brief counseling for alcohol misuse and follow-up, and measure the provision of counseling as one of the core measures for hospital accreditation. Primary care teams that include non-physician providers e. Several large health systems, such as the Veterans Health Administration and Kaiser Permanente, have successfully implemented primary care-based alcohol SBI in a sustainable manner.

These approaches can also be implemented in emergency departments and in obstetrics and gynecology departments. Data on the substance use workforce are incomplete. Nevertheless, it is clear that the workforce is inadequate, as evidenced by its uneven geographic distribution with rural areas underserved , access barriers for adolescents and children, and recruitment challenges across the treatment field.

Moreover, the workforce is aging. For example, 46 percent of psychiatrists are older than age Recent reforms may strain the current workforce in an already overstretched health care system working to address treatment and prevention strategies. A recent study documented staffing models in primary care practices and determined that, even among those designated as patient-centered medical homes, fewer than 23 percent employed health educators, pharmacists, social workers, nutritionists, or community service coordinators, and fewer than half employed care coordinators.

The IOM's report Improving the Quality of Health Care for Mental and Substance Use Conditions , 32 which adapted Crossing the Quality Chasm to address mental and substance use conditions, noted that a critical concern in attracting a skilled workforce is the low salary structure of the substance use disorder treatment workforce.

In practice, the Block Grant is used broadly, and Medicaid less and only with a subset of providers. It is not yet clear whether the integration of substance use disorder treatments in general health care will help to address salary structure. An integrated health and substance use disorder treatment system requires a diverse workforce that includes substance use disorder specialists, physicians, nurses, mental health treatment providers, care managers, and recovery specialists.

This workforce also includes peer recovery coaches a reimbursable service under some state Medicaid programs , health educators, social workers, and other staff who are trained to deliver timely mental health and substance use-related health interventions, such as SBI. As substance use disorder treatment and general health care become more integrated, clinical staff in both systems will need to expand their scope of work, operate in an integrated manner with a variety of populations, and shift their treatment focus as needed.

Health care professionals moving from the specialty workforce into integrated settings will require specific training on treatment planning and care coordination and an ability and willingness to work under the leadership of medical staff.

Working in teams with the broad mandate of improved health is not currently commonplace and will require collaboration among professional and certification bodies. Incorporating peer workers, who bring specific knowledge of patients' experiences and needs and can encourage informed patient decision making, into teams will also require further adjustment.

Improving the Quality of Health Care for Mental and Substance Use Conditions also discussed the shortage of skills both in specialty substance use disorder programs and in the general health care system. Currently, 66 organizations license and credential addiction counselors, , and although a consensus on national core competencies for these counselors exists, they have not been universally adopted. Without a comprehensive, coordinated, and focused effort, workforce expansion and training will continue to fall short of the challenge of meeting the needs of individuals across the continuum of service settings.

HRSA has taken a number of steps to address these workforce challenges as part of its mission to prepare a diverse workforce and improve the workforce distribution to increase access for underserved communities. Among its many programs, HRSA awards health professional and graduate medical education training grants and operates scholarship and loan repayment programs. Of particular note is the National Health Service Corps, where, as of September , roughly 30 percent of its field strength of 9, was composed of behavioral health providers, meeting service obligations by providing care in areas of high need.

The development of the workforce qualified to deliver these services and services to address co-occurring medical and mental disorders will have significant implications for the national workforce's ability to reach the full potential of integration. Effectively integrating substance use disorder treatment and general health care requires the timely exchange of patient health care information. These privacy protections were motivated by the understanding that discrimination attached to a substance use disorder might dissuade people from seeking treatment, and were enacted in the context of patient methadone records being used in criminal cases.

HIPAA does not require patient authorization to share health information for purposes of treatment, payment, or health care operations. With 42 CFR Part 2, patient consent is required to share and use patient identifying information and any information that could be used to identify someone as having, or having had, a substance use disorder, such as payment data.

Given the long and continuing history of discrimination against people with substance use disorders, safeguards against inappropriate or inadvertent disclosures are important. Disclosures to legal authorities can lead to arrest, loss of child custody, or relinquished parental rights. Disclosures to insurers or to employers can render patients unable to obtain disability or life insurance and can cost patients their jobs. Currently, persons with substance use disorders involving illicit drugs are not protected under anti-discrimination laws, such as the ADA.

However, exchanging treatment records among health care providers has the potential to improve treatment and patient safety. For example, in the case of opioid prescribing, a study in health systems of long-term opioid users found those with a prior substance use disorder diagnosis received higher dosages and were co-prescribed sedative-hypnotic medications—which can increase the risk for overdose—more often.

Because of privacy regulations, it is likely that physicians were not aware of their patients' substance use disorders. PDMPs are state-run databases that collect prescribed and dispensed controlled prescription drug information and give prescribers and pharmacists access to a person's controlled substance prescription history. Authorized providers can check the database before prescribing or dispensing. However, PDMPs have many limitations. They do not include information about methadone used for opioid use disorders, which is exclusively dispensed at OTPs, or from programs covered by 42 CFR Part 2.

While disclosure of patient-identifying information that is subject to 42 CFR Part 2 is allowable, it would require written patient consent, and re-disclosures of this information would not be permitted unless the patient consents. In addition, PDMPs only collect prescription information as allowed by their state laws, in most cases controlled substances Scheduled II through IV or V, and thus health care professionals may not be aware of other prescriptions their patients are receiving.

As EHR interoperability and the exchange of health information increases, best practices must be developed for handling substance use disorder treatment data, consistent with state and federal privacy laws. Clearly, integrating health care and substance use disorder treatment within health care systems, as well as integrating the substance use disorder treatment system with the overall health care system, are complex undertakings.

The good news, however, is that a range of promising health care structures, technologies, and innovations are emerging, or are being refined and strengthened, under health reform. These developments are helping to address challenges and facilitate integration. In so doing, they are broadening the focus of interventions beyond just the treatment of severe substance use disorders to encompass the entire spectrum of prevention, treatment, and recovery.

These promising developments include:. Medicaid is not only an increasing source of financing for substance use disorder treatment services, it has become an important incubator for innovative substance use disorder financing and delivery models that can help integrate substance use disorder treatment and mainstream health care systems.

Within the substance use disorder treatment benefit, and in addition to providing the federally required set of services, states also may offer a wide range of recovery-oriented services under Medicaid's rehabilitative services option. These services include therapy, counseling, training in communication and independent living skills, recovery support and relapse prevention training, skills training to return to employment, and relationship skills. Nearly all states offer some rehabilitative mental health services, and most states offer the rehabilitation option for substance use disorder services.

CMS provides various authorities by which states can structure their Medicaid programs, thus providing mechanisms for states to expand and improve their substance use disorder treatment delivery system: This includes authorities to: - Recently, CMS gave states new opportunities to design service delivery systems for substance use disorders through demonstration projects under section This initiative is designed to support states to provide coverage for the full continuum of care; ensure that care is delivered consistent with the ASAM Treatment Criteria; design strategies to coordinate and integrate care; and support quality improvement programs.

The agency is providing technical and program support to states to introduce policy, program, and payment reforms to identify individuals with substance use disorders, expand coverage for effective treatment, expand access to services, and develop data collection, measurement, and payment mechanisms that promote better outcomes.

Medicaid is also encouraging the trend to integration in other ways, including supporting new models for delivering primary care, expanding the role of existing community-based care delivery systems, enacting mental health and substance use disorder parity for Medicaid and Children's Health Insurance Program CHIP as included in the final rule that CMS finalized in March Health homes are grounded in the principles of the primary care medical home, which focuses on primary care-based coordination of diverse health care services, and patient and provider engagement.

The Affordable Care Act created an optional Medicaid State Plan benefit allowing states to establish health homes to coordinate care for participants who have chronic health conditions. Beneficiaries with chronic conditions are eligible to enroll in health homes if they experience or are at risk for a second chronic condition, including substance use disorders, or are experiencing serious and persistent mental health conditions.

These arrangements emphasize integration of care, targeting of health home services to high-risk populations with substance use and mental health concerns, and integration of social and community supports with general health services. As of January , 19 states and the District of Columbia had established Medicaid health home programs — covering nearly one million individuals — and nearly a dozen additional states had plans for establishing them.

States that implement Medicaid health homes receive substantial federal subsidies, including 90 percent federal matching rates for health home services during the first eight quarters after the effective date of health home coverage under the Medicaid state plan, covering comprehensive case management, coordinating services and health promotion, comprehensive transitional care from inpatient to other settings, individual and family support services, linkage and referrals to community-based services, and health IT.

In some settings, these integrated care models are associated with reduced cost and improved cost-effectiveness, and research is underway to test new models. Recognizing the important role that these kinds of integrated care arrangements can play, the American Academy of Family Physicians and SAMHSA have issued reports promoting the inclusion of substance use and mental health services in patient-centered medical homes and related efforts. Another Affordable Care Act provision created opportunities to encourage the integration of primary and specialty care, as well as community and public health systems, by establishing integrated delivery systems known as ACOs.

ACCs are an important variation on the ACO model because, by focusing on the larger community, they can address the social determinants of health and health disparities that have such a profound impact on community members' health and well-being, including their risks for substance misuse, substance use disorders, and related health consequences. Initially developed as a model under Medicare, ACOs have now also been encouraged under Medicaid for its covered populations.

An underlying assumption of the new service delivery and payment models funded in the SIM states is that they will be more effective and produce better outcomes when implemented as part of a broad-based, statewide initiative that brings together multiple payors and stakeholders, and when they use the levers of state government to effect change.

The SIM states are leading the implementation of accountable care systems for Medicaid populations that embrace population health for SIM states, this is defined as health of the community in a geographic area as opposed to the population of patients in the health delivery system. Several states have adopted ACC models that support integration of medical health care services with public health and community-based programs.

Oregon's CCOs are a network of all types of health care professionals physical health care, addiction and mental health care, and dental care providers who have agreed to work together to serve people who receive health care coverage under Oregon's Medicaid plan, which is called Oregon Health Plan. The Oregon Health Authority publishes regular reports on quality, access, and progress toward benchmarks in both prevention and treatment.

Increased insurance coverage and other provisions of the Affordable Care Act have sparked important changes that are facilitating comprehensive, high-quality care for people with substance use disorders. For example, the Affordable Care Act provided mandatory funding for Federally Qualified Health Centers FQHCs receiving grants under section of the public health service act, including community health centers, migrant health centers, health care for the homeless health centers, and public housing primary care centers that is supporting the expansion of their activities and numbers of patients served.

These community health centers emphasize coordinated primary and preventive services that promote reductions in health disparities for low-income individuals, racial and ethnic minorities, rural communities, and other underserved populations. Two-thirds of health centers have been designated as PCMHs. Community health centers provide primary and preventive health services to medically underserved areas and populations and may offer behavioral and mental health and substance use services as appropriate to meet the health needs of the population served by the health center.

As such, they are well-equipped to address co-occurring physical, mental, and substance use disorders, and provide substance misuse prevention, treatment, and RSS to patients. Because they provide services regardless of ability to pay and are required to offer services on a sliding scale fee, they are well-positioned to serve low-income and economically vulnerable patients.

An example of the important role FQHCs can play in improving access to treatment for substance use disorders is their efforts in providing buprenorphine maintenance treatment for opioid-dependent patients within primary care. FQHCs have access to B drug pricing, making the purchase of substance use disorder medications less costly and thus more accessible than for providers who cannot take advantage of this pricing. EHRs and health IT have the potential to support better coordination of services across primary care and specialty substance use disorder treatment, greater safety by reducing harmful drug-drug interactions, and improved monitoring of treatment outcomes and relapse risk in general health care.

Strong health IT systems improve the organization and usability of clinical data, thereby helping patients, health care professionals, and health system leaders coordinate care, promote shared decision-making, and engage in quality improvement efforts. These systems have the capacity to easily provide information in multiple languages and to put patients in touch with culturally appropriate providers through telehealth. Meaningful Use. Using certified EHR technology to improve quality, safety, efficiency, and reduce health disparities; engage patients and family; improve care coordination and population and public health; and maintain privacy and security of patient health information.

Health IT has shown benefits in improving care for patients with chronic conditions, and use is expected to greatly increase because of the Affordable Care Act and related incentives, such as grants supporting health center networks with the implementation and adoption of health IT. Health IT also holds great potential for improving services for individuals with substance misuse problems because they can provide up-to-date medical histories of patients to providers, and they can support care coordination by facilitating communications between primary and specialty care providers across health systems.

For example, educational and training materials including clinical guidelines for physicians e. Many health systems have additional information on wikis for patients and providers. Most have or will have patient portal websites, which can provide patients access to health, mental health, and substance use self-assessments; computerized interventions for reducing alcohol or drug use, anger management, dealing with depression, and other problems; referral sources for smoking quit-lines and self-help groups; information on medications for substance use disorders; and general health information.

Clinical Decision Support. A system that provides health care professionals, staff, patients, or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. Although research suggests that patients with substance use disorders are not using patient portals as much as individuals with other conditions, they have great potential for reaching patients.

To foster systems change, efforts are needed to increase adoption of EHR technology in substance use disorder and mental health treatment organizations. These programs currently lag and are likely to continue to lag behind the rest of medicine. It will be critical to facilitate the uptake of EHRs within the specialty substance use disorder treatment system, to implement common data standards to support interoperability across specialty substance use disorder treatment and mainstream health care, and to coordinate care across systems.

The literature on the effectiveness of drug-focused brief intervention in primary care and emergency departments is less clear, with some studies finding no improvements among those receiving brief interventions. It is also important to emphasize that brief primary care-based interventions by themselves are likely not sufficient to address severe substance use disorders.

However, primary care providers can use other interventions with this population, including providing MAT, providing more robust monitoring and patient education, 49 , 50 and importantly, referring individuals to specialty substance use disorder treatment. Effective referral arrangements that include motivating patients to accept the referral are critical elements to encourage individuals to engage in treatment for their substance use disorder.

A number of strong arguments underpin the growing momentum to integrate substance use disorder services and mainstream health care. The main argument is that substance use disorders are medical conditions like any other—the overarching theme of much of this Report. Recognition of that fact means it no longer makes sense to keep substance use disorders segregated from other health issues.

A number of other realities support the need for integration: Physician prescribing patterns, patient drug diversion selling, sharing, or using medications prescribed for another person , and doctor shopping behaviors have all contributed to the ongoing opioid overdose epidemic. In March , the U. Department of Health and Human Services HHS made addressing the opioid misuse crisis a high priority, announcing a national opioid initiative focused on three priority areas: 1 providing training and educational resources, including updated prescriber guidelines, to assist health professionals in making informed prescribing decisions; 2 increasing use of the opioid overdose reversal drug naloxone; and 3 expanding the use of MAT.

Since then, HHS has initiated many efforts to help reduce prescription opioid misuse and use disorders. Improving prescribing practices is one of these important efforts. Rather, the guideline is meant to inform health care professionals about some of the consequences of treatment with opioids for chronic pain and to consider, when appropriate, tapering and changing prescribing practices, as well as considering alternative pain therapies.

The same month, HHS also released the National Pain Strategy, which outlines the federal government's first coordinated plan for addressing chronic pain that affects so many Americans. The National Heroin Task Force, which consisted of law enforcement, doctors, public health officials, and education experts, was convened to develop strategies to confront the heroin problem and decrease the escalating overdose epidemic and death rate. This included a multifaceted strategy of enforcement and prevention efforts, as well as increased access to substance use disorder treatment and recovery services.

Although only about 4 percent of those who misuse prescription opioids transition to using heroin, concern is growing that tightening restrictions on opioid prescribing could potentially have unintended consequences resulting in new populations using heroin. The concern about opioid overdoses has also triggered efforts by health systems to increase access to naloxone, an opioid antagonist that prevents overdose fatalities by rapidly restoring normal respiration to a person whose breathing has slowed or stopped as a result of opioid use.

Since , community-based organizations in many states have implemented overdose education and naloxone distribution programs for people who use heroin or misuse pharmaceutical opioids and efforts are underway to expand access to naloxone to patients who are prescribed opioids for pain.

Expanded access to naloxone through large health systems could prevent overdose fatalities in broad populations of patients, including patients who may experience accidental overdose from misusing their medications. Many individuals who come to mainstream health care settings, such as primary care, obstetrics and gynecology, emergency departments, and hospitals, also have a substance use disorder. In a study within one health plan, one third of the most common and costly medical conditions were markedly more prevalent among patients with substance use disorders than they were among similar health system members who did not have a substance use disorder.

Because substance use complicates many other medical conditions, early identification and management of substance misuse or use disorders presents an important opportunity to improve health outcomes and reduce health care costs. In addition to the health problems faced by individuals engaged in substance use mentioned above, substance use can adversely affect a developing fetus.

In the United States, fetal alcohol spectrum disorders FASD remain highly prevalent and problematic, even though they are preventable. Opioid pain reliever use among pregnant women has also become a major concern due to neonatal abstinence syndrome NAS , a treatable condition that newborns experience after exposure to drugs while in the mother's womb.

Newborns with NAS are more likely than other babies to also have low birthweight and respiratory complications. The incidence of NAS has increased dramatically in the last decade along with increased opioid misuse. Moreover, in , newborns with NAS stayed in the hospital an average of For women who are considering getting pregnant or are already pregnant, abstaining from all substances is recommended, since NAS is not exclusively caused by opioids.

Adolescents with substance use disorders experience higher rates of other physical and mental illnesses, as well as diminished overall health and well-being. In addition to the physical health problems described above, mental health problems are also over-represented among adolescents with substance use disorders, 92 , 93 particularly attention-deficit hyperactivity disorder, 94 - 98 conduct disorders, 99 anxiety disorders, and mood disorders. Treatment of substance use disorders has historically been provided episodically, when a person experiences a crisis or a relapse occurs.

In addition to chronic care management for severely affected individuals, coordinating services for those with mild or moderate problems is also important. Studies of various methods for integrating substance use services and general medical care have typically shown beneficial outcomes. Care coordination is an essential part of quality in all health care. The Healthcare Effectiveness Data and Information Set HEDIS , The Joint Commission, and organizations such as the National Committee for Quality Assurance emphasize coordination and accountability and the use of evidence-based care and performance indicators to establish and monitor quality and value.

This approach to care delivery proceeds on the assumption that services for the range of substance use disorders should be fully integrated components of mainstream health care. Publicly available quality measurement information helps consumers, health care purchasers, and other groups make informed decisions when choosing services, providers, and care settings. Performance measurement has the dual purpose of accountability and quality improvement. A IOM study on Psychosocial Interventions for Mental and Substance Use Disorders recommended that the substance use disorder field develop approaches to measure quality, similar to approaches used for other diseases.

This includes the development of performance measures, use of health IT for standardized measurement, and utilization of these measures to support quality improvement. Many measures are being tested by public and private health plans, though most have not been adopted widely for quality improvement and accountability. A measure of care continuity after emergency department use for substance use disorders is in process.

Because substance use disorder treatment is currently not well integrated and services are often provided by multiple systems, it can be challenging to effectively measure treatment quality and related outcomes. The ability to track service delivery across these multiple environments will be critical for addressing this challenge.

For example, community monitoring systems to assess risk and protection for adolescents are being developed. Pay-for-performance is an approach for improving quality and for incentivizing programs or health care professionals to produce particular outcomes for example, treatment retention and treatment outcomes.

It has been used more in general health care than in substance use disorder treatment. However, Delaware and Maine have experimented with it in their public substance use disorder treatment systems, and several studies have found improvement in retention and outcomes. Although pay-for-performance is a promising approach, more research is needed to address these concerns. Several models of coordination have been described by researchers. In one such model, coordination ranges from referral agreements to co-located substance use disorder, mental health, and other health care services.

Onsite programs had the highest rates of treatment engagement. These models, as well as recovery-oriented systems of care, provide opportunities for substance use disorder services and mainstream health care to engage in various types of collaborative efforts to integrate their services at all stages: prevention, treatment, and recovery.

Importantly, the models all emphasize the relationship between person-centered, high-quality care and fully integrated models. Innovative financing mechanisms now being explored also allow for formal arrangements to implement some of the models discussed above, including linking to off-site health professionals in specialty substance use disorder treatment settings and vice versa when locating multiple services at one site is not feasible.

Integrating substance use services with general health care e. Prevalence of substance misuse and substance use disorders differs by race and ethnicity, sex, age, sexual orientation, gender identity, and disability, and these factors are also associated with differing rates of access to both health care and substance use disorder treatment.

These differences are often exacerbated by socioeconomic variables. A study of a large health system found that Black or African American women but not Latina or Asian American women were less likely to attend substance use disorder treatment, after controlling for other factors; there were no ethnicity differences for men. In addition, an analysis of longitudinal data from the National Epidemiologic Survey on Alcohol and Related Conditions showed that individuals from most racial and ethnic groups were less likely to receive an alcohol intervention than were White individuals over a 3 year period.

Differences within the various racial and ethnic groups by sex were not studied. A fundamental way to address disparities is to increase the number of people who have health coverage. The Affordable Care Act provides several mechanisms that broaden access to coverage. As a result, more low-income individuals with substance use disorders have gained health coverage, changed their perceptions about being able to obtain treatment services if needed, and increased their access to treatment.

Individuals whose incomes are too high to qualify for Medicaid but are not high enough to be eligible for qualified health plan premium tax credits also rarely have coverage for substance use disorder treatment. Because the new Medicaid population includes large numbers of young, single men—a group at much higher risk for alcohol and drug misuse—Medicaid enrollees needing treatment could more than double, from 1.

Notes: Totals may not sum to percent due to rounding. Ineligible for Financial Assistance share includes those ineligible due to offer of more Another way to address disparities is to ensure that substance misuse prevention, interventions, treatments, and recovery services are tailored and relevant to the populations receiving them.

Several interventions have been adapted explicitly to address differences in specific populations; they were either conducted within health care settings or are implementable in those settings. The list below provides examples of such programs that have been shown to be effective in diverse populations:. In other words, it is expected that the number of people who seek treatment across all racial and ethnic groups will increase.

Few studies have directly compared treatment populations by race and ethnicity. However, some studies have examined race and ethnicity as predictors of outcomes in analyses controlling for many other factors such as age, substance use disorder severity, mental health severity, social supports , and they showed that after accounting for these socioeconomic factors, outcomes did not differ by race and ethnicity.

This body of research has some key caveats. For example, studies have found that matching programs and providers by race or ethnicity may produce better results for Hispanics or Latinos than for other racial and ethnic groups. At the same time, offering programs that are tailored to patient characteristics or that incorporate health care professionals who share similarities with their patients in sex, age, or race or ethnicity may improve willingness to enter and engage in treatment.

It should also be noted that civil rights laws, such as Section of the Rehabilitation Act, the Americans with Disabilities Act ADA , and Section of the Affordable Care Act, protect many people with substance use disorders and impose requirements on substance use disorder treatment programs. These laws require individual assessment of a person with a disability, identifying and implementing needed reasonable modifications of policies and practices when necessary to provide an equal opportunity for a person with a disability to participate in and benefit from treatment programs.

More generally, these laws prohibit programs from excluding individuals from treatment programs on the basis of a co-occurring disability, if the individual meets the qualifications for the program. Additionally, under Title VI of the Civil Rights Act and Section of the Affordable Care Act, providers who receive federal financial assistance must address the needs of people with limited English proficiency. The ADA and Section also apply to discriminatory zoning laws and decisions that operate as a barrier to providers seeking to open or expand substance use disorder treatment programs.

As the section on Electronic Health Records and Health Information Technology shows, health IT holds tremendous promise to provide culturally appropriate services in multiple languages and that incorporate health care professionals with characteristics similar to the target patients' population. With scarce resources and many social programs competing for limited funding, cost-effectiveness is a critical aspect of substance use-related services.

Over the past 20 years, several comprehensive literature reviews have examined the economics of substance use disorder treatment. Evaluations of Medicaid expenditures for substance use disorder treatment show that the costs of treating substance use disorders are more than offset by the accompanying savings to Medicaid in reduced health care costs, such as reductions in future substance use disorder-related hospitalizations and residential treatment costs.

Costs associated with substance use disorders are not limited to health care. The accumulated costs to the individual, the family, and the community are staggering and arise as a consequence of many direct and indirect effects, including compromised physical and mental health, loss of productivity, reduced quality of life, increased crime and violence, misuse and neglect of children, and health care costs.

As described elsewhere in this Report , a substance use disorder is a substantial risk factor for committing a criminal offense. Reduced crime is thus a key component of the net benefits associated with prevention and treatment interventions. Overall, within the criminal justice system, more than two thirds of jail detainees and half of prison inmates experience substance use disorders. Substance use-related costs are also prominent within child welfare and related services.

The estimated prevalence of substance use disorders among parents involved in the child welfare system varies across service populations, time, and place. One widely cited estimate is that between one-third and two-thirds of parents involved with the child welfare system experience some form of substance use problem. The National Survey of Child and Adolescent Weil-Being found that caseworkers perceived substance misuse problems in 23 percent of cases, which was correlated with significantly higher probabilities of severe harm to children 24 percent , compared with parents with no such indication 5 percent.

Children of parents with substance use problems were more likely than others to require child protective services at younger ages, to experience repeated neglect and abuse from parents, and to otherwise require more intensive and intrusive services. Substance use disorders appear to account for a large proportion of child welfare, foster care, and related expenditures in the United States. It is one of the largest health care systems in the United States.

The IOM conducted a comprehensive study of military prevention and treatment services for substance use disorders. Further, service members and veterans suffer from high rates of co-occurring health problems that pose significant treatment challenges, including traumatic brain injury, post-traumatic stress disorder, depression, and anxiety. Along with other recommendations, the IOM report recommended conducting routine screening, integrating substance use treatment with other health care, and implementing evidence-based treatments.

These illustrative examples underscore that the costs associated with substance use disorders are incurred across diverse service systems that serve vulnerable populations. These expenditures might be reduced through more aggressive measures to address substance misuse problems and accompanying disorders. Moreover, many substance use-related services provided through criminal justice, child welfare, or other systems seek to ameliorate serious harms that have already occurred, and that might have been prevented with greater impact or cost-effectiveness through the delivery of evidence-based prevention or early treatment interventions.

Different kinds of economic analyses can be particularly useful in helping health care systems, community leaders, and policymakers identify programs or policies that will bring the greatest value for addressing their needs. Two commonly used types of analyses are cost-effectiveness analysis and cost-benefit analysis. Both types of studies have been used to examine substance use disorder treatment and prevention programs.

Studies have found a number of substance use disorder treatments, including outpatient methadone, alcohol use disorder medications, and buprenorphine, to be cost-effective compared with no treatment. Treatment Settings and Approaches. A study estimating the cost-effectiveness of four different treatment modalities—inpatient, residential, outpatient methadone, and outpatient without MAT—found that the treatment of substance use disorders is cost-effective compared to other health interventions, with outpatient programs without MAT being the most cost-effective.

Methadone Maintenance versus Methadone Detoxification. Cost-effectiveness study. A comparative analysis of two or more interventions against their health and economic outcomes. These outcomes could be lives saved, illnesses prevented, or years of life gained. Cost-benefit study. A study that determines the economic worth of an intervention by quantifying its costs in monetary terms and comparing them with the benefits, also expressed in monetary terms.

Total benefits divided by total costs is called a cost-benefit ratio. If the ratio is greater than 1, the benefits outweigh the costs. Methadone Maintenance versus Maintenance with Other Medications. However, extended-release naltrexone is not off-patent, and therefore these cost findings will likely change when it becomes generic. A measure of the burden of disease used in economic evaluations of the value of health care interventions that accounts for both the years of life lived and the quality of life experienced during those years, relative to quality associated with perfect health.

Buprenorphine-Naloxone versus No Treatment. A study examined individuals with opioid use disorders who had completed 6 months of buprenorphine-naloxone treatment within a primary care setting. A review of cost-effectiveness studies for alcohol SBI in a primary care setting found considerable variability in the estimated cost-effectiveness ratios and cost savings across studies. Using that comparison, alcohol misuse screening achieved a combined score similar to screening for colorectal cancer, hypertension, or vision for adults older than age 64 , and to influenza or pneumococcal immunization.

Because current levels of SBI delivery are much lower than desired, this service deserves special attention by health care professionals and care delivery systems. Interventions that prevent substance use disorders can yield an even greater economic return than the services that treat them. The Washington State Institute for Public Policy has used a standardized model to estimate the cost-benefit of diverse prevention, early intervention, and treatment programs. In a literature review of the economics of substance use disorder treatment, one study highlighted the variability in cost estimates for substance use disorder treatment delivered in specialty settings.

Costs were typically lower when activity-based costing assigning the cost and amount of each activity that is part of the intervention was employed and when the SBI occurred in a primary care setting or was performed by a provider who was not a physician. Additionally, variation was attributed to the wage of the person conducting the screening and the amount of time the screening took.

In recent years, use of MAT has increased. Recent studies have examined extended-release naltrexone, buprenorphine, and methadone for opioid use disorder treatment. While other treatments may be less costly, they are also somewhat less effective. In , about three-quarters of all general health care purchased in the United States was paid for by private insurance, Medicare, or Medicaid. The rest was covered by consumers paying out-of-pocket, by other federal health grants, and by programs and other insurance provided by the DoD, Department of Veterans Affairs, and other state and local programs.

In , the largest share of substance use disorder treatment financing was from state non-Medicaid and local governments 29 percent. Coverage of substance use disorder services under private insurance has waxed and waned over the past 30 years. During the s, insurance benefits and specialty addiction providers expanded, , and from to , substance use disorder spending grew by 6. This expansion was followed by managed care restrictions on reimbursement for substance use disorder treatment in inpatient settings, such as limitations on length of residential rehabilitation stays a common treatment regimen.

Further, the share of substance use disorder financing from private insurance dropped dramatically between and , from 32 percent in to 13 percent in ; this was followed by an increase to 18 percent in , likely due to MHPAEA and qualified health plan coverage now being available through the Affordable Care Act. Approximately 20 percent of people in the United States have health coverage through Medicaid, a joint federal and state health coverage program that provides medical assistance for children, families, and individuals with low income and limited resources; an estimated 12 percent of adult Medicaid beneficiaries have a substance use disorder.

The federal government establishes basic requirements that states must follow in designing their Medicaid programs, including some mandated services that must be covered and guidance regarding payment rate-setting and contractual arrangements, eligibility and quality standards, and provision of optional services.

States can choose to cover or not cover specific treatments or to place restrictions on covered services. In the past, some states have not included certain critical substance use disorder treatment options in their benefit packages e. In many states, Medicaid also does not cover residential treatment, especially for adults. For those who are eligible and have substance use disorders, Medicaid is an extremely important program, as it can cover many services that such individuals may need, such as crisis services and many preventive services.

In addition, while Medicaid does not provide payments for housing e. In states that did not expand Medicaid, racial and ethnic minorities are disproportionately affected. In addition, in these states, young adult single males—a group with high rates of substance use disorders-are ineligible for Medicaid benefits. An estimated 14 to 15 percent of uninsured individuals nationwide who could be newly eligible for Medicaid coverage under the Affordable Care Act have a substance use disorder.

Medicare covers almost all individuals aged 65 or over as well as those eligible because of disabilities. Approximately Prescription drug treatment is generally covered for beneficiaries enrolled in Medicare Part D or a Medicare Advantage plan that includes drug coverage. Medicare does not cover outpatient use of oral methadone for substance use disorders, but Part D can include coverage for medications, such as disulfiram, naltrexone, acamprosate, and buprenorphine.

Although insurance coverage is critical to improving access to and integration of services for individuals with substance use disorders, it is unlikely to cover all the services that such individuals may need, such as crisis services e. Research has shown that uninsured individuals have higher unmet medical needs than do insured individuals, and those without insurance also have higher rates of substance use disorders than do individuals with insurance.

Funds from federal block grants to states for substance use disorder treatment services such as the SABG, which is often used for prevention activities and for maternal, child, and adolescent health services Title V of the Maternal and Child Health Services Block Grant may be used to fill the gaps in treatment services not covered by insurance.

These funds also finance treatment for people without insurance and support community prevention activities. In addition, federal funding for certain community prevention programs encourages public-private partnerships and community collaboration to improve health outcomes. Grants are used to increase screening, counseling, workplace wellness programs, and community prevention. Although investments in prevention have repeatedly demonstrated favorable economic returns, primary prevention for all health conditions still accounts for less than 5 percent of overall health spending in the United States.

Prevention should be seen as an appropriate health cost to be covered by insurance. Current funding options for community prevention, described below, include grants from hospital and health system foundations, hospital-based community benefit programs, tax earmarks, and targeted state programs.

Foundations formed from the conversion of tax-exempt non-profit hospitals and health systems into for-profit entities are required by federal law to invest in health-related activities within the community area served by that hospital. Beginning in , tax-exempt hospitals have been required to provide benefits to the community in return for not paying taxes.

Tax-exempt hospitals must: 1 conduct a community health needs assessment at least once every 3 years; 2 involve public health experts and representatives of the community served by the facility in the needs assessment; 3 make the results of the assessment available to the public; 4 develop an implementation strategy to address each of the community health needs identified through the assessment; and 5 report yearly to the Internal Revenue Service.

Many states also have community benefit programs that must be synchronized with the requirements of the Affordable Care Act. In certain jurisdictions, direct funds from a local or state tax can be earmarked for substance misuse prevention in the same way as tobacco taxes are currently used for public health and health programming in many states.

Jackson County, Missouri, first introduced a dedicated sales tax in to tackle drug use and drug-related crime. The funds are used for a variety of prevention, treatment, and anti-drug and drug-related crime prevention programs. In addition, Florida and Indiana, among other states, earmark alcohol taxes for child and adolescent substance use-related services.

The Massachusetts Legislature passed the first state-based prevention fund, called the Prevention and Wellness Trust Fund, in as part of a health cost control bill. Grantees have a strong focus on extending care beyond clinical sites into the community. It is clear that integrating substance use disorder services with mainstream health care is beneficial for individuals and communities and that health reform is encouraging this trend.

However, several key challenges must be addressed if integration is to be fully successful. The Congressional Budget Office currently estimates that by , 24 million Americans who would otherwise be uninsured will obtain health insurance coverage as a result of the Affordable Care Act. However, the specialty care substance use disorder treatment system faces challenges along with these new opportunities.

Nationally representative data from the National Drug Abuse Treatment System Survey underscore the importance but also the difficulty of integrated care efforts. Fifty-five percent of addiction treatment patients in expansion states are receiving care in organizations that at least have contractual linkages to some medical or health home arrangement. Substance use disorder treatment organizations currently face significant challenges in engaging in care coordination with other types of providers.

Because these organizations have traditionally been organized and financed separately from general health care systems, the two systems have not routinely exchanged clinical information. In a survey of treatment programs to assess their readiness for health reform, 63 percent described their organizations' adoption of EHRs as having not yet begun, or only in the early stages.

For example, private, for-profit treatment facilities were significantly more likely to be early adopters of buprenorphine therapies than were their public or private non-profit peers. This offers promise for increasing adoption and use of health IT by behavioral health providers. Another challenge for effectively coordinating care relates to the need for specialty substance use disorder treatment programs to comply with substance abuse confidentiality regulations 42 CFR Part 2 and state privacy laws when implementing health IT systems.

In addition, substance use disorder treatment organizations face the challenge of communicating with non-health care personnel including those in social service, criminal justice, and educational facilities and even when EHRs are in place these systems lack interoperability the ability to effectively exchange digital health information from an EHR in a common format with the information systems used by social service organizations, hindering communication.

Medical homes are most likely to pursue contractual arrangements with large and technologically sophisticated organizations that are best equipped to meet their needs for timely clinical and administrative information. The move toward integrated care is therefore likely to accelerate consolidation of substance use disorder treatment programs, which may hasten the adoption of new technologies and processes among sophisticated providers.

Particularly in combination with expanded insurance coverage, this trend may attract new partnerships, for example between ACOs, which are integrated delivery systems, and more sophisticated specialty addiction providers. Yet, the same patterns may harm smaller providers, some of whom offer the only culturally competent services for particular patient groups, such as services tailored for specific racial and ethnic populations, sexual and gender minorities, or women in need of trauma-related residential services.

One key challenge for integrating substance use treatment and health care is that implementation of pharmacotherapies i. Research suggests that whether treatment programs offer MAT is influenced by a number of organizational and state-level factors, including differences in organizational size, whether the treatment program is in a hospital setting, whether psychiatric medications are prescribed, whether the program has access to prescribing staff, and whether state Medicaid policies support the use of generic drugs.

Another medication, extended-release injectable naltrexone, approved by the FDA for use in treating individuals with opioid use disorders, is underutilized by programs. For example, one study found that only three percent of United States treatment programs used it for opioid use disorders. One study found that between and , its use for detoxification in specialty opioid treatment programs OTPs increased from 36 percent of programs in the sample to 46 percent; its use for maintenance increased from 37 percent of programs in the sample to 53 percent.

A recent study found that raising this limit further, rather than increasing the number of specialty addiction programs or waivered physicians, may be the most effective way to increase buprenorphine use. Another key challenge is that primary care settings have not yet routinely implemented recommended preventive health and intervention services related to substance misuse.

Currently, the Affordable Care Act requires that all non-grandfathered health plans must cover, without cost-sharing, certain preventive health services recommended by the USPSTF, and women's preventive services and preventive services for infants, children, and adolescents in guidelines supported by HRSA As discussed earlier, the USPSTF recommends alcohol screening and counseling for adults. The USPSTF currently considers the evidence to be insufficient to support screening or behavioral interventions for substance misuse problems in pediatrics.

Hilton Foundation, are currently underway that could add to the evidence base. Major pediatric medical organizations, including the American Academy of Pediatrics, strongly recommend addressing these issues regularly at each well-adolescent visit and appropriate urgent care visits. The Affordable Care Act requires health plans to cover, at no out-of-pocket cost to families, the preventive care services outlined in this schedule.

Bright Futures discusses how to incorporate screening into the preventive services visit for these age groups. Screening and brief intervention for substance misuse is also consistent with the prevention activities recommended in the IOM report Preventing Mental, Emotional, and Behavioral Disorders Among Youth: Progress and Possibilities. The Joint Commission Requirements mandate that hospitals offer inpatients brief counseling for alcohol misuse and follow-up, and measure the provision of counseling as one of the core measures for hospital accreditation.

Primary care teams that include non-physician providers e. Several large health systems, such as the Veterans Health Administration and Kaiser Permanente, have successfully implemented primary care-based alcohol SBI in a sustainable manner. These approaches can also be implemented in emergency departments and in obstetrics and gynecology departments.

Data on the substance use workforce are incomplete. Nevertheless, it is clear that the workforce is inadequate, as evidenced by its uneven geographic distribution with rural areas underserved , access barriers for adolescents and children, and recruitment challenges across the treatment field. Moreover, the workforce is aging. For example, 46 percent of psychiatrists are older than age Recent reforms may strain the current workforce in an already overstretched health care system working to address treatment and prevention strategies.

A recent study documented staffing models in primary care practices and determined that, even among those designated as patient-centered medical homes, fewer than 23 percent employed health educators, pharmacists, social workers, nutritionists, or community service coordinators, and fewer than half employed care coordinators. The IOM's report Improving the Quality of Health Care for Mental and Substance Use Conditions , 32 which adapted Crossing the Quality Chasm to address mental and substance use conditions, noted that a critical concern in attracting a skilled workforce is the low salary structure of the substance use disorder treatment workforce.

In practice, the Block Grant is used broadly, and Medicaid less and only with a subset of providers. It is not yet clear whether the integration of substance use disorder treatments in general health care will help to address salary structure. An integrated health and substance use disorder treatment system requires a diverse workforce that includes substance use disorder specialists, physicians, nurses, mental health treatment providers, care managers, and recovery specialists.

This workforce also includes peer recovery coaches a reimbursable service under some state Medicaid programs , health educators, social workers, and other staff who are trained to deliver timely mental health and substance use-related health interventions, such as SBI. As substance use disorder treatment and general health care become more integrated, clinical staff in both systems will need to expand their scope of work, operate in an integrated manner with a variety of populations, and shift their treatment focus as needed.

Health care professionals moving from the specialty workforce into integrated settings will require specific training on treatment planning and care coordination and an ability and willingness to work under the leadership of medical staff. Working in teams with the broad mandate of improved health is not currently commonplace and will require collaboration among professional and certification bodies.

Incorporating peer workers, who bring specific knowledge of patients' experiences and needs and can encourage informed patient decision making, into teams will also require further adjustment. Improving the Quality of Health Care for Mental and Substance Use Conditions also discussed the shortage of skills both in specialty substance use disorder programs and in the general health care system. Currently, 66 organizations license and credential addiction counselors, , and although a consensus on national core competencies for these counselors exists, they have not been universally adopted.

Without a comprehensive, coordinated, and focused effort, workforce expansion and training will continue to fall short of the challenge of meeting the needs of individuals across the continuum of service settings. HRSA has taken a number of steps to address these workforce challenges as part of its mission to prepare a diverse workforce and improve the workforce distribution to increase access for underserved communities.

Among its many programs, HRSA awards health professional and graduate medical education training grants and operates scholarship and loan repayment programs. Of particular note is the National Health Service Corps, where, as of September , roughly 30 percent of its field strength of 9, was composed of behavioral health providers, meeting service obligations by providing care in areas of high need.

The development of the workforce qualified to deliver these services and services to address co-occurring medical and mental disorders will have significant implications for the national workforce's ability to reach the full potential of integration.

Effectively integrating substance use disorder treatment and general health care requires the timely exchange of patient health care information. These privacy protections were motivated by the understanding that discrimination attached to a substance use disorder might dissuade people from seeking treatment, and were enacted in the context of patient methadone records being used in criminal cases.

HIPAA does not require patient authorization to share health information for purposes of treatment, payment, or health care operations. With 42 CFR Part 2, patient consent is required to share and use patient identifying information and any information that could be used to identify someone as having, or having had, a substance use disorder, such as payment data. Given the long and continuing history of discrimination against people with substance use disorders, safeguards against inappropriate or inadvertent disclosures are important.

Disclosures to legal authorities can lead to arrest, loss of child custody, or relinquished parental rights. Disclosures to insurers or to employers can render patients unable to obtain disability or life insurance and can cost patients their jobs. Currently, persons with substance use disorders involving illicit drugs are not protected under anti-discrimination laws, such as the ADA. However, exchanging treatment records among health care providers has the potential to improve treatment and patient safety.

For example, in the case of opioid prescribing, a study in health systems of long-term opioid users found those with a prior substance use disorder diagnosis received higher dosages and were co-prescribed sedative-hypnotic medications—which can increase the risk for overdose—more often. Because of privacy regulations, it is likely that physicians were not aware of their patients' substance use disorders.

PDMPs are state-run databases that collect prescribed and dispensed controlled prescription drug information and give prescribers and pharmacists access to a person's controlled substance prescription history. Authorized providers can check the database before prescribing or dispensing. However, PDMPs have many limitations. They do not include information about methadone used for opioid use disorders, which is exclusively dispensed at OTPs, or from programs covered by 42 CFR Part 2. While disclosure of patient-identifying information that is subject to 42 CFR Part 2 is allowable, it would require written patient consent, and re-disclosures of this information would not be permitted unless the patient consents.

In addition, PDMPs only collect prescription information as allowed by their state laws, in most cases controlled substances Scheduled II through IV or V, and thus health care professionals may not be aware of other prescriptions their patients are receiving. As EHR interoperability and the exchange of health information increases, best practices must be developed for handling substance use disorder treatment data, consistent with state and federal privacy laws.

Clearly, integrating health care and substance use disorder treatment within health care systems, as well as integrating the substance use disorder treatment system with the overall health care system, are complex undertakings. The good news, however, is that a range of promising health care structures, technologies, and innovations are emerging, or are being refined and strengthened, under health reform.

These developments are helping to address challenges and facilitate integration. In so doing, they are broadening the focus of interventions beyond just the treatment of severe substance use disorders to encompass the entire spectrum of prevention, treatment, and recovery. These promising developments include:. Medicaid is not only an increasing source of financing for substance use disorder treatment services, it has become an important incubator for innovative substance use disorder financing and delivery models that can help integrate substance use disorder treatment and mainstream health care systems.

Within the substance use disorder treatment benefit, and in addition to providing the federally required set of services, states also may offer a wide range of recovery-oriented services under Medicaid's rehabilitative services option. These services include therapy, counseling, training in communication and independent living skills, recovery support and relapse prevention training, skills training to return to employment, and relationship skills.

Nearly all states offer some rehabilitative mental health services, and most states offer the rehabilitation option for substance use disorder services. CMS provides various authorities by which states can structure their Medicaid programs, thus providing mechanisms for states to expand and improve their substance use disorder treatment delivery system: This includes authorities to: - Recently, CMS gave states new opportunities to design service delivery systems for substance use disorders through demonstration projects under section This initiative is designed to support states to provide coverage for the full continuum of care; ensure that care is delivered consistent with the ASAM Treatment Criteria; design strategies to coordinate and integrate care; and support quality improvement programs.

The agency is providing technical and program support to states to introduce policy, program, and payment reforms to identify individuals with substance use disorders, expand coverage for effective treatment, expand access to services, and develop data collection, measurement, and payment mechanisms that promote better outcomes. Medicaid is also encouraging the trend to integration in other ways, including supporting new models for delivering primary care, expanding the role of existing community-based care delivery systems, enacting mental health and substance use disorder parity for Medicaid and Children's Health Insurance Program CHIP as included in the final rule that CMS finalized in March Health homes are grounded in the principles of the primary care medical home, which focuses on primary care-based coordination of diverse health care services, and patient and provider engagement.

The Affordable Care Act created an optional Medicaid State Plan benefit allowing states to establish health homes to coordinate care for participants who have chronic health conditions. Beneficiaries with chronic conditions are eligible to enroll in health homes if they experience or are at risk for a second chronic condition, including substance use disorders, or are experiencing serious and persistent mental health conditions.

These arrangements emphasize integration of care, targeting of health home services to high-risk populations with substance use and mental health concerns, and integration of social and community supports with general health services.

As of January , 19 states and the District of Columbia had established Medicaid health home programs — covering nearly one million individuals — and nearly a dozen additional states had plans for establishing them. States that implement Medicaid health homes receive substantial federal subsidies, including 90 percent federal matching rates for health home services during the first eight quarters after the effective date of health home coverage under the Medicaid state plan, covering comprehensive case management, coordinating services and health promotion, comprehensive transitional care from inpatient to other settings, individual and family support services, linkage and referrals to community-based services, and health IT.

In some settings, these integrated care models are associated with reduced cost and improved cost-effectiveness, and research is underway to test new models. Recognizing the important role that these kinds of integrated care arrangements can play, the American Academy of Family Physicians and SAMHSA have issued reports promoting the inclusion of substance use and mental health services in patient-centered medical homes and related efforts.

Another Affordable Care Act provision created opportunities to encourage the integration of primary and specialty care, as well as community and public health systems, by establishing integrated delivery systems known as ACOs. ACCs are an important variation on the ACO model because, by focusing on the larger community, they can address the social determinants of health and health disparities that have such a profound impact on community members' health and well-being, including their risks for substance misuse, substance use disorders, and related health consequences.

Initially developed as a model under Medicare, ACOs have now also been encouraged under Medicaid for its covered populations. An underlying assumption of the new service delivery and payment models funded in the SIM states is that they will be more effective and produce better outcomes when implemented as part of a broad-based, statewide initiative that brings together multiple payors and stakeholders, and when they use the levers of state government to effect change.

The SIM states are leading the implementation of accountable care systems for Medicaid populations that embrace population health for SIM states, this is defined as health of the community in a geographic area as opposed to the population of patients in the health delivery system.

Several states have adopted ACC models that support integration of medical health care services with public health and community-based programs. Oregon's CCOs are a network of all types of health care professionals physical health care, addiction and mental health care, and dental care providers who have agreed to work together to serve people who receive health care coverage under Oregon's Medicaid plan, which is called Oregon Health Plan.

The Oregon Health Authority publishes regular reports on quality, access, and progress toward benchmarks in both prevention and treatment. Increased insurance coverage and other provisions of the Affordable Care Act have sparked important changes that are facilitating comprehensive, high-quality care for people with substance use disorders.

For example, the Affordable Care Act provided mandatory funding for Federally Qualified Health Centers FQHCs receiving grants under section of the public health service act, including community health centers, migrant health centers, health care for the homeless health centers, and public housing primary care centers that is supporting the expansion of their activities and numbers of patients served.

These community health centers emphasize coordinated primary and preventive services that promote reductions in health disparities for low-income individuals, racial and ethnic minorities, rural communities, and other underserved populations. Two-thirds of health centers have been designated as PCMHs. Community health centers provide primary and preventive health services to medically underserved areas and populations and may offer behavioral and mental health and substance use services as appropriate to meet the health needs of the population served by the health center.

As such, they are well-equipped to address co-occurring physical, mental, and substance use disorders, and provide substance misuse prevention, treatment, and RSS to patients. Because they provide services regardless of ability to pay and are required to offer services on a sliding scale fee, they are well-positioned to serve low-income and economically vulnerable patients.

An example of the important role FQHCs can play in improving access to treatment for substance use disorders is their efforts in providing buprenorphine maintenance treatment for opioid-dependent patients within primary care. FQHCs have access to B drug pricing, making the purchase of substance use disorder medications less costly and thus more accessible than for providers who cannot take advantage of this pricing.

EHRs and health IT have the potential to support better coordination of services across primary care and specialty substance use disorder treatment, greater safety by reducing harmful drug-drug interactions, and improved monitoring of treatment outcomes and relapse risk in general health care. Strong health IT systems improve the organization and usability of clinical data, thereby helping patients, health care professionals, and health system leaders coordinate care, promote shared decision-making, and engage in quality improvement efforts.

These systems have the capacity to easily provide information in multiple languages and to put patients in touch with culturally appropriate providers through telehealth. Meaningful Use. Using certified EHR technology to improve quality, safety, efficiency, and reduce health disparities; engage patients and family; improve care coordination and population and public health; and maintain privacy and security of patient health information.

Health IT has shown benefits in improving care for patients with chronic conditions, and use is expected to greatly increase because of the Affordable Care Act and related incentives, such as grants supporting health center networks with the implementation and adoption of health IT. Health IT also holds great potential for improving services for individuals with substance misuse problems because they can provide up-to-date medical histories of patients to providers, and they can support care coordination by facilitating communications between primary and specialty care providers across health systems.

For example, educational and training materials including clinical guidelines for physicians e. Many health systems have additional information on wikis for patients and providers. Most have or will have patient portal websites, which can provide patients access to health, mental health, and substance use self-assessments; computerized interventions for reducing alcohol or drug use, anger management, dealing with depression, and other problems; referral sources for smoking quit-lines and self-help groups; information on medications for substance use disorders; and general health information.

Clinical Decision Support. A system that provides health care professionals, staff, patients, or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. Although research suggests that patients with substance use disorders are not using patient portals as much as individuals with other conditions, they have great potential for reaching patients.

To foster systems change, efforts are needed to increase adoption of EHR technology in substance use disorder and mental health treatment organizations. These programs currently lag and are likely to continue to lag behind the rest of medicine.

It will be critical to facilitate the uptake of EHRs within the specialty substance use disorder treatment system, to implement common data standards to support interoperability across specialty substance use disorder treatment and mainstream health care, and to coordinate care across systems.

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Margin call forex example Recent Developments in Alcoholism. Although only about 4 percent of those who misuse prescription opioids transition to using heroin, concern is growing that tightening restrictions on opioid prescribing could potentially have unintended consequences resulting in new populations using heroin. They can:. Once the assessment phase of the strategic IT plan is completed, the executive team, with the help of IT leadership, should formulate a plan to update the IT infrastructure. As such, they are well-equipped to address co-occurring physical, mental, and substance use disorders, and provide substance misuse prevention, treatment, and RSS to patients. Department of Labor. One positive consequence was the initial development of effective and inexpensive behavioral change strategies rarely used in the treatment of other chronic illnesses.
Forex documentary now ifc Insurance Law. This area of research should involve institutions that provide services to individuals with serious co-occurring problems specialty mental health agenciesindividuals with legal problems criminal justice agencies and drug courtsindividuals with employment or other social issues, as well as the larger community, determining how to most effectively link each of these subpopulations with a recovery-oriented systems of care. Financing Systems for Substance Use Disorder Services Inabout three-quarters of all general health care purchased in the United States was paid for by private insurance, Medicare, or Medicaid. The IOM conducted a comprehensive study of military prevention and treatment services for substance use disorders. Nursing Subspecialties.
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They can usually be identified from changes in the Fixed Assets section of the long-term assets section of the balance sheet. Some examples of investing cash flows are payments for the purchase of land, buildings, equipment, and other investment assets and cash receipts from the sale of land, buildings, equipment, and other investment assets. Cash flows from financing activities are cash transactions related to the business raising money from debt or stock, or repaying that debt.

They can be identified from changes in long-term liabilities and equity. Examples of financing cash flows include cash proceeds from issuance of debt instruments such as notes or bonds payable, cash proceeds from issuance of capital stock, cash payments for dividend distributions, principal repayment or redemption of notes or bonds payable, or purchase of treasury stock. Investors do not always take a negative cash flow as a negative. Why would investors and lenders be willing to place money with Amazon?

Much of this was through delaying payment on inventories. Another reason lenders and investors were willing to fund Amazon is that investing payments are often signs of a company growing. Figure Which of these transactions would not be part of the cash flows from the operating activities section of the statement of cash flows? Figure Which is the proper order of the sections of the statement of cash flows? Figure Which of these transactions would be part of the financing section?

Figure Which of these transactions would be part of the operating section? Figure Which of these transactions would be part of the investing section? Figure What categories of activities are reported on the statement of cash flows? Does it matter in what order these sections are presented? Figure Describe three examples of operating activities, and identify whether each of them represents cash collected or cash spent. Figure Describe three examples of investing activities, and identify whether each of them represents cash collected or cash spent.

Any transaction that is related to acquiring or disposing of long-term assets like land, buildings, equipment, stocks, bonds, or other investments. Can be cash spent for purchase of long-term assets, or cash collected from sale of long-term assets. Figure Describe three examples of financing activities, and identify whether each of them represents cash collected or cash spent. Figure In which section of the statement of cash flows would each of the following transactions be included? For each, identify the appropriate section of the statement of cash flows as operating O , investing I , financing F , or none N.

Note: some transactions might involve two sections. Figure Provide journal entries to record each of the following transactions. Submit a short memo that provides the following information:. Cash paid for the capitalized development expenditure. Cash paid for the self constructed asset. Cash received from disposal of non-current assets. Loans granted to other party except by the financial institution.

Cash received in respect of loan receivables. Cash received as a result of government grant. Interest and dividend income received on long term investments. Net cash flow from investing activities B. Proceeds received on issue of ordinary shares. Proceeds received on issue of loan notes, debentures or bonds. Bank loan borrowed. Repayments of loan notes, debentures, bonds or a bank loan. Repayment of finance lease by lessee. Dividend paid to the owners of finance. Net cash flow from financing activities C.

The entity will report cash flow from operating activities either using direct method or indirect method. Have you forgotten your password? Are you a new user? Sign up or. Scope The requirements of this standard are applicable for the preparation and presentation of statement of cash flows which is presented as an essential component of the financial statements in each accounting period. Definitions Cash It encompasses currency notes, coins used as currency and short term deposits accessible on demand.

Cash Equivalents The short term investments which are highly liquid and are convertible in to identifiable amount of cash within a period of three months or less, these have least chances of variation in value, are termed as cash equivalents These are normally held by entity in order to meet its short term cash needs or commitments rather than held for investment purposes These also include bank overdrafts which are held by the entity for the purpose of cash management.

Cash Flows The inflows and outflows in the normal conduct of the business, of cash and cash equivalents are termed as cash flows. Operating Activities The principal business activities of the entity, which generate revenues for the entity are termed as operating activities Investing Activities The activities which are undertaken by the entity, for the purchase of long term assets and investments which are not the part of cash equivalents , including the disposal of such long term assets and investments are termed as investing activities.

Financing Activities The activities which are undertaken by the entity to raise capital or long term funds for the business, and which results in change in the equity and borrowed funds of the entity are termed as financing activities Presentation of Statement of Cash Flows The entity is required prepare the statement of cash flows by classifying such cash flows into operating, investing and financing activities. Operating Activities The cash flows which are generated by the principal business activities of the entity are termed as cash flows from operating activities.

The following are the examples of cash flows from operating activities: Cash received related the sale of goods Cash received related to rendering of service Cash received related to royalty or commissions income Cash received related to the sale of investments, which are held for trading Cash paid or received by a financial institute for the grant and receipt of loan amount Cash received or paid by the insurance company in respect of for premiums and claims Cash paid to suppliers for purchase of goods or services Salaries Paid to employees; Any cash paid or received as a refund of income tax Any cash received from disposal of a non-current asset is not the part of cash flows from operating activities, instead it is included in cash flows from investing activities.

Investing Activities The activities which are undertaken by the entity, for the purchase of long term assets and investments which are not the part of cash equivalents , including the disposal of such long term assets and investments are termed as investing activities.

The following are the examples of cash flows from investing activities: Cash paid to purchase non-current assets tangible and intangible both Cash paid to purchase long term investments other those held for trading Cash paid for the capitalized development expenditure Cash paid for the self constructed asset Cash received from disposal of non-current assets tangible and intangible both and long term investments Loans granted to other party except loans granted by the financial institution Cash received in respect of loan receivables Cash received as a result of government grant Interest and dividend income received on long term investments Financing Activities The activities which are undertaken by the entity to raise capital or long term funds for the business, and which results in change in the equity and borrowed funds of the entity are termed as financing activities.

The following are the examples of cash flows from investing activities: Proceeds received on issue of equity instruments such as ordinary shares Proceeds received on issue of loan notes, debentures or bonds Bank loan borrowed Repayments of loan notes, debentures, bonds or a bank loan Repayment of finance lease by lessee Dividend paid to the owners of finance Reporting Cash Flows from Operating Activities The entity will report cash flow from operating activities either using: Direct Method or Indirect Method Direct Method Under direct method, the entity will present the gross cash inflows and outflows related to the major classes, related to the operations which will be obtained from the accounts of the entity.

Indirect Method Under indirect method, the cash flow from operating activities are determined by adjusting the profit or loss before tax for the effect of non-cash items such as depreciation, amortization , impairment loss and provision and the items which are related to investing and financing activities However, this method supports the use of direct method, because under direct method users are able to evaluate the information about the cash inflows and outflows related to the major classes of the operations which is not available under indirect method.

Reporting Cash Flows from Operating Activities The entity will present cash inflows and outflows related to major classes of the investing and financing activities, under the respective functions as per the requirements of this standard. Cash Flows in Foreign Currency The entity is required to adjust the cash flows in foreign currency as follows: Cash flows which arise from a foreign currency transaction will be presented in the functional currency of the entity, using the exchange rate on the date of cash flow.

Cash flows related to the foreign subsidiary will be translated, using the exchange rate on the date of cash flow. The exchange gain and loss related to foreign currency transactions are unrealized, therefore are treated as non-cash items in the preparation of statement of cash flows.

Interest and Dividend The entity will account for the cash flows related to interest and dividend as follows: The interest and dividend income can either be presented under operating activities as these are used to determine the profits, or under investing activities as these are related investments. The interest expense can either be presented under operating activities as these are used to determine the profits, or under financing activities as these are related cost for the funds borrowed.

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Operating, Financing, and Investing Activities - Managerial Accounting (Ch. 12 V. 1)

Significant Noncash Investing and Financing Activity. Issuance of capital stock. Financing Activity. Amortization of intangible assets. What are Financing Activities? Obtaining cash from investors and creditors. Issuing stock, borrowing money, buying and selling treasury stock, and paying cash. Deduct gains and add losses that resulted from investing and financing activities. • Analyze changes to noncash current asset and current liability accounts.