NIH Public Access

Challenges and Opportunities for Integrating Preventive

Substance-Use-Care Services in Primary Care through the

Affordable Care Act

Udi E. Ghitza, PhD and Betty Tai, PhD

Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of

Health, United States Department of Health and Human Services, Bethesda, MD, USA

Abstract

Undertreated or untreated substance use disorders (SUD) remain a pervasive, medically-harmful

public health problem in the United States, particularly in medically underserved and low-income

populations lacking access to appropriate treatment. The need for greater access to SUD treatment

was expressed as policy in the Final Rule on standards related to essential health benefits, required

to be covered through the 2010 Affordable Care Act (ACA) health insurance exchanges. SUD

treatment services have been included as an essential health benefit, in a manner that complies

with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. Consequently, with

the ACA, a vast expansion of SUD-care services in primary care is looming. This commentary

discusses challenges and opportunities under the ACA for equipping health care professionals

with appropriate workforce training, infrastructure, and resources to support and guide science-

based Screening, Brief Intervention, and Referral to Treatment (SBIRT) for SUD in primary care.

Keywords

Substance use disorders; Affordable Care Act; addiction treatment; drug abuse treatment; primary

care; medical settings; electronic health record; health information technology; prevention;

medical home; implementation science; health care reform; health services research; patient-

centered medical home; electronic medical record

Undertreated or untreated substance use disorders (SUD) remain a pervasive, medically-

harmful public health problem in the United States (U.S.), especially in medically

underserved and low-income populations lacking access to appropriate treatment. In 2012,

nearly 90% of the 23 million people aged 12 or older in the U.S. who needed treatment for

an illicit drug or alcohol use problem did not receive treatment at a specialty facility in the

past year.

Individuals with untreated SUD are at a significantly greater risk for health

problems from chronic co-occurring conditions such as type 2 diabetes mellitus, chronic

obstructive pulmonary disease, hypertension, depression, anxiety disorders, various cancers,

and major psychosis.

2,3

Health care professionals in primary care settings are in a unique

position to perform Screening, Brief Intervention, and Referral to Treatment (SBIRT) for

SUD to detect early and to prevent alcohol and other drug use problems and adverse medical

consequences of tobacco use, unhealthy alcohol use, and the nonmedical use of prescription

and illicit drugs. A science-based, preventive care approach, SBIRT is used to identify

people at high risk for unhealthy alcohol use, tobacco use, and nonmedical or illicit drug

Please address correspondence to: Udi E. Ghitza, PhD; Center for the Clinical Trials Network, National Institute on Drug Abuse,

National Institutes of Health, 6001 Executive Boulevard, Bethesda, MD 20892, USA; (301) 443–6697; [email protected].

NIH Public Access

Author Manuscript

J Health Care Poor Underserved. Author manuscript; available in PMC 2014 April 13.

Published in final edited form as:

J Health Care Poor Underserved. 2014 February ; 25(1 0): 36–45. doi:10.1353/hpu.2014.0067.

NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript

use; to offer them counseling as needed to address medically-harmful use; and to get them or

to link them—as appropriate—with the care they need for their alcohol or other drug use

problem. Integrating SBIRT with primary care in medical settings effectively reduces

tobacco and unhealthy alcohol use in adults 18 years or older, and data are accumulating for

its role in reducing drug abuse and improving overall health as well.

4,5

Integrating SBIRT

with primary care services in general medical settings aims to provide appropriate

preventive care to the many people in the U.S. at risk for SUD who do not receive the

treatment they need for their alcohol or other drug problems.

The 2010 Affordable Care Act (ACA) provides unprecedented opportunities for expanded

insurance coverage and increased funding for science-based SUD treatment services in

medical settings, such as SBIRT integrated within primary care.

The public health need for

greater access to SUD treatment in primary care was expressed as policy in the Final Rule

on standards related to essential health benefits (EHBs) required to be covered through the

ACA health insurance exchanges. Services for SUD have been included as an EHB, in a

manner that complies with the Mental Health Parity and Addiction Equity Act (MHPAEA)

of 2008.

That law applies to large group health plans and mandates insurance-plan

coverage for SUD treatment services to provide those benefits in no more a restrictive

manner than all other medical and surgical benefits covered by the plan.

The MHPAEA

applies to both inpatient and outpatient settings. In this manner, the ACA is designed to

greatly increase access to SUD treatment services for the approximately 21 million people in

the U.S. in need of care for an alcohol or other drug use problem who do not receive

appropriate treatment.

1,7

In the context of health care reform through the ACA, this

commentary reviews challenges and opportunities for providing health care professionals in

primary care suitable workforce training, infrastructure, and resources to support and guide

SBIRT for SUD.

Workforce Training Needs for Integrating SBIRT in Primary Care under the

ACA

Under the ACA, both Medicaid and private insurance coverage is likely to increase for

medically underserved and low-income populations with multiple chronic co-occurring

behavioral health disorders like SUD.

6,7

This presents important opportunities for state

Medicaid agencies to coordinate services with SUD treatment agencies to more closely

integrate continuity of care and funding streams for treating low-income and medically

underserved individuals with SUD and other chronic co-morbid conditions.

However,

recent data suggest many SUD treatment agencies are poorly prepared to do so.

Additionally, many are not well prepared for the impending ACA provisions related to

workforce training.

This training is needed to leverage meaningful use of health

information technology systems to deliver and monitor evidence-based treatments in a

patient-centered medical home manner, in support of a continuum of integrated SUD and

primary care services.

There are also vast shortages of health care professionals trained in

addiction medicine.

Several ACA workforce provisions are designed to identify and

address barriers to and shortages in workforce training in behavioral health medicine and

broader health care services in medical settings. For example, the ACA establishes a

National Health Care Work Force Commission. This Commission is an advisory panel

composed of expert leaders in the health care labor force field whose duties are to serve as a

resource for the U.S. Congress, the President, and state and local governments to assess

whether workforce education and training capacity is being met for effectively

implementing the ACA, and how to address identified barriers. This Commission’s

responsibilities include evaluating whether education and training capacity exists for

integrating mainstream health care delivery systems with the behavioral health care

workforce needed to offer behavioral health care services under the ACA.

The ACA

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charges the National Center for Health Care Workforce Analysis to work in cooperation

with this Commission to develop performance measures for analyzing the health care

workforce and performance of workforce training programs under the ACA.

In addition,

the National Health Care Work Force Commission is charged with collaborating with the

U.S. Department of Health and Human Services (DHHS) to help the federal government

plan, solicit, review, and monitor the progress of State Health Care Workforce Development

Grants.

The purpose of these grants is to provide funding to states to develop

comprehensive workforce expansion education, planning, and implementation strategies to

execute those plans effectively in support of state and local level workforce development

under the ACA.

Therefore, this Commission is critical to helping the U.S. federal

government oversee health care workforce training. This oversight is informed by expert

understanding of current needs to meet the demand for having the necessary workforce

capacity to cover behavioral health care and broader medical services effectively under the

ACA health insurance exchanges.

However, it remains to be determined whether the U.S.

Congress will appropriate the necessary funding to allow this Commission to carry out these

responsibilities, and whether it will continue funding for State Health Care Workforce

Development Grants to support the ACA implementation.

Scarcity of health care professional education and training in SBIRT is another substantial

barrier to expanding the necessary medical capacity under the ACA to increase access to

evidence-based treatment for SUD in low-income and medically under-served populations.

Nationwide efforts are needed to enhance health care professionals’ skills and training in

science-based SUD screening and brief intervention.

12,13

Establishing a strong foundation of

well-trained health care professionals in addiction medicine requires that organizations

setting health care curriculum and medical school accreditation standards work together with

state authorities who receive State Health Care Workforce Development Grants, members of

the National Health Care Work Force Commission, professional societies/associations,

educational institutions, and/or federal and state government policymakers to institute policy

changes ensuring that standardized evidence-based SBIRT curricula and training are

delivered to students in health care profession disciplines pertinent to SUD care in medical

settings.

Several provisions in Title V of the ACA boost financial resources for training an expanded

health care workforce on treating SUD and other behavioral health conditions in general

medical settings.

For example, these provisions award grants from the U.S. federal

government to eligible graduate psychology and social work schools and programs to recruit

students and provide clinical training in treating mental health conditions, including SUD, in

medical settings. These programs address a need for federal-government financial support to

train non-physician clinicians such as social workers, psychologists, and child and

adolescent mental health care providers to deliver science-based SUD and mental health

preventive care in primary care settings. However, more nationwide resources are needed to

support SUD-treatment workforce training in medical settings, and to provide strong

technical assistance to integrate this behavioral-health care workforce with primary-care

services, in order to expand the capacity for implementing effective SUD preventive-care

and treatment services under the ACA within a chronic care model of disease

management.

Electronic Health Record-based Needs for Integrating SBIRT in Primary

Care under the ACA

Another key step toward better integration of SBIRT with other health care system services

in U.S. medical settings is to promote the adoption and meaningful use of brief and validated

screening and brief assessment tools for SUD in interoperable electronic health record

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systems (EHRs).

Toward this end in the context of the ACA and MHPAEA pay-for-

performance incentive policies, it is also essential to develop EHRs-based validated clinical

quality measures/performance measures to evaluate performance of SBIRT’s

implementation to improve clinical practice and quality of care. In primary care

settings,

14–18

this can be supported through development and implementation of a science-

based clinical quality measure (CQM)/performance measure reporting on the utilization of

systematic SUD screening, intervention/brief counseling procedures and delivery of

appropriate follow up, as needed.

Standardization of this performance measure for its wide

adoption and meaningful use in EHRs using Common Data Elements (CDEs) and common

data standards would provide a standardized terminology for the uniform collection and

exchange of health information across multiple EHRs platforms. These CDEs are data

elements that have been identified and defined for common use across different EHRs and

other data sources. Performance-measure standardization using CDEs is an important means

to enable data integration from multiple EHRs, which would allow for broader and more

effective coordinated care management of SUD as a chronic disease under the ACA. Indeed,

SUD is a chronic relapsing brain disease which must be managed in a patient-centered

manner with other co-occurring diseases. Integration of evidence-based SBIRT in primary

care is critical for implementing SUD services in patient-centered medical homes and other

medical settings under the ACA. Integration of SBIRT with primary care can be facilitated

through the meaningful utilization of such EHR-based CDEs and performance measures

together with pragmatic point-of-care decision support tools which could easily be

incorporated in busy medical-setting workflows.

14–18

Meaningful use of EHRs-based tools

also helps health care professionals in developing appropriate holistic treatment plans based

upon the patients’ complete medical histories taking into account medications and other

treatments furnished by other providers.

To promote safe and effective patient care for SUD within medical settings in this manner,

the National Institute on Drug Abuse Center for the Clinical Trials Network (NIDA CCTN)

and National Cancer Institute (NCI), in collaboration with the Substance Abuse and Mental

Health Services Administration (SAMHSA), is supporting the development, validity and

reliability testing, and electronic specification of a standardized and science-based

composite CQM/performance measure. This CQM would be for combined screening and

intervention for substance use (including tobacco use, unhealthy alcohol use, illicit drug use,

and nonmedical prescription drug use) to support validated and standardized substance use

screening, assessment of level of risk for SUD, and intervention/brief counseling or referral

to specialty care (as needed) by primary care providers.

This performance measure,

designed for primary care settings, reports on the percentage of patients aged 18 years and

older who were screened at least once within the last 24 months for tobacco use, unhealthy

alcohol use, nonmedical prescription drug use, and illicit drug use using a systematic

screening method and who received an intervention (e.g., brief counseling) for all positive

screening results. The NIDA CCTN has submitted to the U.S. Centers for Medicare and

Medicaid Services (CMS) a description and draft of this measure for inclusion in CMS’s list

of candidate performance measures under consideration. The NIDA CCTN is supporting

ongoing development as well as feasibility, validity, and reliability testing of this composite

performance measure for final submission to CMS for consideration and possible inclusion

in its performance-measure reporting programs, including in the core set of clinical quality

measures on which eligible professionals are required to report performance in order to

receive reimbursement incentives under the CMS Incentive Program for the Meaningful Use

of EHRs. This measure is also currently being considered for inclusion among the CMS

Physician Quality Reporting System (PQRS) performance measures and among the

Medicare Shared Savings Program quality measures. Development and broad use of such a

substance use screening and intervention performance measure in integrated health care-

system EHRs also would be an important means by which NIDA CCTN and other federal

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and community stakeholders would promote in the context of the ACA the broad and

systematic collection of standardized data on substance use screening, intervention and

follow up in EHRs of primary care settings. This in turn would be an important means by

which to accelerate translational implementation science research on how to most effectively

improve integration of SUD preventive services within primary care. This translational

research will also likely facilitate the creation of big data sets to inform the advancement of

a science-based “learning health care system,” as recently advocated by the U.S. Institute of

Medicine (IOM).

Recommendations for Future Translational Research to Advance Science-

based Implementation of SUD Treatment under the ACA

Implementation-science research is needed to identify and develop valid and reliable EHRs-

based performance standards/metrics of effective coordinated or integrated chronic patient

management (including SBIRT) and self-management of SUD with other co-occurring

chronic diseases. Meaningful use of these performance metrics together with pragmatic

point-of-care decision support tools relevant to SUD preventive care would help standardize

the delivery of actionable goal-driven treatment plans in the ACA health care systems, such

as patient-centered medical homes (PCMHs). It would be useful for these performance

standards/ metrics to be compatible with the U.S. Department of Health and Human Services

strategic plan on treatment of Multiple Chronic Conditions.

In addition, in order to

strengthen the links between behavioral medicine (for example, mental health and SUD

treatment) and primary care in the context of the ACA, there is a need to further develop

common data standards and Common Data Elements to facilitate the uniform systematic

data collection and outcome and performance reporting in these integrated health care

systems.

Importantly, embedded in these integrated health care systems, there is a need to create

disorder/disease-specific patient registries. These patient registries are critical to better

understand how patients with SUD and other chronic co-occurring conditions receive the

care they need under the ACA. Patient registries are also needed to understand how patients

best utilize treatment and self-management resources, most effectively respond to preventive

care such as SBIRT, and how their co-occurring health problems are managed most

effectively in medical settings. They are also needed to more fully characterize co-

morbidities with SUD and responses to treatment regimens in different patient

subpopulations. Patient registries are also an important means to evaluate dose/response

relationships of treatment implementation, as well as associations of treatment

implementation with drug use outcomes and long-term morbidity and mortality outcomes.

Furthermore, well-designed patient registries could facilitate identification of effective

behavioral and pharmacological treatments in patient subgroups to steer the SUD treatment

field toward practice-informed adaptive-research designs to advance chronic care

management (CCM) in a “learning health care system.”

In addition, expansion of

behavioral health care under the ACA offer unprecedented opportunities to establish high-

quality patient registries which may be leveraged as a platform on which EHRs may be used

for facilitating conduct of low-cost point-of-care randomized controlled trials (RCTs).

Point-of-care RCTs using registry EHRs that seek to translate evidence-based practices into

routine clinical care could also capitalize on development of inexpensive mobile-

technologies to speed up patient recruitment, enrollment and collection of data from real-

world settings remotely at a low cost.

Patient registries could also be leveraged for data-

mining and other big data analytical purposes to assist in developing evidence-based clinical

decision support tools and clinical practice guidelines to implement practical science-based

treatment plans within the context of the ACA health care systems.

Safeguards needed to

ensure privacy and confidentiality protection for patients with substance use problems,

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which need to be implemented in patient registries, have been discussed elsewhere.

Other

implementation science research is needed on how to design practical, actionable brief

interventions tailored to best match risk categories produced by SUD screening and brief

assessment. This health services research also needs to determine how such interventions

can most easily be routinely delivered by trained health care professionals at medical

settings in a brief/user-friendly manner by simplifying interventions to address busy

workflow issues and the training needs of staff at these settings.

Furthermore, implementation science research is needed on how most effectively to leverage

meaningful use of health information technology innovations, such as e-health, mobile-

health, and telemedicine technologies, not only to measure, monitor, and evaluate

performance standards for quality improvement in clinical practice but also to enhance

access and extend treatment resources to low-income and medically underserved

populations. This is particularly important for low-income and medically underserved

communities suffering disproportionately from ill health in which lack of access to properly

trained SUD-treatment health professionals remains a major obstacle to receiving timely and

effective SUD treatment.

E-health, mobile-health, and telemedicine technologies are a

means to extend the reach of properly trained health professionals knowledgeable in

science-based SUD treatment by promoting communication independent of distance.

They

also enable continuous monitoring and science-based intervention tools to be applied in a

team-based, proactive approach to integrate preventive SUD care and CCM into primary

care for patients with SUD and other chronic co-morbid diseases.

Thus, leveraging and

meaningfully using mobile-health and telemedicine technologies as physician extenders

offer opportunities for enhancing care efficiency in PCMHs and other primary care settings

supported through the ACA.

An important impediment to providing effective SBIRT in primary care settings under the

ACA is ensuring that temporary behavioral change motivated by primary-care brief

interventions (BI) remains consistent over time. Methods delivered by mobile-health

technologies to help sustain behavioral change would be very useful. Effective techniques

for sustaining behavioral change over time are likely to share characteristics such as the

ability of feedback delivered to be individualized as conditions change. In the ACA primary

care settings, rigorous systematic research is needed to evaluate effectiveness of leveraging

mobile-health technologies which function as physician aids and offer prompt individualized

feedback to patients to help sustain health-promotion behavioral changes motivated by

primary-care BIs. Mobile-health applications are needed which could be programmed by

providers to ensure that patients follow through with their treatment plans, such as

adherence to action plans agreed upon during primary-care brief interventions. The patients’

answers should inform delivery of individualized feedback supporting self-management

skills. The mobile-health applications would in this manner help patients comply with

SBIRT brief intervention principles and track health care actions which have been

completed, such as linkage to indicated follow-up treatment.

In summary, the ACA promotes SUD preventive care and CCM in the context of PCMHs

and other primary care settings. The ACA’s provisions support whole-person wellness by

(1) embracing and funding eligible providers to adopt and implement coordinated chronic

care models in the context of PCMHs; (2) training of a multidisciplinary PCMH workforce

to implement such care; (3) the adoption and meaningful use of EHRs; and (4) leveraging

telemedicine, mobile-health technologies, and patient registry infrastructures to increase

treatment access, capacity, and reach in low-income and medically underserved populations.

The ACA also eliminates the lifetime caps and restricts the annual caps on services/benefits

instituted by many insurance plans.

Further discussion has been presented elsewhere in

recently published papers on barriers and opportunities for leveraging meaningful use of

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EHRs in coordinating patient-centered care, and integrating SUD preventive care and

chronic care management in PCMHs and community health centers.

3,13,14,16,23–25

Advancing the important implementation-science research discussed above and effectively

disseminating promising findings from them to policymakers and other key stakeholders in

charge of implementing the ACA would be powerful drivers to increase the delivery of

evidence-based SUD services such as SBIRT and CCM in tandem with broader health care

services in primary care settings and patient-centered medical homes. Such health-services

research would also promote a high-quality, integrated approach to behavioral health and

whole-person wellness, according to a “learning health care system.” Indeed, the U.S.

Institute of Medicine (IOM) concluded that key “learning health system features are likely to

include use of electronic health records (EHRs) to accumulate data about the results of

specific treatments across different types of patients. Well-built electronic health records

would enable health professionals to enter data about treatments into the patient record

routinely. Systems technologists could then assemble treatment-specific files across all

patients while purging the files of patient identifiers, and researchers could in turn mine

these files to determine which treatments have worked.”

The vision and trend of

transporting clinical research to health care-system (HCS) settings, and leveraging of HCS-

based EHRs to advance big-data implementation science, could play a key role in closing

the current gap between SUD clinical research and practice within the context of the ACA.

Furthermore, adoption and meaningful use in HCS EHRs of a science-based, standardized

performance measure for combined screening and intervention for tobacco use, unhealthy

alcohol use, illicit drug use, and nonmedical prescription drug misuse would provide an

important means by which to facilitate systematic collection and integration of big data sets

to bridge the knowledge divide between SUD-preventive-care (including SBIRT) research

and clinical practice, thereby promoting quality improvement of patient-centered care.

Advancing these critical implementation-science research directions and performance

measures/metrics is likely to play a key role in promoting science-based integration of

preventive care such as SBIRT for substance use disorders within general medical settings in

the context of the ACA’s health care reform.

Acknowledgments

Udi E. Ghitza and Betty Tai are employees of the Center for the Clinical Trials Network of the National Institute on

Drug Abuse, National Institutes of Health, the funding agency for the National Drug Abuse Treatment Clinical

Trials Network. The opinions in this manuscript are those of the authors and do not represent the official position of

the U.S. government.

Notes

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