The Perceived Impact of 42 CFR Part 2 on Coordination and Integration of Care: A Qualitative Analysis.

OBJECTIVE: Title 42 of the Code of Federal Regulations Part 2 (42 CFR Part 2) controls the release of patient information about treatment for substance use disorders. In 2016, the Substance Abuse and Mental Health Services Administration (SAMHSA) released a proposed rule to update the regulations, reduce provider burdens, and facilitate information exchange. Oregon's Medicaid program (Oregon Health Plan) altered the financing and structure of medical, dental, and behavioral care to promote greater integration and coordination. A qualitative analysis examined the perceived impact of 42 CFR Part 2 on care coordination and integration. METHODS: Interviews with 76 stakeholders (114 interviews) conducted in 2012-2015 probed the processes of integrating behavioral health into primary care settings in Oregon and assessed issues associated with adherence to 42 CFR Part 2. RESULTS: Respondents expressed concerns that the regulations caused legal confusion, inhibited communication and information sharing, and required updating. Addiction treatment directors noted the challenges of obtaining patient consent to share information with primary care providers. CONCLUSIONS: The confidentiality regulations were perceived as a barrier to care coordination and integration. The Oregon Health Authority, therefore, requested regulatory changes. SAMHSA's proposed revisions permit a general consent to an entire health care team and allow inclusion of substance use disorder information within health information exchanges, but they mandate data segmentation of diagnostic and procedure codes related to substance use disorders and restrict access only to parties with authorized consent, possibly adding barriers to the coordination and integration of addiction treatment with primary care.

State parity laws and access to treatment for substance use disorder in the United States: implications for federal parity legislation.

IMPORTANCE: The passage of the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Affordable Care Act incorporated parity for substance use disorder (SUD) treatment into federal legislation. However, prior research provides us with scant evidence as to whether federal parity legislation will hold the potential for improving access to SUD treatment. OBJECTIVE: To examine the effect of state-level SUD parity laws on state-aggregate SUD treatment rates and to shed light on the impact of the recent federal SUD parity legislation. DESIGN, SETTING, AND PARTICIPANTS: We conducted a quasi-experimental study using a 2-way (state and year) fixed-effect method. We included all known specialty SUD treatment facilities in the United States and examined treatment rates from October 1, 2000, through March 31, 2008. Our main source of data was the National Survey of Substance Abuse Treatment Services, which provides facility-level information on specialty SUD treatment. INTERVENTIONS: State-level SUD parity laws during the study period. MAIN OUTCOMES AND MEASURES: State-aggregate SUD treatment rates in (1) all specialty SUD treatment facilities and (2) specialty SUD treatment facilities accepting private insurance. RESULTS: The implementation of any SUD parity law increased the treatment rate by 9% (P < .001) in all specialty SUD treatment facilities and by 15% (P = .02) in facilities accepting private insurance. Full parity and parity only if SUD coverage is offered increased the SUD treatment rate by 13% (P = .02) and 8% (P = .04), respectively, in all facilities and by 21% (P = .03) and 10% (P = .04), respectively, in facilities accepting private insurance. CONCLUSIONS AND RELEVANCE: We found a positive effect of the implementation of state SUD parity legislation on access to specialty SUD treatment. Furthermore, the positive association is more pronounced in states with more comprehensive parity laws. Our findings suggest that federal parity legislation holds the potential to improve access to SUD treatment.

Reflections on working for Senator Edward Kennedy, a vital ally in the effort to improve mental health access and care.

The author worked as a health policy fellow in the office of Senator Edward M. Kennedy in 1999. These reflections on that experience provide a description of the ambience of working on health policy issues in the US Congress, how the author utilized his community psychiatric knowledge and skills to assist in the process of developing and promoting various health and mental health related issues, and what it was like working in the Kennedy office. In the wake of his death, the Senator's long and influential career and especially his role in advancing health and mental health access and care improvement cannot be overstated.

Biomedicalization and alcohol studies: implications for policy.

The reduction of alcohol problems to genetic and biological processes is not new; however, biomedicalization is progressively dominating how alcohol issues are viewed in the U.S. This paper illustrates the process of biomedicalization in the alcohol field by examining: 1) the organizational move of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to the National Institutes of Health in 1992; 2) the emphasis on biomedical goals in NIAAA's five-year Strategic Plan; 3) increased NIAAA funding of biomedical research from 1990-2002; and, 4) trends in the growing proportion of biomedical information provided in NIAAA's Reports to Congress. The implications of this dominance of the biomedical approach on policy are profound. As biomedicalization prevails as a dominant lens by which alcohol problems are framed, policymakers will tend to move towards individualistic solutions to social problems. Broader community and societal based efforts to understand and control alcohol problems may be increasingly replaced by a focus on individuals thereby omitting important environmental factors.

Addressing lesbian, gay, bisexual, and transgender issues from the inside: one federal agency's approach.

The mission of the Substance Abuse and Mental Health Services Administration (SAMHSA) is to protect and serve underserved and vulnerable populations. Congress established SAMHSA under Public Law 102-321 on October 1, 1992, to strengthen the nation's health care capacity to provide prevention, diagnosis, and treatment services for substance abuse and mental illnesses. SAMHSA works in partnership with states, communities, and private organizations to address the needs of people with substance abuse and mental illnesses as well as the community risk factors that contribute to these illnesses. As part of its efforts to address the unique needs of special populations, SAMHSA has reached out to the lesbian, gay, bisexual, and transgender (LGBT) community. SAMHSA and its centers (Center for Substance Abuse Treatment, Center for Substance Abuse Prevention, and Center for Mental Health Services) have made a concerted effort, through both policy and programs, to develop services responsive to this community.

A multisite study of the effectiveness of methamphetamine treatment: an initiative of the Center for Substance Abuse Treatment.

In 1998, responding to national and regional epidemiological data indicating that methamphetamine (MA) abuse was a growing problem in the United States, the Center for Substance Abuse Treatment (CSAT) initiated a multisite MA treatment study. Through a collaborative approach among CSAT, seven treatment sites, and a coordinating center, the study compares the clinical and cost effectiveness of a manualized, cognitive-behavioral outpatient treatment developed by the Matrix Center in Los Angeles to the treatment approaches currently employed by the treatment sites. The study also explores technology transfer issues associated with integrating the Matrix approach within existing treatment settings. CSAT's approach to the initiation and management of this type of study is discussed.