Addiction is on the rise, but physicians can help. I wrote this story to help a small Medicaid HMO talk about how their innovative community reinvestment program gives pioneering clinicians the support they need to invent new treatments for addiction.
Hennepin Health: The Courage to Innovate
An epidemic of poisoning
In 2016, opioids killed 153 people in Hennepin County, Minnesota. That year deaths from cocaine and amphetamines rose dramatically too, and 84 county residents died after what the sheriff calls “acute alcohol intoxication.” Those startling figures don’t even account for the many, many more Hennepin County residents killed by addiction in subtler ways: by drug-related violence, in accidents caused by people too impaired to walk or drive, by cirrhosis or hepatitis C, by despair and suicide. Even Minnesota, nationally renowned for treatment centers and a thriving culture of recovery, addiction is killing more and more of us all the time.
Many people see the epidemic of substance addiction as a moral and social crisis. But addiction might also be something much simpler — and maybe much easier to remedy.
JoAn Laes, M.D., is an addiction medicine specialist, and she was frustrated. At Hennepin County Medical Center (HCMC), where she works in the addiction medicine department, she’d see patients come into the hospital after an overdose of alcohol, opiates or some other mood-altering substance. She and her colleagues would treat the acute poisoning, then the patient would leave — usually without getting any help for the underlying addiction.
“People would show up with a drug overdose,” Dr. Laes recalls, “and there wasn’t much we could do. Maybe there was a drug and alcohol counselor available to talk to them, but probably not — there were only two counselors for our 500-bed hospital. So we basically had to give these patients lists of phone numbers for treatment options and tell them, ‘Follow up on your own.’”
Needless to say, that approach didn’t work very well. “We’d see many of these patients multiple times, after multiple overdoses,” Dr. Laes says.
For an addictionologist, little could be more distressing than to watch people get poisoned, again and again, by the same deadly chemicals. Worse yet, Dr. Laes knew she could change the course of many patients’ addiction, simply by writing a prescription for drugs like naltrexone or acamprosate that work by diminishing the power of addictive craving in the brain. “These medications aren’t new, but our health system doesn’t yet use them very widely,” Dr. Laes explains. “Our counselors, who knew a lot about behavioral addiction treatment, weren’t trained to talk to patients about these other therapies. Most patients didn’t even know they had medical options.” And so the epidemic of poisoning continued.
In frustration, Dr. Laes came up with an idea: What if she and her colleagues could not only treat patients for overdoses, but also for the underlying chemical dependency? To make that more aggressive outreach work, she thought, HCMC would need more help — maybe another Licensed Drug and Alcohol Counselor (LADC), a physician assistant or nurse practitioner, maybe time to consult with other physicians. They’d definitely need to bring the LADCs they had under the umbrella of addiction medicine, so they could coordinate their work with the addiction medicine specialists and other clinical staff. “I just want to do inpatient consultations with patients who have addictions,” she told an HCMC colleague one day. “How can I get this started?”
Well, her colleague told her, there was actually a program especially designed to get just such ideas off the ground — grants to support experiments aimed at improving the health of people in Hennepin County. Dr. Laes applied for a grant for her idea, and she got it. The work began in October 2015. Two years later, HCMC hasn’t treated addiction the same way since.
The courage to innovate
The money to fund Dr. Laes’s idea came from Hennepin Health, the county-owned health insurer that serves people on Medical Assistance. Ross Owen, health strategy director for Hennepin County, smiles when he remembers Dr. Laes’s application for funding. “She’s a doctor who realized that people admitted to HCMC weren’t being treated for addiction,” he says. That’s a little crazy, he adds, “since the people we care for are deeply affected by addiction.” When her proposal came in, it sounded like exactly the kind of experiment Hennepin Health wanted to encourage.
Where does this money come from? “After we’ve paid for our members’ medical bills and operated our health plan, we take resources that are left over and share them with our partner organizations that work with us to care for county residents — HCMC, NorthPoint Health Center, Hennepin County,” Ross explains. “And some of that money funds what we call reinvestment initiatives. We solicit proposals for improving how we care for people. Every year, we fund a few projects, from six to ten or so. We measure the impact of those projects and bring that information back into the work we do. It’s a way for us to try new ideas, to take risks, to see what new practices might work — and to shore up infrastructure and plan for the long term to create better health for people in Hennepin County.”
“It’s intentional,” says Amy Harris-Overby, director of HCMC’s population health program. “With these grants, Hennepin Health is intentionally taking the value that’s been created in the health plan and creating public benefit by testing new ideas.” The best thing about the reinvestment grants, she says, is simple: “They give us the courage to innovate. Every project we approve has merit, and we give it a chance. Sometimes they work beautifully; other times, we have to admit they don’t, and learn from the failure.”
What does failure look like? Amy and Ross chuckle as they reel off a list of promising reinvestment projects that just didn’t turn out to work. Their favorite example was the time when Hennepin Health got into the business of renting apartments. “Up to half of our members don’t have housing they can count on,” Ross says, “and our teams of social workers hustle all day to help people who are sick find a safe place to stay. The idea was, why not just rent a block of apartments ourselves, so we wouldn’t have to deal with landlords?” It was a radical and brilliant idea — and testing it out showed conclusively that it didn’t work. “Instructive failure,” as Amy calls it, is actually success. By funding small, promising projects, measuring them and learning from them, Hennepin Health behaves more like a startup than like an old-fashioned HMO. They move fast, they learn each experiment, they jettison what fails and double down on demonstrated success.
“We already pay”
For a county-operated insurer like Hennepin Health, success means a measurably better life for county residents — less expensive health care, better experiences for patients, more effective medical care and prevention. But beyond the usual horizon of health care, Hennepin Health and its partners think of their work in the broadest possible terms. “As a part of Hennepin County,” Ross says, “we are the people who bear the cost of inequities and poor health, outside our role as a health plan.”
The connections between medical care and overall community health are sometimes hard to understand, and Ross and Amy take every opportunity to explain them. People in Hennepin County who get health insurance through the recent expansion of Medicaid — many whom are Hennepin Health members — account for more than half of the county’s corrections budget, Ross explains, and more than half of visits to emergency shelters. “If we can’t keep our people well,” he adds, “everyone in Hennepin County is going to pay for the care they need, in one way or another. We already pay — in the criminal-justice system, in public safety, in the foster-care system.”
The only question is whether public resources would be better spent getting people well than in locking them up, policing them or taking away their children. That’s what reinvestment grants are designed to find out.
An antidote for hopelessness
Today, Dr. Laes has the resources she needs to change the way HCMC helps people suffering from the agony of chemical addiction. “What that physician did with addiction medicine has been one of our most exciting projects,” says Ross, with evident delight. “It was a small investment that’s gone a really long way in how we take care of people.” The grant process let Hennepin Health leaders hear a novel idea from a physician they might never have met otherwise. They closely observed the results of her pilot project, and then they rapidly shared, expanded, beefed up … what worked. “Dr. Laes has seen her innovative idea change standard practice at HCMC.”
With their grant funding, Dr. Laes and her colleagues hired a new LADC to counsel people who come to HCMC with substance problems. They hired a new advanced practice provider to talk to people while they are in a hospital bed recovering. Even more importantly, she says, “the Hennepin Health grant allowed us to take a team approach. The counselors have better connections to me and my colleagues, and we work together to make sure that each patient has the best long-term care plan possible. We meet all the time, we talk about our patients, and we coordinate between what happens in the hospital and where they go next.”
The long-term care is just as important as the inpatient consultation. “The LADCs are integral to the work we do,” says Dr. Laes. “They know the entire community network of treatment options, help make appointments for patients and help them access funding for treatment. Physicians and physician assistants like me get people with opiate use disorder hooked up with our addiction medicine program, which uses medication-assisted treatments like methadone or buprenorphine. We have an outpatient clinic, where we follow up with people to continue any medications we start in the hospital.”
The evidence Dr. Laes amassed during the grant period made a compelling case for the work they were doing. In a three-month period, the LADC worked with 333 HCMC patients, and the physician and advanced practice provider consulted with 72. The need for their help was clear: tree out of four of those patients said they were currently using alcohol, 28 percent said they were using stimulants, 22 percent reported using opioids. But the big news, for Dr. Laes and Hennepin Health, was what those consultations accomplished. “We found a 4.4% decrease in 90-day readmissions for patients with substance use diagnoses,” Dr. Laes reports, “and a 2.5% decrease for patients with alcohol.”
Beyond readmission metrics, the payoff of Dr. Laes’s work happens right there at the bedside of a patient who’s suffering. “Most of the time, my patients haven’t heard of the medications we can offer them to treat their addiction,” she says. “They tell me, ‘I’ve been through 28-day treatment twenty times, and then I fall back into my old habits. I’ve learned what treatment programs have to teach me. I just can’t change.’” To people who’ve felt it, that hopelessness is the most toxic poison of all.
“Then I tell them about naltrexone or acamprosate, and we get it started right there while they’re still in the hospital.” She pauses for a second, then smiles: “It’s generally a pretty good visit.”