A year ago, state officials were certain they had devised reforms to rescue Oregon's addiction treatment system from decades of neglect.
Gov. John Kitzhaber was among the optimists who believed health care reform would also transform the addiction system.
"We're going to see significant impact," the governor said last fall.
Instead, state officials are spending money and manpower to fix reforms that don't work. Oregonians suffering from substance abuse are still waiting for better care. And taxpayers still aren't seeing any relief from a public health crisis that costs them an estimated $6 billion a year.
The expansion of health coverage has led to a surge among people now insured for addiction treatment. But Pam Martin, director of the state Addiction and Mental Health Services Division, acknowledges some clinics have more people seeking service than they can treat.
"That's a clear gap," she said.
State officials acknowledge the state is behind on virtually every step of their vision to serve an estimated 303,000 untreated substance abusers in Oregon.
Nowhere is the state's failure more evident than the very cornerstone of the reform effort.
Nearly two years ago, the state decided a new 15-minute visit with a doctor was the cure for what ailed the addiction treatment system. State officials reasoned that a process used by other states would help Oregon identify substance abusers and route them to treatment.
But medical clinics have resisted using the sessions for two reasons. The state imposed a maddening billing system at the outset and doctors have little formal training in addiction medicine.
There is one more reason, Martin acknowledged.
"Physicians have told me they don't have time," Martin said.
Last spring, Martin and her executive team concluded the new doctor sessions weren't going well. They created a new job, hiring Michael Oyster in April at a $68,000 annual salary to fix the procedure. Six months later, officials reported, he is still analyzing the problem.
As Oyster tackles his task, other problems persist inside state government.
The Addictions and Mental Health Services Division can't demonstrate what's working in treatment and what's not. Agency officials are still unable to pull reliable information from a year-old data system.
They have watched as the share of Oregonians getting publicly supported care dropped from 4 percent five years ago to 2 percent last year.
And participation in treatment remained stubbornly level at 20,000 people a year – a fraction of those in need. New health care coverage appears to be accelerating that number finally, with the state reporting 22,500 people engaged in treatment this spring.
The state, meanwhile, has thrown more patients into a system that historically has produced widely uneven results.
Addicts aren't always getting into the programs best suited for their needs. Some treatment centers, for instance, focus on long-term heroin addicts while others were intended to serve paroling criminals. But treatment in Oregon is a mix-and-match proposition, with drug addicts sometimes finding themselves in programs meant for drunk drivers.
Treatment experts and law enforcement officials say that until this is fixed, substance abusers awaiting treatment or relapsing will continue their destructive lifestyles.
The result is new crimes, more kids shifted to foster care, a continued drain on state welfare services, drivers maiming and killing others, and more. There will be more lost work time and on-the-job injuries, and professionals mishandling their duties.
A rocky start to reform isn't surprising. Treatment clinics once viewed as a social service now orbit in the health care system. Reform put them in the same universe as hospitals, physicians, mental health clinics, dentists and more.
As state officials considered what to do about addiction treatment in the new system, they locked in on the 15-minute doctor visit, technically known as Screening, Brief Intervention, and Referral to Treatment.
In this annual screening, doctors question patients about alcohol and drug use, alert them to any concerns, and as needed refer patients to a specialist. The screening is intended to identify those "whose drinking or drug use may cause or complicate their ability to successfully handle health, work, or family issues," according to guidance issued last year by the state.
"Brief interventions can help clients reduce or stop misuse, acting as a first step in the treatment process to determine if clients can stop or reduce on their own," the Addictions and Mental Health Services Division said more recently.
Experts say that is an oversell.
"There's no silver bullet with how we're going to address the unmet addictions needs of individuals in Oregon," said Silas Halloran-Steiner, head of the Yamhill County Health and Human Services Department. "To think that the SBIRT is the sole way to do that would be an error."
Jim Winkle, an Oregon Health & Sciences University researcher who advised the state on the process, said the screen is effective and can reduce alcohol use by risky drinkers.
"There is no evidence that it is effective for drug abuse," Winkle said.
A recently concluded university study advised against "widespread implementation" of the screening for drug users because it did no good.
Despite shortcomings, the screening is the lone measure state officials watch to gauge how well health care reform is working in addiction treatment.
Bruce Goldberg, former director of the Oregon Health Authority, said in an interview last fall before he left the agency that it would be a "red flag" if the procedure wasn't widely used.
In June, only three of 17 health care organizations reported using the screening to the extent expected by state officials.
"It's a tremendous concern," said Martin, the addictions agency's director.
The screening was problematic from the start two years ago.
One care organization blamed the state for its limited use because "delayed and complex instructions" from the state "make this very challenging."
Health care executives say physicians have been slow to add the screening to their practices.
"Physicians cite barriers that include limited time during the patient visit, lack of knowledge and training, fearing negative patient reactions, and feeling uncomfortable discussing substance use," according to the state's screening training material.
Dr. Andy Antoniskis, medical director of Providence Portland Medical Center and expert in addiction care, said physicians get little schooling in addictions. He said they learn more at medical school about diseases they are likely never to encounter than they do about addictions. Asking them now to be the gatekeeper for an improved addiction system is a tall order.
"That's pretty intense for a primary care provider who doesn't even understand much about addictions," said Antoniskis.
Kitzhaber recognizes this problem in his plans for health care reform.
"We need to make sure that we're backing primary care providers with training and other kinds of assistance as they integrate addiction treatment into their every day practice," the governor said in a statement to The Oregonian.
Health Share of Oregon, a coordinated care organization, is confronting that need head on, said Dr. David Labby, chief medical officer.
"We are going to do a major educational effort for our providers around addictions," said Labby. It's going to be very basic – how to recognize substance abuse, what are the treatment modalities. We understand that there is a lack of knowledge on the provider side around substance abuse disorders."
Identifying substance abusers, though, does no good if they don't get proper treatment. Paul Bellatty is puzzling how to stop the waste of money on treatment that doesn't work.
Bellatty is a nerd's nerd. He has advanced degrees in quantitative genetics. He has worked for the U.S. Environmental Protection Agency as a biostatistician. He now is a researcher for the Oregon Department of Corrections on loan to the Oregon Youth Authority.
He recently turned his penchant for solving mysteries with math to addiction care, spring boarding off earlier studies of inmate care.
Bellatty posed key questions about care in Oregon:
What is the effectiveness of each treatment provider in Oregon?
Can we identify the best provider for each client?
Can we identify clients not well served with existing services?
In each instance, the answer for Bellatty is yes. More rigorous analysis should happen sooner so Oregon doesn't have to "tolerate years of service and a recidivism period before ineffective programs are improved or eliminated," he said in a recent paper.
Bellatty encouraged "service matching," linking substance abusers with programs best suited for their care. He uncovered starkly varying chances of success among the state's 10 largest providers. A particular client had an 85 percent chance of success in one program, but only 15 percent in another.
"Most administrators would enlarge the best programs and eliminate the least effective programs," Bellatty wrote.
Bellatty estimated a system could be up and useful within a year.
"It seems strange we haven't done this before," Bellatty said. "We should have developed these methodologies years ago.
Such reforms won't immediately cure underfunded treatment. Addiction clinics worry that health organizations now supervising patient care are under so much pressure to cut costs they will restrict spending on addiction care.
Hooked on Failure: The series
- A months-long investigation by The Oregonian discovered troubling failures in Oregon’s addiction treatment system. Substance abusers are paying the price – and so are Oregonians who continue to be their victims. The estimated annual cost to taxpayers: $6 billion.
Clinics point to the decision by care organizations to pay the same for addiction services paid in the past. That perpetuates service gaps.
This is especially pronounced in residential treatment, where substance abusers move into a clinic for days or weeks for intense care.
Clinics are paid an average of $152 a day per patient, but a recent state study concluded they ought to be paid $229 to cover their costs. An industry-sponsored consultant's report echoed that finding -- recommending $258 a day -- and further noted that counselors in Oregon clinics carry double the average national caseload. What's more, they are paid little more than fast-food workers at an average of $14.74 an hour.
Experts say there are similar disparities in outpatient care. The result, they say, is that poorly paid counselors are shouldering a huge portion of Oregon's expectation that treatment of addicts will dramatically improve.
They also are anticipating a surge of new clients now insured for addiction care.
"We have a significant concern about capacity in the system," said Dean Andretta of the Willamette Valley Community Health.
"Nobody could predict the impact of adding hundreds of thousands of people to the system," Martin said.
Kitzhaber said the transformation won't "happen overnight," but signs of success are popping up around the state.
Gov. John Kitzhaber
"We are seeing behavioral health care professionals being trained and placed in primary care offices, so when something comes up in the course of a regular doctor's visit, people get help right away," Kitzhaber said. "We are seeing health care navigators working with the highest need clients to ensure they are getting access to timely and effective care."
Those pockets of progress are coming independent of state government. Around Oregon, some clinics and local government agencies on their own have devised new ways to care for substance abusers. Their steps are being watched closely within the treatment profession – and by Martin and her team – as possible role models.
Yamhill County is the scene for such innovations.
To improve addiction care, Yamhill Community Care Organization of McMinnville is employing certified recovery mentors – counselors who are former addicts. The mentors help craft treatment plans and move patients back to the community. They also prowl the community, including drug-dealing locations, to approach potential patients on their turf and on their terms.
"We're paying them to engage folks and motivate them to enter services," said Halloran-Steiner, Yamhill County's agency head.
Recovery mentor William Harley, an ex-felon and former drug user, watches for recovering addicts who are struggling, stepping in to overcome problems. He plays mediator at medical clinics, state social service agencies and employment agencies, helping addicts who aren't always effective in making their needs known.
"Our job is to show them that it's not just a program that's going to help you. We'll work with them, support them," Harley said. "For me, it was the only thing that worked."
Yamhill also found resources to open homes that can be safe havens for families that need treatment and have kids who are risk of being removed. It now operates four homes serving 12 parents and 18 children.
"If they have stable housing, we can build a care plan without having a child lose a parent or going to foster care," said Halloran-Steiner. Yamhill plans soon to open two more family homes.
Yamhill also hired four behavior specialists to work in medical clinics. They're available to immediately provide a warm "hand off" when a doctor refers a patient to treatment.
In Southern Oregon, All Care Health Plan focused on one of the riskiest populations – pregnant women who are substance abusers. Every pregnant All Care patient is screened for substance use. The effort is producing healthier babies and better mothers.
Doctors, hospitals and treatment clinics earn more with better results.
"You're getting paid to produce outcomes, not just see people," Kitzhaber said.
Yet the state can't assess those outcomes because its data doesn't exist or is suspect.
For instance, the Addictions and Mental Health Services Division recently produced a report showing that the percentage of Oregonians being diagnosed with narcotic addictions was dropping. Questioned about the drop, agency officials said they couldn't explain because they didn't think that was really the situation.
Martin, the director in charge of the division, admitted frustration.
"We're doing the best we can," she said.
-- Les Zaitz