If the results from a Blue Cross Blue Shield of Michigan pilot program hold up, Dr. William Beecroft hopes to create a new model for health insurers to cover treatment for substance use disorder.
For more than a year, Beecroft has run a medically assisted treatment pilot program with Pine Rest Christian Mental Health Services and Henry Ford Health System’s Maplegrove Center in West Bloomfield. The CLIMB project, short for Community-based Life-changing Individualized Medically-assisted evidence-Based treatment, has generated lower relapse rates among people treated for opioid addiction.
The key: Rather than treat addiction as an acute-care episode, the program approaches substance use disorder like a chronic illness such as diabetes or heart disease that requires a much more coordinated approach and long-term continuous treatment.
“For years and years, physicians and trainees have learned to take care of substance use disorders in general, and opioid use disorder specifically, as an acute-care illness, kind of like a broken bone or pneumonia or something. They’re treated to get better and it’s a very short-term fix,” said Beecroft, medical director for behavioral health at Blue Cross Blue Shield of Michigan.
“That doesn’t work. These are chronic illnesses,” he said.
CLIMB’s roots go back to 2000 and a pivotal article in the Journal of the American Medical Association (JAMA) that offered evidence that drug dependency was a chronic medical illness, Beecroft said. That’s a contrast to the “generally held view that drug dependence is primarily a social problem, not a health problem,” according to an abstract on the JAMA article.
Beecroft is now working to validate that view through the CLIMB pilot program, which was crafted in response to the opioid crisis in Michigan and across the U.S.
“Once you are an opioid user, your brain is always hardwired to be an opioid user. Even though you can be in remission the rest of your life, also known as recovery, you still have the same problem that is caused by exposure to the opioid,” Beecroft said. “You always have the propensity to go right back down that path unless you stay vigilant and continue in treatment on a long-term basis.”
CLIMB seeks to achieve that by changing the standard of care for substance use disorder. Through the pilot, Blue Cross Blue Shield pays for eligible members who are addicted to opioids to receive initial inpatient treatment and detox, followed by medically-assisted outpatient treatment and other support for at least two years.
Launched in 2018 with Blue Care Network and later extended to Blue Cross Blue Shield’s PPO coverage, the CLIMB program uses recovery coaches and care managers, and focuses on education in areas such as nutrition, exercise, relaxation and stress management so people dealing with substance use disorder can learn to better care for themselves. The pilot’s support services are designed to help a recovering addict “cope with your life in the real world” and “then help you deal with all of those stresses that will pull you back into a use pattern again,” Beecroft said.
He likens the approach to teaching diagnosed diabetics how to give themselves an injection of insulin, as well as offering instruction on how to improve their diet and lifestyle to manage their disease.
When Blue Shield Blue Shield pitched the CLIMB pilot program, Pine Rest was quick to sign on, said Mariah DeYoung, substance abuse director for the professional practice group and manager of sub-acute detox and residential programs at Pine Rest.
The decision to participate in CLIMB was “pretty much a one-lunch meeting where a few of us sat down and said, ‘Yes, this makes sense. This is what we would do if we didn’t have the insurance restrictions, so we’re in,’” DeYoung said. Blue Cross Blue Shield promised easier and longer coverage authorizations for people who met the criteria and had an opiate diagnosis.
Pine Rest fully supports the approach, she said.
“It is a chronic, ongoing life change that people deal with on a daily basis. It’s not unlike diabetes or high cholesterol. While a patient might get their illness under control or manageable, it is something that they focus on and live with every day for the rest of their life,” she said. “Any time we can get better care (and) more approval from the insurance companies to keep people in treatment longer, that’s always a good thing.”
Blue Cross Blue Shield launched CLIMB amid a process “of really relooking at the behavioral health system from soup to nuts, from the bottom to the top, and this is on the agenda,” Beecroft said. He hopes the state’s largest health insurer ultimately makes CLIMB a regular program.
“The ultimate benefit would be to make this the new specification for care,” he said. “It’s a core program that really changes a standard of care. Even though it’s been around for the last 20 years in the literature and there are places that are doing this, it’s not been the standard of care that everybody does.”
Blue Cross Blue Shield presently contracts with about 30 inpatient substance abuse treatment centers around the state and 600 providers for outpatient care.
In the first nine months, CLIMB patients who went to Maplegrove or Pine Rest for detox and inpatient treatment later followed up with intensive outpatient care 20 percent more often than Blue Cross Blue Shield members who went through “treatment as usual” for addiction and were not part of the pilot, Beecroft said. The percentage is based on a comparison of CLIMB participants with Blue Cross members who received treatment elsewhere.
Relapse rates for about 220 CLIMB participants averaged 21 percent, compared to a 36 percent network average prior to the pilot. That’s an initial improvement that Beecroft calls “pretty impressive.”
“We are proving the point that this works,” he said.
A decision by Blue Cross Blue Shield on transitioning CLIMB care protocols from a pilot program to broader deployment could come in early 2020, Beecroft said.
The results so far verify “what prescribers and therapists here already felt,” said DeYoung at Pine Rest.
She hopes the CLIMB model with opioids expands across not just Blue Cross Blue Shield’s care network but all health insurers, as well as to other substances. Alcohol remains the top diagnosed addiction that Pine Rest treats, DeYoung said.
“The longer people can stay in treatment at the beginning of their first treatment episode, or even if they do relapse and they come back two or three times, and the more consistent they can be on an outpatient basis or a residential level of care, it will reduce the number of times they need that high acuity of detox,” she said.
‘Addiction doesn’t discriminate’
Blue Cross Blue Shield’s effort to change treatment protocols comes as a welcome move for care providers who treat substance use disorder and have seen their caseloads climb in recent years.
The number of people Pine Rest treats annually grew 37 percent from 2014 to 2018 to more than 26,500. The increase came across all substances, DeYoung said. She attributes the increase over five years to a greater willingness by people to seek help with overcoming an addiction and “people are more aware of where to get help.”
At Hope Network’s Center for Recovery in Grand Rapids, opioid use disorder now accounts for 85 percent to 95 percent of the caseload, said Clinical Director Flavio Da Silva.
Five years ago, it was “it was a little closer to even” between people addicted to opioids and other substances, Da Silva said. The opioid caseloads come across all age and demographic groups, he said.
“Addiction doesn’t discriminate — it just doesn’t,” Da Silva said.
Hope Network’s Center for Recovery provides evaluation and outpatient treatments, including medically-assisted treatment, plus a Community Living Program in which patients reside in apartments and receive treatment from staff.
Hope Network operates recovery clinics in Grand Rapids, Manistee, Traverse City and Petoskey. The Grand Rapids clinic in any given month treats 250 clients. Petoskey treats 240 to 250 clients a month, while Traverse City treats an average of 115 people, Da Silva said.
Hope Network is considering a new location in the Upper Peninsula, Da Silva said. He recalls attending a conference late last summer in Houghton where people were asking if Hope Network could expand into the U.P.
“‘Can we pull you here? Can we talk about what we need here? Can you talk about what services you provide?’” Da Silva said of the conversations at the time. “It’s a consistent theme. We’re always having constant discussions about needs in the community and where we should go.
“We recognize that the need is bigger than what’s currently being served.”
‘A long road’
Hope Network’s Da Silva has worked in addiction treatment since 2010. He was withWest Brook Recovery on East Beltline Avenue when it was acquired by Hope Network last March.
Da Silva shares the view that addiction needs to be treated as a chronic illness.
“We’ve known for a long time that addiction is not a quick fix. We’ve known for a long time that it’s progressive and fatal if not fixed,” he said. “We don’t treat it like a chronic illness in the sense of diabetes. We don’t expect that person to turn around and do 100 percent perfect going forward.
“We’re making progress, but we’re not there yet. It’s a long road.”
EDITOR’S NOTE: This story has been updated to note that Da Silva worked for West Brook Recovery when it was acquired by Hope Network.