By Laura Thomas
Second in a series
Northern California KP found itself scrambling in the early 1990s to enhance its substance abuse treatment program to meet new government mandates and employer group expectations. But a dedicated and innovative team of psychiatrists and psychologists soon caught up with the trend to treat addicts with the latest methods.
Mimicking the KP Southern California chemical dependency program established in the 1970s gave the Northern California programs upgrade a jumpstart. Since then, The Permanente Medical Group (TPMG) has conducted studies and pilot programs to improve care and “mainstream” alcoholics and addicts into the primary care program for early intervention.
Charles Moore, MD, now chief of addiction medicine at KP Sacramento, and Lyman Boynton, MD, who had begun the alcoholism program in KP San Francisco, headed south in the early 1990s for consultations with Don Gragg, MD, and Tony Radcliffe, MD, at Fontana Medical Center and at the outpatient chemical dependency program at the Los Angeles Medical Center.
“We literally stole their design. We made copies of all the written documents they used for patient care in their facilities and used it as a template to design our programs,” Moore said. Psychiatrist David Pating, MD, Moore, and psychologist Steve Allen, PhD, who cheerfully refer to themselves as “dinosaurs,” were all involved in setting up Northern California’s programs in the early 1990s.
Exxon Valdez spill prompts new regulations
All health plans were compelled to offer these services after the Exxon Valdez oil spill disaster propelled Congress to pass the Omnibus Transportation Employee Testing Act of 1991.
With the mandate to test employees and get serious about treating employees’ drug and alcohol problems, major employers threatened to “carve out” (go elsewhere for) the behavioral health portion of their employees’ health insurance coverage if Kaiser Permanente didn’t offer more extensive treatment.
“It was a confluence of pressures that brought about a concerted effort to build an integrated care system for treating addiction,” remembers Pating, chief of addiction medicine today at Kaiser Permanente San Francisco.
They hired new staff and got busy trying out new ideas. “There was a certain frenetic excitement that we had,” Pating recalled. “We would redesign the program and curriculum until we could get it to be really the best.”
Pilot programs began at KP San Francisco and Sacramento, and then expanded to Vallejo, Santa Clara and Oakland; in 2006, departments were established at Hayward, Santa Rosa, Fresno, Walnut Creek and Modesto.
What emerged in the ensuing years was a more comprehensive curriculum of individual and group work led by trained counselors that focused on helping addicts confront their illness and work on recovery over an extended period.
Success for intensive day treatment
Treatment might begin with 40 hours a week of intense day treatment, followed by weeks of group therapy, tapering off over one to three years. Patients requiring detoxification were managed by primary care physicians or sent to contract facilities.
“We argued our model would be more effective than a 28-day or 30-day (inpatient) program,” said psychologist Steve Allen, who helped set up the program in KP Vallejo, “because with (28-day treatment) there is a high relapse problem.” The response (to intense day treatment) was so positive, he remembered, that employers who had carved out their behavioral health coverage returned to Kaiser Permanente, and “employee assistance programs were advising (companies) that did not have Kaiser Permanente to sign up.”
In addition, fewer chemically dependent patients showed up in the emergency room (ER). “We managed detox as an outpatient (service) better than we thought, and ER responded positively,” Pating said.
Chemical Dependence Recovery Program (CDRP) staffers moved on to work with the psychiatry department to coordinate care for patients with the dual diagnosis of depression and addiction. They also put into place Northern California KP’s innovative Early Start program for pregnant women with drug or alcohol problems, which began in 2003.
Today, 42 KP prenatal clinics in Northern California have a team of specialists who do initial screening and then follow women throughout their pregnancy with a program to counsel and support them in reducing their use. Based on continuing evaluation of the results in baby birth weight and other factors, with the help of the Division of Research (DOR), the program has been expanded to the Hawaii Region and part of Southern California since 2006.
Ambitious research to validate treatment methods
In the intervening years, the “dinosaur” pioneers also began a partnership with TPMG’s Division of Research to study the quality of substance abuse care and possible costs savings realized by providing this type of treatment.
In the October 2000 issue of Health Services Research, TPMG researchers, led by Connie Weisner, doctor of public health, published a study of outcomes for patients who began treatment in KP’s Sacramento alcohol and drug treatment program from 1994 to 1996.
The study, “The Outcome and Cost of Alcohol and Drug Treatment in an HMO: Day Hospital Versus Traditional Outpatient Regimens,” compared the success and costs of an intensive six-hours-a-day program to a two-to-eight-hours-per-week program.1
In 2001, Weisner, Moore and others studied the benefits of integrating primary care with substance abuse services at KP Sacramento. They found that substance abuse patients who were mainstreamed were more likely to be abstinent at six months. They continued to track those patients for another nine years and found those who continued to get primary care were less likely to be hospitalized or use the emergency room. 2
It’s taken a lot of research, numerous pilot programs and persistence on the part of Pating and his colleagues, but Kaiser Permanente is moving forward along with the nation in mainstreaming substance abuse treatment.
The research team recently obtained a $2.5 million National Institutes of Health grant for primary care medical teams to screen for substance abuse, offer brief interventions, and study the results.
Health care reform’s impact on addiction care
Full integration will require overcoming the reluctance of primary care doctors to take on increased workloads and to acquire new skills associated with treating addiction, Pating said. But he predicts that in the next five to 10 years there will be major changes in this arena, pushed by mandates in the 2010 Affordable Care Act that require parity between the treatment of substance abuse and other chronic medical conditions.
Pating et al. recently compiled an analysis of the future of substance abuse programs in the new climate created by the health care reform act. The report, published in Psychiatric Clinics of North America in June 2012, reviews current systems and examines the expansion of addiction treatment to include new methods and settings. The report also discusses changing technology, new financing/payment mechanisms and expanded information management processes.
In the journal report, Pating notes that about 23.5 million American adults have a substance abuse disorder, but only 10.4 % receive the addiction treatment they need. He adds that integrating these patients into the primary care setting may be the only hope for some who won’t seek addiction treatment due to societal stigma.3
1 “The Outcome and Cost of Alcohol and Drug Treatment in an HMO: Day Hospital Treatment Versus Traditional Outpatient Regimens,” Kaiser Permanente Division of Research staffers Constance Weisner, doctor of public health; Jennifer Mertens, MA; Sujaya Parthasarathy, PhD; Charles Moore, MD, MBA; Enid M. Hunkeler, MA; Teh-wei Hu, PhD, UC Berkeley; and Joe V. Selby, MD, former DOR director, October 2000, Health Services Research.
2 “Integrating Primary Medical Care With Addiction Treatment: A Randomized Controlled Trial,” DOR researchers Constance Weisner, doctor of public health; Jennifer Mertens, MA; Sujaya Parthasarathy, PhD; Charles Moore, MD, MBA; and Yun Lu, MPH, 2001 Journal of the American Medical Association (JAMA).
3 “New Systems of Care for Substance Use Disorders. Treatment, Finance, and Technology under Health Care Reform,” David R. Pating, MD, Kaiser Permanente Division of Research; Michael M. Miller, MD, University of Wisconsin; Eric Goplerud, PhD, MA, University of Chicago; Judith Martin, MD, BAART Turk Street Clinic, San Francisco, CA; and Douglas M. Ziedonis, MD, University of Massachusetts; Psychiatric Clinics of North America, June 2012.
By Laura Thomas
First in a series
Despite Kaiser Permanente’s early emphasis on preventive health care, pervasive 20th century American attitudes about alcohol and drug abuse curbed Health Plan leaders’ willingness to tackle addiction as a bona fide treatable illness.
“Very few physicians or even psychiatrists are willing to treat the chronic alcoholic, just as few lawyers go into the specialty of bankruptcy law,”
Paul Gliebe, MD, of the University of California medical school, told Kaiser Permanente physicians in 1953. “The chronic alcoholic is in most instances looked upon as a bankrupt personality.”
The American Medical Association (AMA) was also reluctant to empathize with alcoholics, stopping short of declaring alcoholism a disease in 1956, while encouraging hospitals to admit patients suffering from the symptoms.1
“Since the earliest era, (Kaiser) Permanente (KP) physicians had resisted the idea of comprehensive care for alcoholism, self-inflicted wounds, or other self-induced illness,” the late KP San Francisco pediatrician John Smillie, MD, wrote in his 1991 book, Can Physicians Manage the Quality and Costs of Health Care?
This resistance existed despite some early voices in Kaiser Permanente who pointed out what the Permanente organization accepts today – that social and behavioral imbalances lead to disease and the symptoms include addiction and depression, now being recognized as diseases in themselves.
KP psychiatrist Kahn warns addicts need early care
One early KP psychiatrist, Bernard Kahn, MD, sounded an alarm at a Permanente Medical Group planning meeting in Monterey in 1960. From that vantage point, Kahn described the modern, ever-present pressures of managing technology, work and leisure:
“Our national consumption of tranquilizers and alcohol prove we are a nervous nation. Let’s face it: the internist, the surgeon, the general practitioner, our Drop-In (Clinic) physicians are treating this kind of illness – the intangible, aggravating, emotional upsets, day in and day out – regardless of what the Health Plan contract reads.”
Kahn asserted that the Health Plan needed to extend its preventive care to include alcoholics because they would surely develop chronic disease without treatment for their addiction. “(In this area) we’re already too late, and we are covering end-stage disease (caused by alcoholism).”
Dr. Kahn, a retired Navy psychiatrist, was helping to craft a cost-effective and practical psychiatric program, along with The Permanente Medical Group (TPMG) pioneer Morris Collen, MD, in the 1950s. Collen was concerned that traditional psychiatric appointments were too long at 50 minutes and would add unduly to Health Plan costs. He wanted Kahn to develop a program based on a 30-minute appointment. Unfortunately, Kahn died of a heart attack before he could accomplish the task, Dr. Collen said in his 1986 oral history.
KP institutes psychiatry program in late 1950s
In the late 1950s, Kahn and psychologist Nicholas Cummings had been successful in establishing a KP psychiatry program. But treatment for alcoholism and other addictions was kept at arm’s length until it was pushed by the federal government for its employees in 1969, physician leader Raymond Kay, MD, wrote in his 1979 book on the history of the KP Southern California medical group.2
The AMA also took its time to define alcoholism as a disease. It waited until 1967 to declare it a “disease that merits the serious concern of all members of the health professions.” By then, President Lyndon Johnson had publicly called for more study and treatment for alcoholism, and health insurance plans had begun to respond.1
Richard Merrick, MD, then a young internist at KP’s Harbor City Medical Center in Southern California, said he was approached by the department chief in early 1971. “They needed at least one physician from each area to start an alcoholism program.
“There were 12 or 15 doctors in the department at the time and he came to me last because he had been turned down by everyone. There was zero interest at that time in having anything to do with ‘those people’. That was the common mentality at the time.”
There was little understanding of the functional alcoholic or socialite imbibing wine, he said, only of the “stinking drunk. There was hardly any concept of addictions being diseases. They were defects of character. It was a matter of choice. These people were ‘bad’ so how could you treat that?” he said.
Dr. Merrick hired a recovering alcoholic to help him organize a one-night-a-week outpatient clinic, which lasted for three-and-a-half years. But if a patient was going through withdrawal symptoms, he or she could not be admitted easily.
“They had to have a seizure to get admitted. That’s how crazy it was for a while,” he remembered. “Once in a while I would sneak somebody in, and I would take all kinds of heat from the Health Plan because they would tell me it wasn’t a covered benefit.”
But industry and the government were determined to extend addiction treatment to as many American workers and their families as possible. Recognizing the need, KP regions began instituting coverage in the late 1970s, usually offering outpatient treatment services through the psychiatry department with a copayment and yearly cap on the number of counseling appointments or group meetings a member could use.
By the early 1980s, alcoholics were no longer falling “through the cracks at Kaiser (Permanente),” according to Andrus Skuja, MD, then chief of the alcohol and drug abuse program in South San Francisco. His comments in an interview in the KP Reporter employee newsletter in December 1982 reflected Merrick’s early experience in Southern California:
During the 1980s as the nation recognized cocaine as a new addiction problem, KP saw the need to treat many other drug addictions. It was a little tough at first. Many alcohol counselors were not comfortable with “heroin addicts or pill users, and they didn’t seem to realize that the dynamics were all the same. Addiction is addiction,” Merrick recalled. “In the San Fernando Valley, one clinic treated alcoholics and another treated addicts other than alcoholics . . . that lasted for a while.”
Kaiser Permanente resisted the initial trend of sending people to 30-day inpatient treatment programs even though many large employers and well-off unions, such as the longshoremen, were pushing it. KP established inpatient detoxification programs at KP Fontana for Kaiser Steel Mill employees in 1978 and in Carson just south of Los Angeles in 1988.
Thirty days was the gold standard based on the Minnesota model of alcoholism treatment that health insurers recognized and were willing to pay for. It got a large push when Betty Ford, wife of President Gerald Ford, spoke of her alcoholism in 1978 and later lent her name to the Betty Ford Center for alcoholics and drug addicts.1
Merrick, who was never convinced of the need for the month-long inpatient stay, noted: “We never kept them in for 30 days . . . As it has shaken out, I was right.
“It was just common sense. If you are a functioning alcoholic and not going through detox, why on earth do you need to be in for 30 days when you can do equivalent work on an outpatient basis over a longer period of time, because treatment for alcoholism or any drug is a lifelong thing . . . There is nothing magical about the 30 days.”
This inpatient treatment model died off everywhere in the early 1990s and was replaced by less expensive residential treatment as an alternative for patients with special needs.
Next time: 1990s spawn research and refinement of addiction care
1 Slaying the Dragon: The History of Addiction Treatment and Recovery in America, William L. White, Chestnut Health Systems/Lighthouse Institute, 1998
2 Historical Review of the Southern California Permanente Medical Group, Raymond M. Kay, MD, 1978, publisher: the Southern California Permanente Medical Group.