“Obamacare could overwhelm addiction services” was the headline of an April 27 news article by the Associated Press. The article cited a “surge of patients” that would put a great demand on a treatment system that will not be ready to handle it and would be swamped. The fact that there are waiting lists for treatment now, as the article detailed, is hardly a secret. But whether there really will be thousands of people with brand-new insurance showing up for treatment in January is still an unknown.

“I hope we have that problem,” said Michael Walsh, president of the National Association of Addiction Treatment Providers (NAATP). “But the reality is, we’re trying to fight for every dollar now.” The big question mark is what kind of treatment will be covered, he told ADAW. With no final rule on parity yet, treatment providers don’t know what kind of treatment to be prepared to offer, he said, posing the following questions: “Are the final regulations going to be written in a way that insurance companies will pay for beds that are available? Will it be doctors only? Hospitals only?”

Walsh added that not everyone who needs treatment seeks it out. Of the 20 million people who need some kind of treatment, only 3 million would try to get it even if they could afford it, because they don’t think they need it, according to surveys by the Substance Abuse and Mental Health Services Administration (SAMHSA). “Only a small percentage will search out treatment unless we are training physicians and nurses on how to identify and refer,” Walsh told ADAW.

“And let’s say that all the people who do want it will be able to get it — that would be great for us. But what kind of payment would there be?” asked Walsh. “We’re seeing less reimbursement now than before the parity law was passed.” While the Affordable Care Act requires that the benefit be there, it is the parity law that would make the benefit accessible. “We see so many insurance company denials,” Walsh said.

Another problem is workforce, said Walsh — nobody knows what kind of licensure and training addiction treatment workers are going to need, state by state. “In a perfect world, you’re going to have to train the workforce,” he said. Payers — Medicaid or insurance companies — may require a master’s degree, for example. But again, the future isn’t clear.

“One of the things we’re telling our membership is that they may not have a workforce that has the proper certification and licensure,” he said. “We don’t know what they’re going to require, so it’s hard to plan. If I run a facility, do I wait to find out what those requirements are or do I do training now? What if I spend all this money on training, and then it isn’t needed?”

Plenty of money, but not staff

In Vermont, it’s not reimbursement but workforce problems that are most likely to impede capacity expansion, said Barbara Cimaglio, deputy commissioner of the Department of Alcohol and Drug Programs in the Department of Health. Vermont has expanded its addiction treatment capacity with its innovative “hub and spoke” system and a steady infusion of new funding (see ADAW, October 29, 2012), but there is a workforce shortage.

“As we have expanded, we are consistently challenged by finding qualified staff, especially medical staff,” she said, adding that this is what keeps her up at night. “We’re trying to ramp up new services and step into the healthcare world, but there aren’t enough training programs,” she said. “Even if you have the money, you have to have staff, and they have to be skilled.”

She said the state is looking for all levels of staff, with a focus on peers. “There are many peers out there, but they need to go through training,” she said. “We need clinicians, licensed alcohol and drug counselors, addiction nurses who are experienced with medications, clinicians who can work with co-occurring and psychiatric conditions,” she said.

And medical staff need to be well trained in addictions. Initially in Vermont the buprenorphine program attracted many doctors. But after a year, these doctors dropped out of the program — treating addiction was too “tough” for them, said Cimaglio. It’s because they were just giving the medication, and not providing support. “This disease will never be treated with just medication,” she said. But finding physicians who are trained in addiction is extremely difficult, especially in rural areas.

Good business to be in?

Walsh of NAATP said that there are many investors “swimming around, wondering if they should get into this business, and they’re looking at everything from the high-end private pay to Medicare, Medicaid and insurance.” The more sophisticated business models are considering all payment streams, in part because there is so little certainty about parity, said Walsh. “If all these people with money are looking at our industry, maybe it means there will be patients,” he said. But the question is whether those programs will be detoxification-only, followed by medication-only, depending on what is reimbursed. “That’s why the final rule is so important,” said Walsh.

The Department of Health and Human Services continues to say the parity final rule will be out before the end of the year.