The SUD Redesign

By Monica E. Oss, Chief Executive Officer, OPEN MINDS

Nearly 10% of Americans with a substance use disorder (SUD) are hospitalized each year. This compares with the 8.4% rate of hospitalizations among all U.S. adults, according to a recent study, Prevalence Of Hospitalizations Among A National Sample Of U.S. Adults With Substance Use Disorders. Among those with an alcohol, cannabis, and/or tobacco use disorders, these hospitalized adults were more likely to have a serious mental illness. The study also found that most consumers hospitalized with an SUD did not receive an evidence-based treatment during their stay. 

In addition, adults hospitalized with SUDs were significantly more likely to have complex health needs: 58.4% had two or more co-occurring medical or psychiatric conditions, compared to just 28.6% of hospitalized adults without SUDs. More than a third (34.8%) had three or more chronic conditions, and 40.4% had a co-occurring mental illness—nearly triple the 14.1% rate seen among non-SUD peers.

Challenges like these—both clinical and financial—prompted the Missouri Behavioral Health Council (MBHC) to assemble state leaders and SUD provider organizations to rejuvenate the state’s Comprehensive Substance Treatment And Rehabilitation (CSTAR) program. CSTAR is funded by Medicaid and the Missouri Department of Behavioral Health (DBH). Their approach was the focus of the recent OPEN MINDS Circle Executive Roundtable discussion, “A Statewide SUD Redesign: The Missouri CSTAR Program Case Study.” The case study was presented by Natalie Cook, Vice President of MBHC’s CLIVE Solutions, and Ryan Essex, Chief Operating Officer of Gibson Center for Behavioral Change, a MBHC member organization.

MBHC is a statewide network of 30-plus member agencies that provide a comprehensive array of psychiatric and substance use treatment services and supports for children, adolescents, adults, and seniors. The MBHC provider network includes 14,000 staff who treat 300,000-plus consumers annually. The Gibson Center for Behavioral Change provides comprehensive behavioral health and substance use treatment services, servicing over 1,600 consumers each year. Established in 1979 as a halfway house, the center has evolved over four decades into a multifaceted provider offering outpatient and residential treatment, detoxification, medication-assisted treatment (MAT), and specialized programs, including the Substance Awareness Traffic Offender Program (SATOP).

This CSTAR Transformation Workgroup started working in late 2019. “The Missouri CSTAR program was developed in the 1990s and has had very few program updates since it was developed,” Ms. Cook said. “SUD reimbursement rates are typically lower than other Medicaid rates, and that was certainly true in Missouri. Those rates did not correlate with the level of staff that was providing the services, so it incentivized lower-level, low-cost staff services, and de-incentivized the high-level, high-cost staff services.”

The clinical and financial structure of the new CSTAR model centers around daily bundled rates based on American Society of Addiction Medicine (ASAM) criteria, allowing for real-time transitions between levels of care. To transform Missouri’s SUD program, the Workgroup revised the Medicaid State Plan Amendment to implement a new payment model to cover ASAM levels of care (LOC). “What we really liked about the ASAM criteria was that it had objective decision-making, it had a multidimensional assessment, and it created a continuum of care that was very different from what we were doing. And, it was shown to improve outcomes and standardized training,” Ms. Cook said. The new model replaced the traditional fee-for-service structure—which billed in 15-minute increments—with a reimbursement model based on ASAM LOC. ASAM Level 1 retains traditional billing, with rates adjusted for current market costs, while Levels 2 and 3 use daily bundled rates. This structure allows for real-time clinical transitions without needing to pause care or change authorization types. “You can go up and down based on where you are clinically,” explained Ms. Cook. Covered services within the bundle include intensive outpatient programming, peer support, treatment coordination, and MAT. As Mr. Essex noted, “This lets us actually treat the whole person. We’re not billing for each piece—we’re treating someone based on what they need that day.”

To be eligible for the ASAM rates, provider organizations are required to incorporate several evidence-based practices, such as trauma-informed care. They also need a tobacco treatment specialist and to participate in a Zero-Suicide Academy.

A major innovation in Missouri’s approach is the statewide data-sharing platform that enables provider organizations to access referral information, client engagement data, and care coordination tools in real time. “We built a data-sharing network so that every provider could look across the system—not just their own EHR,” Ms. Cook noted. This interoperability has improved both clinical decision-making and outcome tracking. Another standout feature is the integration of peer recovery support specialists as a core part of care teams. Mr. Essex emphasized, “The biggest shift is we built teams that include people with lived experience—and that’s been huge for engagement and retention. Our folks trust them.”

The model’s performance has shown measurable improvements. There was a 34% decrease in hospitalizations realized within a year of implementing the new payment model. And, within the first six months of the program’s implementation, provider organizations reported an 18% increase in consumer encounters and a 65% revenue increase. Mr. Essex shared that provider organizations have seen an increase in treatment retention and a drop in crisis-driven care. “We had one client who’d been to the ER 14 times in three months,” he said. “After starting CSTAR services with us, he stabilized, got housing, and hasn’t been back once in over a year.” Clients report greater satisfaction with services and a stronger connection to their care teams. The bundled structure and real-time data tools have allowed providers to “focus more on people and less on paperwork,” according to Ms. Cook. Together, the clinical flexibility, financial model, and integrated workforce represent a scalable blueprint for other states facing similar challenges.

“I had to ask my staff if that [readmission] drop was due to the fact that people were staying engaged in treatment longer, or the fact that people were completing treatment, discharging, and not coming back,” said Mr. Essex. “What we found was that people were just engaging longer. We weren’t seeing that level of dropout and readmission that we had been seeing over the years because of the new level of care that we were providing.”

For other states looking to reform their SUD programs, Mr. Essex had some words of advice: “Involve your providers and your provider associations. One of the biggest pitfalls is thinking that it can be done by a single entity.”

Mr. Essex and Ms. Cook both emphasized that for those planning similar changes, the process will take longer than anticipated. Program implementation costs are a large factor: organizations must budget for paying outside consultants and training resources. Also, they recommend that organizations commit to meet, track, and report on the service thresholds for different levels of care, such as the number of hours that a consumer is receiving treatment, for provider organizations to receive that daily bundled rate. And Ms. Cook and Mr. Essex said that organizations should plan appropriately for electronic health record (EHR) configurations necessary for complying with new documentation and billing requirements. Feedback from Missouri providers has been positive. According to Ms. Cook, “Treatment is no longer focused on the singular issue of substance use. ASAM allows for a much more comprehensive look at the patient.”