As I find myself writing this first column for 2010, it seems natural to look forward and anticipate some of the issues and challenges that will be facing providers of addiction treatment in this New Year. For many of us, the turning of the calendar could not have come too soon! 2009 was a very difficult year in so many different ways. Nevertheless, with all the uncertainly we faced just 12 months ago, we are now ready to march forward into 2010 with renewed resolve!

For providers of addiction treatment, the past year was dominated by two very large forces. The first force was the fragile economy and its tremendous impact both on your own operations and on the larger communities around you. Rising unemployment, rising health care costs, shrinking self-pay markets and tight credit markets made 2009 operations very challenging. While years past might have been years where you could experiment with solutions, 2009 was a year where you needed to get it right the first time! The second large impacting force of 2009 was healthcare reform! This year-long debate and process dominated almost every publication, every conference and every phone conversation. The good news was that addiction treatment was at the table and was included in the discussions. The confusing news is that we are not yet sure what we actually got and what all the implications might be.

What we know is that both the Senate and the House have each passed a health reform bill, which address many of the same issues, but have significant differences. The next steps will be for a conference committee made up of both members of the Senate and the House to begin to meet and “work out the differences.” Assuming that that is possible, the final document will then go back to both the House and the Senate for a vote. Everyone would like to have the healthcare reform bill to the President before his State of the Union Speech. At the very beginning of this process, two key principles were identified as drivers of the entire process: Healthcare reform was intended to address the issue of the 40+ million Americans who were uninsured and healthcare reform was intended to reduce or at least bend the curve of healthcare costs.

Because we were at the table, we had language inserted in both the Senate and the House bills referencing the need to insure that no matter how health insurance was made available, it needed to include a benefit which provided coverage for the disease of addiction. Much like the federal Parity legislation, this was benefit language and there remains considerable ambiguity around how people will be able to access that benefit.

While the press focused on issues such as the “public option,” early opt-in to Medicare, taxing Cadillac healthcare plans, electronic health records and portability of healthcare plans, there are literally thousands of additional pages in each version of the reform bill which need to be read, digested and understood.

What seems rather clear is that this process is much more than the passing of a single bill and the signing of legislation by the President of the United States. This is a remarkable process which is indeed, healthcare reform! My prediction is that over the next 10 to 15 years, the way healthcare is delivered, the way healthcare results are evaluated and the way healthcare is financed and paid for will fundamentally change. This is all about healthcare reform!

For the past 50 years, those involved in addiction treatment have championed the cause of having addiction recognized by other health care providers as a disease on equal footing with all other diseases. While there remain skeptics, the official position is that addiction is a disease and it needs to be diagnosed and treated as other diseases.

That recognition has come just in time for healthcare reform. As we look into 2010 and beyond, these may well be the challenges and topics which will dominate the press, conferences and conversations:

1. How do we ensure that there is clear documentation of a person having been or being treated for their addiction in their “consolidated medical record”? How do we balance issues of sound medical practice and patient confidentiality?
2. How do we define what constitutes core addiction treatment and what constitutes helpful but extra interventions? The public is very confused as to what addiction treatment is and what addiction treatment is not.
3. How will we define the ultimate goal of addiction treatment? Will it be long-term sustainable recovery, or will it be symptom reduction?
4. How will we identify what interventions (treatment activities) are the most cost-effective for which populations?
5. What will be the role of specialty addiction treatment in an era of reform where integration may be emphasized over any specialty treatment?

For 2010, I see a great deal of energy and activity on sorting out the reform aspect of what we did in 2009. It is those thousands of pages and all the fine print that will hold the key to 2010 and well beyond.

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