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Financial incentives for quality improvement and feedback on specific clients are two approaches to improving the quality of treatment for individuals with substance use disorders. We examined the impacts of these interventions in Washington State by randomizing outpatient substance use treatment agencies into intervention and control groups. From October 2013 through December 2015, agencies could earn financial incentives for meeting performance goals incorporating both achievement relative to a benchmark and improvement from agencies' own baselines. Weekly feedback was e-mailed to agencies in the alert or alert plus incentives arms. Difference-in difference regressions controlling for client and agency characteristics showed that none of the interventions significantly affected client engagement after outpatient admissions, overall or for sub-groups based on race/ethnicity, age, rural residence, or agency baseline performance. Treatment agencies offered insights related to several themes: delivery system context (e.g., agency time and resources needed during transition to a managed behavioral healthcare system), implementation (e.g., data lag), agency issues (e.g., staff turnover), and client factors (e.g., motivation). Interventions took place during a time of Medicaid expansion and planning for statewide integration of mental health and substance use disorder treatment into a managed care model, which may have resulted in agencies not responding to the interventions. Moreover, incentives and alerts at the agency-level may not be effective when factors are at play beyond the agency's control. [ABSTRACT FROM AUTHOR]

Health plan policies can influence delivery of integrated behavioral health and general medical care. This study provides national estimates for the prevalence of practices used by health plans that may support behavioral health integration. Results indicate that health plans employ financing and other policies likely to support integration. They also directly provide services that facilitate integration. Behavioral health contracting arrangements are associated with use of these policies. Delivery of integrated care requires systemic changes by both providers and payers thus health plans are key players in achieving this goal. [ABSTRACT FROM AUTHOR]

Background: Recovery, a primary goal of addiction treatment, goes beyond abstinence. Incorporating broad domains with key elements that vary across individuals, recovery is a difficult concept to measure. Most addiction-related quality measurement has emphasized process measures, which limits evaluation of treatment quality and long-term outcomes, whereas patient-reported outcomes are richer and nuanced. To address these gaps, this study developed and tested a patient-reported outcome measure for addiction recovery, named Response to Addiction Recovery (R2AR). Methods: A multi-stage mixed methods approach followed the Patient-Reported Outcomes Measurement Information System (PROMIS) measure development standard. People with lived experience (PWLE) of addiction, treatment providers, and other experts contributed to item distillation and iterative measure refinement. From an item bank of 356 unique items, 57 items were tested via survey and interviews, followed by focus groups and cognitive interviews. Results: Face validity was demonstrated throughout. PWLE rated item importance higher and with greater variance than providers, yet both agreed that "There are more important things to me in my life than using substances" was the most important item. The final R2AR instrument has 19 items across 8 recovery domains, spanning early, active, and long-term recovery phases. Respondents assess agreement for each item as (1) a strength, and (2) importance to ongoing recovery. Conclusion: R2AR allows PWLE to define what is important to their recovery. It is designed to support treatment planning as part of clinical workflows and to track recovery progress. Inclusion of PWLE and providers in the development process enhances its face validity. Including PWLE in the development of R2AR and using the tool to guide recovery planning emphasizes the importance of patient-centeredness in designing clinical tools and involving patients in their own care. [ABSTRACT FROM AUTHOR]

Background: An increasing number of medications are available to treat addictions. To understand access to addiction medications, it is essential to consider the role of private health plans. To contain medication expenditures, most U.S. health plans use cost-sharing and administrative controls, which may impact physicians' prescribing and patients' use of addiction medications. This study identified health plan approaches to manage access to and utilization of addiction medications (oral and injectable naltrexone, acamprosate, and buprenorphine).Methods: Data are from a nationally representative survey of private health plans in 2010 (n=385 plans, 935 products; response rate 89%), compared to the same survey in 2003. The study assessed formulary inclusion, prior authorization, step therapy, overall restrictiveness, and if and how health plans encourage pharmacotherapy.Results: Formulary exclusions were rare in 2010, with acamprosate excluded most often, by only 9% of products. Injectable naltrexone was covered by 96% of products. Prior authorization was common for injectable naltrexone (85%) and rare for acamprosate (3%). Step therapy policies were used only for injectable naltrexone (41%) and acamprosate (20%). Several medications were often on the most expensive tier. Changes since 2003 include fewer exclusions, yet increased use of other management approaches. Most health plans encourage use of addiction pharmacotherapy, and use a variety of methods to do so.Conclusions: Management of addiction medications has increased over time but it is not ubiquitous. However, health plans now also include all medications on formularies and encourage providers to use them, indicating that they value addiction pharmacotherapy as an evidence-based practice. [ABSTRACT FROM AUTHOR]

Purpose: In the United States, many individuals with attention-deficit/hyperactivity disorder (ADHD) pay for their medications using private health insurance coverage. As in other drug classes, private insurers are actively seeking to influence use and costs, particularly for newer and costlier medications. The approaches that insurers use may have important effects on patients' access to medications. This article examines approaches (eg, copayments, prior authorization, and step therapy) that commercial health plans are using to manage newer medications used to treat ADHD and changes in approaches since 2003. Methods: Data are from a nationally representative survey of commercial health plans in 60 market areas regarding alcohol, drug abuse, and mental health services in 2010. Responses were obtained from 389 plans (89% response rate), reporting on 925 insurance products. For each of 6 branded ADHD medications, respondents were asked whether the plan covered the medication and, if so, on what copayment tier each medication was placed and whether it was subject to prior authorization or step therapy. Measures of management approach were constructed for each medication and for the group of medications. Bivariate and multivariate analyses were used to test for association of the management approach with various health plan characteristics. Findings: There was considerable variation across these 6 medications in how tightly they were managed by health plans, with newer medications being subject to more stringent management. The proportion of insurance products relying solely on copayment tiering to manage new ADHD medications appears to have decreased since 2003. Less than half of insurance products (43%) managed these 6 medications solely by use of tier 3 or 4 placement, and most of the remainder (48%) used other restrictions (with or without tier 3 or 4 placement). The average insurance product restricted access to at least 3 of the 6 brandonly medications examined, whether through copayment tier placement or other approaches. More ADHD medications were left unrestricted in health maintenance organization products than in preferred provider organization ones, products with internal or hybrid-internal contracts for behavioral health, those not contracting with pharmacy benefits managers, and those with for-profit ownership. Implications: Many plans have supplemented copayment tiering with other approaches, such as prior authorization and step therapy, to influence use and decrease costs. It may be that plans have found copayments to be less effective in redirecting use in this medication class. The effect on clinical outcomes was not examined in this study but should be prioritized using other data sources. [ABSTRACT FROM AUTHOR]

Abstract: Administrative data from five states were used to examine whether continuity of specialty substance abuse treatment after detoxification predicts outcomes. We examined the influence of a 14-day continuity of care process measure on readmissions. Across multiple states, there was support that clients who received treatment for substance use disorders within 14-days after discharge from detoxification were less likely to be readmitted to detoxification. This was particularly true for reducing readmissions to another detoxification that was not followed with treatment and when continuity of care was in residential treatment. Continuity of care in outpatient treatment was related to a reduction in readmissions in some states, but not as often as when continuity of care occurred in residential treatment. A performance measure for continuity of care after detoxification is a useful tool to help providers monitor quality of care delivered and to alert them when improvement is needed. [Copyright &y& Elsevier]

Abstract: The relationship between engagement in outpatient treatment facilities in the public sector and subsequent arrest is examined for clients in Connecticut, New York, Oklahoma and Washington. Engagement is defined as receiving another treatment service within 14days of beginning a new episode of specialty treatment and at least two additional services within the next 30days. Data are from 2008 and survival analysis modeling is used. Survival analyses express the effects of model covariates in terms of “hazard ratios,” which reflect a change in the likelihood of outcome because of the covariate. Engaged clients had a significantly lower hazard of any arrest than non-engaged in all four states. In NY and OK, engaged clients also had a lower hazard of arrest for substance-related crimes. In CT, NY, and OK engaged clients had a lower hazard of arrest for violent crime. Clients in facilities with higher engagement rates had a lower hazard of any arrest in NY and OK. Engaging clients in outpatient treatment is a promising approach to decrease their subsequent criminal justice involvement. [Copyright &y& Elsevier]

Abstract: We evaluate the effects of a performance contract (PC) implemented in Delaware in 2001 and participation in quality improvement (QI) programs on waiting time for treatment and length of stay (LOS) using client treatment episode level data from Delaware (n =12,368) and Maryland (n =147,151) for 1998–2006. Results of difference-in-difference analyses indicate that waiting time declined 13 days following the PC, after controlling for client characteristics and historical trends. Participation in the PC and a formal QI program was associated with a decrease of 20 days. LOS increased 22 days under the PC and 24 days under the PC and QI programs, after controlling for client characteristics. The PC and QI programs were associated with improvements in LOS and waiting time, although we cannot determine which aspects of the programs (incentives, training, and monitoring) resulted in these changes. [Copyright &y& Elsevier]

Information about treatment services can be ascertained in several ways. We examine the level of agreement among data on substance user treatment services collected via multiple methods and respondents in the nationally representative Alcohol and Drug Services Study (ADSS, 1996--1999), and potential reasons for discrepancies. Data were obtained separately from facility director reports, treatment record abstracts, and client interviews. Concordance was generally acceptable across methods and respondents. Although any of these methods should be adequate, additional information is gleaned from multiple sources. [ABSTRACT FROM AUTHOR]

Financing, payment, and organization and management of alcohol and other drug (AOD) treatment services are closely intertwined and together determine whether people have access to treatment, how the treatment system is designed, and the quality and cost of treatment services. Since the 1960s, changes in these arrangements have driven changes in the delivery of AOD treatment, and recent developments, including the passage of Federal parity legislation and health reform, as well as increasing use of performance contracting, promise to bring additional changes. This article outlines the current state of the AOD treatment system and highlights implications of these impending changes for access to and quality of AOD treatment services. [ABSTRACT FROM AUTHOR]

Connecting people to mental health and substance abuse services is critical, given the extent of unmet need. The way health plans structure access to care can play a role. This study examined treatment entry procedures for specialty behavioral health care in private health plans and their relationship with behavioral health contracting arrangements, focusing primarily on initial entry into outpatient treatment. The data source was a nationally representative health plan survey on behavioral health services in 2003 ( N = 368 plans with 767 managed care products; 83% response rate). Most health plan products initially authorized six or more outpatient visits if authorization was required, did not routinely conduct telephonic clinical assessment, had standards for timely access, and monitored wait time. Products with carve-outs differed on several treatment entry dimensions. Findings suggest that health plans focus on timely access and typically do not heavily manage initial entry into outpatient treatment. [ABSTRACT FROM AUTHOR]

Health plans appear to be moving toward less stringent management, but it is not known whether behavioral health care arrangements mirror the overall trend. To improve access to and quality of behavioral health services, it is critical to track plans’ delivery of these services. This study examined plans’ behavioral health care arrangements and changes over time using a nationally representative health plan survey regarding alcohol, drug abuse, and mental health services in 1999 ( N = 434, 92% response) and 2003 ( N = 368, 83% response). Findings indicate health plans’ behavioral health service provision changed significantly since 1999, including a large increase in contracting with managed behavioral health care organizations. Some evidence of loosening administrative controls such as prior authorization implies easier access to services. However, increased prevalence of higher levels of cost sharing suggests financial barriers have grown. These changes have important implications for enrollees seeking care and for providers working to meet patients’ needs. [ABSTRACT FROM AUTHOR]

The article reports on the benefit limits for mental health and substance abuse treatment (MH/SA). Most private health plans limit the number of days, visits or dollars available for MH/SA. For instance, 90% limit out patient MH and 93% limit on SA treatment. Insurers' perceived that benefit limit is for cost containment purposes. As a result, it will place major financial burdens for families for long lasting treatment: an average of $2, 710 for mental visits, or $2, 400 for substance abuse.

Abstract: Health plans have implemented cost sharing and administrative controls to constrain escalating prescription expenditures. These policies may impact physicians'' prescribing and patients'' use of these medications. Important clinical advances in the pharmacological treatment of addiction highlight the need to examine how pharmacy benefits consider medications for substance dependence. The extent of restrictions influencing the availability of these medications to consumers is unknown. We use nationally representative survey data to examine the extent and stringency of private health plans'' management of naltrexone and disulfiram for alcohol dependence, and buprenorphine for opiate dependence. Thirty-one percent of insurance products excluded buprenorphine from formularies, whereas 55% placed it on the highest cost-sharing tier. Generic naltrexone is the only substance dependence medication that is both rarely excluded from formularies and usually placed on a lower cost-sharing tier. These findings demonstrate that pharmacy benefits have an impact on access to medications for substance abuse. [Copyright &y& Elsevier]

OBJECTIVES: To examine the prevalence of unhealthy drinking patterns in community-dwelling older adults and its association with sociodemographic and health characteristics. DESIGN: Cross-sectional analysis of nationally representative survey data. SETTING: The data source was the 2003 Access to Care file of the Medicare Current Beneficiary Survey, which represents the continuously enrolled Medicare population. PARTICIPANTS: Community-dwelling Medicare beneficiaries aged 65 and older (N=12,413). MEASUREMENTS: The prevalence of unhealthy alcohol use by older adults defined in relation to two parameters of recommended limits: monthly use exceeding 30 drinks per typical month and “heavy episodic” drinking of four or more drinks in any single day during a typical month in the previous year. Sociodemographic and health status variables were also included. RESULTS: Nine percent of elderly Medicare beneficiaries reported unhealthy drinking, with higher prevalence in men (16%) than women (4%). In logistic regression analyses with the full sample, higher education and income; better health status; male sex; younger age; smoking; being white; and being divorced, separated, or single were associated with higher likelihood of unhealthy drinking. Among drinkers, in addition to sociodemographic variables, self-reported depressive symptoms were positively associated with unhealthy drinking. Among unhealthy drinkers, race and ethnicity variables were associated with likelihood of heavy episodic drinking. CONCLUSION: Almost one in 10 elderly Medicare beneficiaries report exceeding recommended drinking limits. Several distinct unhealthy drinking patterns were identified and associated with sociodemographic and health characteristics, suggesting the value of additional targeted approaches within the context of universal screening to reduce alcohol misuse by older adults. [ABSTRACT FROM AUTHOR]

With the growing number of Hispanics in the U.S. and the accompanying growing number of Hispanic clients in the specialty substance abuse treatment system, it is increasingly pertinent to ensure that they receive appropriate and relevant treatment for substance use disorders. We use nationally representative data to determine the sociodemographic, substance use, mental health, and treatment characteristics of Hispanic clients in specialty substance abuse treatment, as compared to non-Hispanic White clients. Hispanic clients are in treatment more often for heroin use and are referred to treatment more often by the criminal justice system. More White clients receive individual counseling than Hispanic clients. Hispanic clients have fewer co-occurring mental disorders than White clients, but a similar history of mental health treatment. These findings set the stage for refining the agenda to develop the most effective treatments for Hispanics with substance use disorders. [ABSTRACT FROM AUTHOR]

Abstract: This study examines the association between adherence to during-treatment process measures of quality (defined as initiation and engagement in treatment as developed by the Washington Circle) and outcome measures (defined as arrests and incarcerations) in the following year. The data come from the Oklahoma Department of Mental Health and Substance Abuse Services administrative data system linked to data from state criminal justice agencies. Clients who initiated a new episode of outpatient treatment and who engaged in treatment were significantly less likely to be arrested or incarcerated in the following year. Initiation of substance abuse treatment alone, without engagement in treatment, was not significantly associated with arrests or incarcerations. These findings validate the clinical importance of the Washington Circle performance measures of initiation and engagement. Applying the “process-of-care” measures can make a difference when they are used as a target for quality improvement in treatment facilities. [Copyright &y& Elsevier]

Background: Screening for substance abuse and mental health in primary care can improve detection. One way to advance screening is for health plans to require it.Objectives: We developed national estimates of the prevalence and type of mental and substance-use condition screening health plans require of primary care practitioners.Design: In 1999 (N = 434, response rate = 92%) and 2003 (N = 368, response rate = 83%), we conducted a nationally representative health plan survey regarding alcohol, drug, and mental health services, including screening requirements.Participants: Health plans reported on screening requirements of their top three private insurance products. Products were categorized by type (HMO, POS, or PPO), behavioral health contracting arrangements, tax status, market area population, and region.Measurements: We asked whether primary care practitioners are required to use a general health screening questionnaire (including mental health, alcohol, or drugs items) and/or a screening questionnaire focused on mental health, alcohol, or drug problems.Results: By 2003, 34% of products had any behavioral health screening requirements. Although there was no increase from 1999 to 2003 in requirements for any kind of behavioral health screening, requirements for using a standard screening instrument declined for mental health but increased for alcohol and drug screening. PPOs showed the largest increase in prevalence of behavioral health screening requirements. Products contracting with managed behavioral health organizations were more likely to require screening.Conclusions: Most products do not require behavioral health screening in primary care. More screening could help to improve identification of behavioral health conditions, a first step towards effective treatment. [ABSTRACT FROM AUTHOR]

Abstract: Background:: In the past decade, health insurers have increased their reliance on cost control policies such as prior authorization and 3-tier formularies. Little is known about how these policies are being applied to psychotropic medications, many of which have low rates of patient adherence. Objective:: This study reports on plans'' cost-sharing tier placement and authorization policies for 12 brandonly psychotropic medications in 3 classes: antidepressants, antitipsychotics, and medications for attentiondeficit/hyperactivity disorder (ADFID). Methods:: Data were from a nationally representativesurvey of private health plans regarding mental health and substance-abuse services in 2003; 368 plans responded (83% response rate). Results were weighted and represent national estimates of health-plan characteristics. Results:: The majority of insurance products provided unrestricted placement on Tier 2 (medium copayment) for at least 2 brand-only antidepressants and at least 2 brand-only antipsychotics. This approach allows clinicians some limited leeway in initial medication selection. However, most patients who did not respond to the Tier-2 options typically faced a substantial escalation in copaynnent (Tier 3), possibly leading to premature medication discontinuation. For ADHI)5 the options were considerably more limited, with 22.1% of products applying some restriction to all 3 medications and only 15.9% of products leaving all 3 medications unrestricted. Plans with specialty contracts for mental health were considerably more likely to use Tier 3 (highest copayinerit) as their only restriction approach. Conclusions:: Based on the results of this analysis,private plans were managing psychotropic costs using copayment incentives rather than administrative controls. This approach was less intrusive for clinicians, but resulting higher copayments could worsen already high rates of nonadherence; future research should examine this issue. [Copyright &y& Elsevier]

Performance measures, which evaluate how well health care practitioners' actions conform to practice guidelines, medical review criteria, or standards of quality, can be used to improve access to treatment and the quality of treatment for people with alcohol and other drug problems. This article examines different types of quality measures, how they fit within the continuum of care, and the types of data that can be used to arrive at these measures. The Washington Circle measures—identification, initiation of treatment, and treatment engagement—are a widely used set of performance measures. [ABSTRACT FROM AUTHOR]

The nationally representative Alcohol and Drug Services Study (ADSS, 1996–1999) is used to examine employment counseling's impact on treatment participation and on postdischarge abstinence and employment. Employment counseling (EC) is among the more frequently received ancillary services in substance user treatment. The ADSS study sample showed it was received by 13% of all (N = 988) nonmethadone outpatient clients, and 42% of the 297 clients with a need for it. Clients who received needed EC (met need) are compared to clients who did not receive needed EC (unmet need). Met-need clients had significantly longer treatment duration and greater likelihood of employment postdischarge than unmet-need clients. Both groups were as likely to complete treatment and be abstinent at follow-up. Implications are discussed. Future needed research and unresolved critical issues are also noted. [ABSTRACT FROM AUTHOR]

Recent initiatives to improve private insurance coverage for substance abuse and mental health in the United States have mostly focused on equalizing coverage limits to those found in general medical care. Federal law does not address cost sharing (copayments and coinsurance), which may also deter needed care or impose significant financial burdens on enrollees. This article reports on cost sharing requirements for outpatient care in a nationally representative sample of managed care plans in 1999. Levels of cost sharing are substantial, with around 40 percent of products requiring copayments of $20 or more and another 15 percent requiring coinsurance of 50 percent. Cost sharing for outpatient substance abuse treatment is very similar to that for mental health. Compared to general medical care, at least 30 percent of products impose higher cost sharing for substance abuse and mental health treatment. Future parity initiatives should be examined for how they address differences in cost sharing as well as limits. [ABSTRACT FROM AUTHOR]

The article represents the proceedings of a symposium at the 2001 RSA Meeting in Montreal, Canada. The organizer/chair was Stephen Magura. The presentations examined: (1) How managed care organization policies may affect enrollees' use of alcohol and other drug (AOD) treatment, by Constance Horgan and associates; (2) The determinants of patients' access to and utilization of AOD treatment in a large health maintenance organization, by Jennifer R. Mertens and Constance Weisner; (3) The impact on treatment access and costs of a statewide carve-out for AOD treatment for Medicaid, by Donald Shepard and associates; and (4) The predictive validity of a new patient assessment technology developed, in part, to better justify AOD treatment in response to the demands of managed care, by Stephen Magura and associates. [ABSTRACT FROM AUTHOR]

Many U.S. employers have carved substance abuse and mental health services out of their medical plans, changing the way millions of people access care. Employers that take this approach contract directly with specialized vendors, bypassing their general health plans. Since carving out may alter access and treatment, there is a need to understand why employers take this approach. This article reviews various hypotheses about why purchasers carve out and tests them using data from a survey of America's largest employers, the Fortune 500 firms. Size is the strongest predictor of an employer's decision to carve out behavioral health once other characteristics are controlled for. Employers that report they value coordination are less likely to carve out, while those that value special expertise are more likely to carve out. Employers are less likely to carve out enrollees in health maintenance organizations (HMOs) than those in other types of plans. [ABSTRACT FROM AUTHOR]

Presents the research challenges of using insurance claims data sets to study substance abuse. Use of administrative data to analyze costs to employers; Utilization of services for treating abuse of specific drugs; Effects of managed care strategies.

PURPOSE Over 29 million Americans have alcohol use disorder (AUD). Though there are effective medications for AUD (MAUD) that can be prescribed within primary care, they are underutilized. We aimed to explore how primary care physicians familiar with MAUD make prescribing decisions and to identify reasons for underuse of MAUD within primary care. METHODS We conducted semistructured interviews with 19 primary care physicians recruited from a large online database of medical professionals. Physicians had to have started a patient on MAUD within the last 6 months in an outpatient setting. Inductive and deductive thematic analysis was informed by the theory of planned behavior. RESULTS Physicians endorsed that it is challenging to prescribe MAUD due to several reasons, including: (1) somewhat negative personal beliefs about medication effectiveness and likelihood of patient adherence; (2) competing demands in primary care that make MAUD a lower priority; and, (3) few positive subjective norms around prescribing. To make MAUD prescribing a smaller component of their practice, physicians reported applying various rules of thumb to select patients for MAUD. These included recommending MAUD to the patients who seemed the most motivated to reduce drinking, those with the most severe AUD, and those who were also receiving other treatments for AUD. CONCLUSIONS There is a challenging implementation context for MAUD due to competing demands within primary care. Future research should explore which strategies for identifying a subset of patients for MAUD are the most appropriate and most likely to improve population health and health equity. [ABSTRACT FROM AUTHOR]

Opioid use disorders (OUDs) are receiving significant attention in the U.S. as a public health crisis. Access to treatment for OUDs is essential and was expected to improve following implementation of the federal parity law and the Affordable Care Act. This study examines changes in coverage and management of treatments for OUDs (opioid treatment programs (OTPs) as a covered service benefit, buprenorphine as a pharmacy benefit) before, during, and after parity and ACA implementation. Data are from three rounds of a nationally representative survey conducted with commercial health plans regarding behavioral health services in benefit years 2003, 2010, and 2014. Data were weighted to be representative of health plans' commercial products in the continental United States (2003 weighted N = 7,469, 83% response rate; 2010 N = 8,431, 89% response rate; and 2014 N = 6,974, 80% response rate). Results showed treatment for OUDs was covered by nearly all health plan products in each year of the survey, but the types and patterns varied by year. Prior authorization requirements for OTPs have decreased over time. Despite the promise of expanded access to OUD treatment suggested by parity and the ACA, improved health plan coverage for treatment of OUDs, while essential, is not sufficient to address the opioid crisis. [ABSTRACT FROM AUTHOR]

Employers and health plans increasingly offer incentives to individuals to help shape their health behaviors including utilization of recommended care. However, despite the focus on patient-centered health care in the broader field, incentives are often one-size-fits-all. “Person-centered incentives” take into account individual differences that are often unobservable to those managing incentives programs and incorporate choice into the incentives structure. The authors propose multiple dimensions of person-centered incentives to consider and suggest a research agenda to determine their impact. Person-centered incentives may constitute a valuable addition to the toolbox of ways to encourage individuals to improve their health behaviors. [ABSTRACT FROM AUTHOR]

Abstract: This paper presents the rationale and feasibility of standardized performance measures for use of pharmacotherapy in the treatment of substance use disorders (SUD), an evidence-based practice and critical component of treatment that is often underused. These measures have been developed and specified by the Washington Circle, to measure treatment of alcohol and opioid dependence with FDA-approved prescription medications for use in office-based general health and addiction specialty care. Measures were pilot tested in private health plans, the Veterans Health Administration (VHA), and Medicaid. Testing revealed that use of standardized measures using administrative data for overall use and initiation of SUD pharmacotherapy is feasible and practical. Prevalence of diagnoses and use of pharmacotherapy vary widely across health systems. Pharmacotherapy is generally used in a limited portion of those for whom it might be indicated. An important methodological point is that results are sensitive to specifications, so that standardization is critical to measuring performance across systems. [Copyright &y& Elsevier]

The authors examined the relationship between treatment quality, using during-treatment process measures, and mutual-help group (e.g., Alcoholics Anonymous) attendance after outpatient substance use disorder (SUD) treatment for 739 clients in the Alcohol and Drug Services Study. Logistic regression models estimated any and regular mutual-help attendance after treatment. Clients referred to mutual-help groups were significantly more likely to attend any mutual help after treatment. Results were mixed for facility offered mutual-help groups; treatment engagement and retention were not significant. These findings offer treatment providers further evidence of the importance of referring clients to post-treatment mutual-help groups, an effective, low-cost option. [ABSTRACT FROM PUBLISHER]

Background: Little is known about the practitioners in managed behavioral healthcare organization (MBHO) networks who are treating mental and substance use disorders among privately insured patients in the United States. It is likely that the role of the private sector in treating behavioral health will increase due to the recent implementation of federal parity legislation and the inclusion of behavioral health as a required service in the insurance exchange plans created under healthcare reform. Further, the healthcare reform legislation has highlighted the need to ensure a qualified workforce in order to improve access to quality healthcare, and provides an additional focus on the behavioral health workforce. To expand understanding of treatment of mental and substance use disorders among privately insured patients, this study examines practitioner types, experience, specialized expertise, and demographics of in-network practitioners providing outpatient care in one large national MBHO. Methods: Descriptive analyses used 2004 practitioner credentialing and other administrative data for one MBHO. The sample included 28,897 practitioners who submitted at least one outpatient claim in 2004. Chi-square and t-tests were used to compare findings across types of practitioners. Results: About half of practitioners were female, 12% were bilingual, and mean age was 53, with significant variation by practitioner type. On average, practitioners report 15.3 years of experience (SD = 9.4), also with significant variation by practitioner type. Many practitioners reported specialized expertise, with about 40% reporting expertise for treating children and about 60% for treating adolescents. Conclusions: Overall, these results based on self-report indicate that the practitioner network in this large MBHO is experienced and has specialized training, but echo concerns about the aging of this workforce. These data should provide us with a baseline of practitioner characteristics as we enter an era that anticipates great change in the behavioral health workforce. [ABSTRACT FROM AUTHOR]

Abstract: Five states (Connecticut, Massachusetts, New York, North Carolina, and Oklahoma) have incorporated the Washington Circle (WC) substance abuse performance measures in various ways into their quality improvement strategies. In this article, we focus on what other states and local providers might learn from these states'' experiences as they consider using WC performance measures. Using a case study approach, we report that the use of WC measures differs across these five states, although there are important common themes required for adoption and sustainability of performance measures, which include leadership, evaluation of specification and use of measures over time, state-specific adaptation of the WC measure specifications, collaboration with consultants and partners, inclusion of WC measures in the context of other initiatives, reporting to providers and the public, and data and resource requirements. As additional states adopt some of the WC measures, or adopt other performance measurement approaches, these states'' experiences could help them to develop implementations based on their particular needs. [Copyright &y& Elsevier]

Abstract: Performance measures have the potential to drive high-quality health care. However, technical and policy challenges exist in developing and implementing measures to assess substance use disorder (SUD) pharmacotherapy. Of critical importance in advancing performance measures for use of SUD pharmacotherapy is the recognition that different measurement approaches may be needed in the public and private sectors and will be determined by the availability of different data collection and monitoring systems. In 2009, the Washington Circle convened a panel of nationally recognized insurers, purchasers, providers, policy makers, and researchers to address this topic. The charge of the panel was to identify opportunities and challenges in advancing use of SUD pharmacotherapy performance measures across a range of systems. This article summarizes those findings by identifying a number of critical themes related to advancing SUD pharmacotherapy performance measures, highlighting examples from the field, and recommending actions for policy makers. [ABSTRACT FROM AUTHOR]

This study examined service user characteristics and determinants of access for enrollees in integrated EAP/behavioral health versus standard managed behavioral health care plans. A national managed behavioral health care organization’s claims data from 2004 were used. Integrated plan service users were more likely to be employees rather than dependents, and to be diagnosed with adjustment disorder. Logistic regression analyses found greater likelihood in integrated plans of accessing behavioral health services (OR 1.20, CI 1.17–1.24), and substance abuse services specifically (OR 1.23, CI 1.06–1.43). Results are consistent with the concept that EAP benefits may increase access and address problems earlier. [ABSTRACT FROM AUTHOR]

Abstract: The Washington Circle, a group focused on developing and disseminating performance measures for substance abuse services, developed three such measures for private health plans. In this article, we explore whether these measures are appropriate for meeting measurement goals in the public sector and feasible to calculate in the public sector using data collected for administrative purposes by state and local substance abuse and/or mental health agencies. Working collaboratively, 12 states specified revised measures and 6 states pilot tested them. Two measures were retained from the original specifications: initiation of treatment and treatment engagement. Additional measures were focused on continuity of care after assessment, detoxification, residential or inpatient care. These data demonstrate that state agencies can calculate performance measures from routinely available information and that there is wide variability in these indicators. Ongoing research is needed to examine the reasons for these results, which might include lack of patient interest or commitment, need for quality improvement efforts, or financial issues. [Copyright &y& Elsevier]

This study evaluated how a change in gatekeeping model at a health maintenance organization affected performance indicators for specialty outpatient mental health care. Gatekeeping in one division changed from in-person evaluations to a call center with routine authorization for the first eight visits. Using 1996–1999 claims data (including 2 years pre- and 2 years postintervention), the study compared performance indicator results in the affected division and another where the model did not change. Subjects included 122,751 continuously enrolled persons. Dependent variables were mental health emergency room use, treatment initiation, treatment engagement, and family treatment for child patients. After controlling for secular trends at the other division and enrollee characteristics, the division that changed gatekeeping experienced no significant impact on most indicators and an increase in family treatment for children. The move to call-center gatekeeping did not appear to have a negative impact on treatment process as reflected in these indicators. [ABSTRACT FROM AUTHOR]

Objective: To measure how a change in gatekeeping model affects utilization of specialty mental health services.Data Sources/study Setting: Secondary data from health insurance claims for services during 1996-1999. The setting is a managed care organization that changed gatekeeping model in one of its divisions, from in-person evaluation to the use of a call-center.Study Design: We evaluate the impact of the change in gatekeeping model by comparing utilization during the 2 years before and 2 years after the change, both in the affected division and in another division where gatekeeping model did not change. The design is thus a controlled quasi-experimental one. Subjects were not randomized. Key dependent variables are whether each individual had any specialty mental health visits in a year; the number of visits; and the proportion of users exceeding eight visits in a year. Key explanatory variables include demographic variables and indicators for patient diagnoses and their intervention status (time-period, study group).Data Collection/extraction Methods: Claims data were aggregated to create analytic files with one record per member per year, with variables reporting demographic characteristics and mental health service use.Principal Findings: After controlling for secular trends at the other division, the division which changed gatekeeping model eventually experienced an increase in the proportion of enrollees receiving specialty mental health treatment, of 0.5 percentage point. Similarly, there was an increase of about 0.6 annual visits per user, concentrated at the low end of the distribution. These changes occurred only in the second year after the gatekeeping changes.Conclusions: The results of this study suggest that the gatekeeping changes did lead to increases in utilization of mental health care, as hypothesized. At the same time, the magnitude of the increase in access and mean number of visits that we found was relatively modest. This suggests that while the change from face-to-face specialty gatekeeping to call-center intake does increase utilization, it is unlikely to overwhelm a system with new demand or create huge cost increases. [ABSTRACT FROM AUTHOR]

In this article we discuss the strengths and weaknesses of using different types of data sources for alcohol and drug abuse services research. To do this, we describe four types of data sources used in substance abuse services research: surveys of organizations, medical records, claim and encounter data and program-level administrative data. For each, we outline where to obtain data, how each type has been used, and the advantages and challenges. This overview should allow investigators to think more critically about the datasets they now use; providers to understand the types of data sources most appropriate for specific research questions so as to participate more fully in research; and policy makers to interpret correctly results based on different types of data. Moreover, it should foster better communication among these stakeholders in collaborative projects to improve the effectiveness of services for people with addictions. [ABSTRACT FROM AUTHOR]

Background: Acute 24-h detoxification services (detox) are necessary but insufficient for many individuals working towards long-term recovery from opiate, alcohol or other drug addiction. Longer engagement in substance use disorder (SUD) treatment can lead to better health outcomes and reductions in overall healthcare costs. Connecting individuals with post-detox SUD treatment and supportive services is a vital next step. Toward this end, the Massachusetts Medicaid program reimburses Community Support Program staff (CSPs) to facilitate these connections. CSP support services are typically paid on a units-of-service basis. As part of a larger study testing health care innovations, one large Medicaid insurer developed a new cadre of workers, called Recovery Support Navigators (RSNs). RSNs performed similar tasks to CSPs but received more extensive training and coaching and were paid an experimental case rate (a flat negotiated reimbursement). This sub-study evaluates the feasibility and impact of case rate payments for RSN services as compared to CSP services paid fee-for-service.Methods: We analyzed claims data and RSN service data for a segment of the Massachusetts Medicaid population who had more than one detox admission in the last year and also engaged in post-discharge CSP or RSN services. Qualitative data from key informant interviews and Learning Collaboratives with CSPs and RSNs supplemented the findings.Results: Clients receiving RSN services under the case rate utilized the service significantly longer than clients receiving CSP services under unit-based billing. This resulted in a lower average cost per member per month for RSN clients. However, when calculating total SUD treatment costs per member, RSN client costs were 50% higher than CSP client costs. Provider organizations employing RSNs successfully implemented case rate billing. Benefits included allowing time for outreach efforts and training and coaching, activities not paid under the unit-based system. Yet, RSNs identified staffing and larger systems level challenges to consider when using a case rate payment model.Conclusions: Addiction is a chronic disease that requires long-term investments. Case rate billing offers a promising option for payers and providers as it promotes continued engagement with service providers. To fully realize the benefits of case rate billing, however, larger systems level changes are needed. [ABSTRACT FROM AUTHOR]

Background: Some US payers are starting to vary payment to providers depending on patient outcomes, but this approach is rarely used in substance use disorder (SUD) treatment.Purpose: We examine the feasibility of applying a pay-for-outcomes approach to SUD treatment.Methods: We reviewed several relevant literatures: (1) economic theory papers that describe the conditions under which pay-for-outcomes is feasible in principle; (2) description of the key outcomes expected from SUD treatment, and the measures of these outcomes that are available in administrative data systems; and (3) reports on actual experiences of paying SUD treatment providers based on patient outcomes.Results: The economics literature notes that when patient outcomes are strongly influenced by factors beyond provider control and when risk adjustment performs poorly, pay-for-outcomes will increase provider financial risk. This is relevant to SUD treatment. The literature on SUD outcome measurement shows disagreement on whether to include broader outcomes beyond abstinence from substance use. Good measures are available for some of these broader constructs, but the need for risk adjustment still brings many challenges. Results from two past payment experiments in SUD treatment reinforce some of the concerns raised in the more conceptual literature.Conclusion: There are special challenges in applying pay-for-outcomes to SUD treatment, not all of which could be overcome by developing better measures. For SUD treatment it may be necessary to define outcomes more broadly than for general medical care, and to continue conditioning a sizeable portion of payment on process measures. [ABSTRACT FROM AUTHOR]

Although evidence points to the benefits of continuity of care after detoxification (detox), especially when continuity of care occurs within a short time after discharge from a detox episode, the rate at which clients engage in continued treatment after detox remains low. The goal of the study was to develop and deploy a specially trained workforce, called recovery support navigators (RSNs), to increase the likelihood of clients continuing onto treatment after detox. Continuity of care is defined as receiving any substance use disorder (SUD) treatment service within 14 days of discharge from the index detox. We examined whether clients in the RSN Intervention group were more likely to meet the continuity of care after detox criteria than clients in the treatment-as-usual (TAU) group. A quasi-experimental intervention versus comparison group study was conducted. Data were from the Massachusetts Behavioral Health Partnership (MBHP), a Beacon Health Options company that manages behavioral health benefits for a subset of Medicaid beneficiaries in the state. Inclusion in the analytic sample (N = 4,236) required that the client's index admission to detox was between 3/29/13 and 3/31/15. RSN Intervention versus TAU status was assigned based on provider organization where the index detox occurred. Analyses were conducted on an intent-to-treat basis. Overall, the continuity of care rate across all study groups was 42%. The rate by study group was 38% for the TAU and 45% for the RSN group. Clients who were in the RSN group were significantly more likely to have continuity of care after discharge from detox than those in the TAU (OR = 1.233, p < .05, 95% CI = 1.044, 1.455). Clients who entered detox at a site that provided specialized training to RSN, which included motivational interviewing and educational sessions related to treatment issues, and allowing them to bill with a flexible daily case rate instead of the usual fee-for-service billing, were more likely to have continuity of care after discharge from detox compared to clients in the TAU group. [ABSTRACT FROM AUTHOR]

Program-level financial incentives are used by some payers as a tool to improve quality of substance use treatment. However, evidence of effectiveness is mixed and performance contracts may have unintended consequences such as creating barriers for more challenging clients who are less likely to meet benchmarks. This study investigates the impact of a performance contract on waiting time for substance use treatment and client selection. Admission and discharge data from publicly funded Maine outpatient (OP) and intensive outpatient (IOP) substance use treatment programs (N = 38,932 clients) were used. In a quasi-experimental pre-post design, pre-period (FY 2005-2007) admission data from incentivized (IC) and non-incentivized (non-IC) programs were compared to post-period (FY 2008-2012) using propensity score matching and multivariate difference-in-difference regression. Dependent variables were waiting time (incentivized) and client selection (severity: history of mental disorders and substance use severity, not incentivized). Despite financial incentives designed to reduce waiting time for substance use treatment among state-funded outpatient programs, average waiting time for treatment increased in the post period for both IC and non-IC groups, as did client severity. There were no significant differences in waiting time between IC and non-IC groups over time. Increases in client severity over time, with no group differences, indicate that programs did not restrict access for more challenging clients. Adequate funding and other approaches to improve quality may be beneficial. [ABSTRACT FROM AUTHOR]

Health plans are key players in substance use treatment in the United States, and the opioid crisis presents new challenges for them. This article is part of the HEALing Communities Study (HCS) funded by NIH, which seeks to facilitate communities' adoption of activities that might reduce overdose deaths, including overdose prevention education and naloxone distribution, medication for opioid use disorder, and safer opioid prescribing. We examine how health plans in one state (Massachusetts) are adapting to encourage and sustain activities that help communities to address opioid use disorder (OUD). We conducted semi-structured interviews with managers of behavioral health services at eight health plans in Massachusetts that that have Medicare, Medicaid, and commercial lines of business. Two plans in this sample contract with a specialized behavioral health organization ("carve-out"). The interviewees also completed a survey on policies regarding access to treatment and opioid prescribing. Interviews were recorded and transcribed and analyzed using thematic analysis. Analysis of the data included intended influence of the policies at three levels: member level (micro), group or community level (meso), and system or institutional level (macro). All health plans developed strategies to increase access to treatment for OUD, primarily through eliminating or decreasing cost-sharing, eliminating pre-authorization for MOUD, and increasing supply of providers. Health plans encourage qualified practitioners to offer MOUD, but most do not provide incentives or training. Identifying high risk populations is a focus of health plans in this sample. Naloxone is a covered benefit in all health plans, although with variation in monthly limits and cost-sharing. Most health plans take measures to influence opioid prescribing. Health plans' activities are predominately aimed at the micro (member) level with little ability to influence at the macro (wider system-level changes). This study provides insight into how health plans develop strategies to address the rise in OUD and fatal opioid overdoses, many of which are key in the HCS initiative. How active a role health plans play in addressing the opioid crisis varies, even within the insurance industry in one state (Massachusetts). • There is a high degree of variability in how active a role health plans play in increasing access to care. • Plans are more active in encouraging individual-level interventions and less active in promoting community-level initiatives. • We found very little collaboration among health plans with stakeholders beyond the healthcare system. [ABSTRACT FROM AUTHOR]

Background: Despite the importance of continuity of care after detoxification and residential treatment, many clients do not receive further treatment services after discharged. This study examined whether offering financial incentives and providing client-specific electronic reminders to treatment agencies lead to improved continuity of care after detoxification or residential treatment.Methods: Residential (N = 33) and detoxification agencies (N = 12) receiving public funding in Washington State were randomized into receiving one, both, or none (control group) of the interventions. Agencies assigned to incentives arms could earn financial rewards based on their continuity of care rates relative to a benchmark or based on improvement. Agencies assigned to electronic reminders arms received weekly information on recently discharged clients who had not yet received follow-up treatment. Difference-in-difference regressions controlling for client and agency characteristics tested the effectiveness of these interventions on continuity of care.Results: During the intervention period, 24,347 clients received detoxification services and 20,685 received residential treatment. Overall, neither financial incentives nor electronic reminders had an effect on the likelihood of continuity of care. The interventions did have an effect among residential treatment agencies which had higher continuity of care rates at baseline.Conclusions: Implementation of agency-level financial incentives and electronic reminders did not result in improvements in continuity of care, except among higher performing agencies. Alternative strategies at the facility and systems levels should be explored to identify ways to increase continuity of care rates in specialty settings, especially for low performing agencies. [ABSTRACT FROM AUTHOR]

Introduction: Recent payment reforms promote movement from fee-for-service to alternative payment models that shift financial risk from payers to providers, incentivizing providers to manage patients' utilization. Bundled payment, an episode-based fixed payment that includes the prices of a group of services that would typically treat an episode of care, is expanding in the United States. Bundled payment has been recommended as a way to pay for comprehensive SUD treatment and has the potential to improve treatment engagement after detox, which could reduce detox readmissions, improve health outcomes, and reduce medical care costs. However, if moving to bundled payment creates large losses for some providers, it may not be sustainable. The objective of this study was to design the first bundled payment for detox and follow-up care and to estimate its impact on provider revenues.Methods: Massachusetts Medicaid beneficiaries' behavioral health, medical, and pharmacy claims from July 2010-April 2013 were used to build and test a detox bundled payment for continuously enrolled adults (N=5521). A risk adjustment model was developed using general linear modeling to predict beneficiaries' episode costs. The projected payments to each provider from the risk adjustment analysis were compared to the observed baseline costs to determine the potential impact of a detox bundled payment reform on organizational revenues. This was modeled in two ways: first assuming no change in behavior and then assuming a supply-side cost sharing behavioral response of a 10% reduction in detox readmissions and an increase of one individual counseling and one group counseling session.Results: The mean total 90-day detox episode cost was $3743. Nearly 70% of the total mean cost consists of the index detox, psychiatric inpatient care, and short-term residential care. Risk mitigation, including risk adjustment, substantially reduced the variation of the mean episode cost. There are opportunities for organizations to gain revenue under this bundled payment design, but many providers will lose money under a bundled payment designed using historic payment and costs.Conclusions: Designing a bundled payment for detox and follow-up care is feasible, but low case volume and the adequacy of the payment are concerns. Thus, a detox episode-based payment will likely be more challenging for smaller, independent SUD treatment providers. These providers are experiencing many changes as financing shifts away from block grant funding toward Medicaid funding. A detox bundled payment in practice would need to consider different risk mitigation strategies, provider pooling, and costs based on episodes of care meeting quality standards, but could incentivize care coordination, which is important to reducing detox readmissions and engaging patients in care. [ABSTRACT FROM AUTHOR]