Achieving Value in Substance Use Disorder Treatment: Paying for What Works (and Not Paying for What Doesn’t)
[cross-posted from CHERISH]
More than 100 policymakers, practitioners, and researchers discussed and debated how payment policy can promote evidence-based, cost-effective substance use disorder treatment, in a recent workshop hosted by the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV and HIV (CHERISH) and the Leonard Davis Institute of Health Economics at the University of Pennsylvania. By design, the workshop was highly interactive with roundtable discussions among panelists and participants. The day-long event took stock of the many ongoing efforts, examined the evidence, and explored promising models to achieve value in substance use disorder treatment.
Value-Oriented Substance Use Disorder Treatment: “A Journey Rather than a Destination”
Colleen Barry, PhD, Johns Hopkins Bloomberg School of Public Health, set the stage by discussing the recent report by the Committee on Medication-Assisted Treatment for Opioid Use Disorder of the National Academies of Sciences, Engineering, and Medicine. “The good news,” she said, “is that when it comes to treatment for opioid use disorder, we know much of what we need to know to be able to act. But as a society, we are not acting anywhere near the level of forcefulness and urgency that is needed.”
Barry highlighted two fundamental conclusions of the National Academies committee:
- Opioid Use Disorder (OUD) is a treatable chronic brain condition (contrary to the notion that it is a moral failing or reflects a lack of the self-discipline), and
- FDA-approved medications like methadone and buprenorphine – commonly referred to as Medication Assisted Treatment (MAT) – are effective and save lives but are often inaccessible and misunderstood. Even the term MAT is misleading, because it implies that medication is somehow an adjunct to treatment rather than the first line of treatment.
Barry highlighted how participants across all sectors need to work together to push for change and many of her suggestions for doing so were echoed during the rest of the workshop.
Barry then posed the question of the day – how can payment and a value-oriented approach improve care? Notably, panelists found that the answer to this question is complex: “a journey rather than a destination.” Throughout the day, discussion moved from the barriers to a value-oriented approach, towards model programs and solutions. The following shares highlights from the discussion.
Barriers to value-oriented care
Poor access to medications
Despite the evidence supporting FDA-approved medications for opioid use disorder, access to these medications is limited. Two-thirds of facilities focused on addiction provide no medication treatment, and less than 1 of every 15 treatment facilities in the US provide all three FDA-approved medications. Medications are often unavailable in criminal justice systems, where officials may be reluctant to prescribe them for inmates or may even discontinue medication treatment, despite serious repercussions such as relapse, overdose, and death.
Although the number of providers who have buprenorphine waivers has increased, many providers with waivers write few or no prescriptions. When they do, the prescriptions are often of inadequate duration, and care is fragmented. For example, payers/providers may limit buprenorphine treatment to six months, even though evidence shows that patients often have better outcomes when treated for longer.
Among the primary barriers to achieving high-value substance use disorder (SUD) treatment is stigma. Discussion focused on how much of the national public blames people who use opioids for having SUD and how language reinforces this (e.g., words like addict, abuse, junkie, clean, dirty, habit). These attitudes and beliefs form social norms that work directly against public health initiatives. Attendees indicated that the federal government and the private sector should address stigma and take action to make medication treatment available to more people in more places. Public agencies can replace stigmatizing messaging campaigns with messages conveying that medication treatment works.
Lack of quality and outcome measures
Another barrier to achieving high-value treatment is the lack of good quality and outcome measures by which payers, families, and other stakeholders can compare existing programs. Though evidence for medication treatment is strong, the question persists: what do payers want to see in the data that will enable them to decide what treatment programs to pay for and what not to pay for? As one panelist mentioned, “if we can’t define what is good and what we want to see, then we can’t pay for it.” Panelists brought up the idea of developing consensus measures around high-value care that can be quantified with reportable data.
Why would programs continue to provide services that are low or no value? Why would regulatory agencies continue to certify these programs? And why would payers continue to reimburse them? After people receive non-evidence based interventions such as 72-hour detox or 28-day rehabilitation without medication, a panelist noted, “They’re in exactly the same place they were in before they went to the program, if not in a more dangerous position.”
Panelists discussed the urgency of the issue while audience members discussed the possibility, feasibility, and political viability of using existing economic levers to reduce the use of therapies that simply don’t work. The discussion highlighted several model programs that have helped de-adopt low-value care, as well as promising new strategies to be tried.
Innovative Programs and Demonstrations
One exemplary program described was Virginia’s Addiction Recovery Treatment Services (ARTS) program, which transformed benefits under Medicaid to include an integrated continuum of SUD treatment services. With increased funding (and a federal waiver), Virginia implemented standards around opioid prescribing, provider trainings, and a new treatment system that covers a full range of evidence-based care. Results from the first year show increases in medication treatment, increases in outpatient SUD providers and networks, and decreases in emergency department (ED) visits.
Participants emphasized that new strategies could be used in demonstration projects as a way to improve and expand access to SUD treatment, with the potential for scaling up if successful. For example, projects could test the effectiveness of blended payment model that includes care management fees, and an incentive based on quality measures (ones that may capture retention and treatment).
Recovery Support Navigators
An intervention implemented in a segment of the Massachusetts Medicaid population involved recovery support navigators and incentives to address revolving door issues where patients go in and out of detox but never connect to treatment. Recovery support navigators meet patients in the ED or in detox and set up appointments in primary care settings where medications can be initiated. Navigators are paid on a case rate instead of fee for service to give them more flexibility to spend time organizing services for the client, and the clients receive gift cards contingent on receiving primary care and for reaching other milestones.
Screening and Treatment in Prisons
A program in Rhode Island’s jails and prison includes SUD screening upon entry, options to initiate one of three medications for opioid use disorder, and for those already taking medication, maintenance at the proper dose for up to a year. The discussion highlighted how programs like this require political will, strong leadership, provider training, and education to secure buy-in from policymakers and elected leaders.
High-touch Outpatient Support
In CleanSlate’s high-touch outpatient model patients are seen with some intensity (once or twice a week), especially at the beginning of their treatment. They receive short prescriptions that reinforce compliance with provider visits for prescription renewals. Psychosocial support is built into the program with care coordination that connects patients with services such as Supplemental Nutrition Program (SNAP) for Women, Infants and Children, and other social services, mental health care, and dental care. Though this model is primarily – and intentionally – insurance-based, it does include a cash-based program that uses a sliding scale fee.
Clinical Redesign in Primary Care
Clinical redesign is a system used at the Camden Coalition of Healthcare Providers, in which redesign teams work in primary care offices to help with patient flow and understand how to take on a new treatment area. In Camden, they helped primary offices figure out how they could commit to seeing any Medicaid patient within seven days of discharge from a local hospital. The results showed that getting providers to a point at which they felt comfortable with the process was key to success.
Other Potential Solutions
During roundtable discussions, participants reflected on setting state regulations related to evidence based care. A key area of agreement was the importance of not mandating specific treatments, but giving more money/incentives to those that deliver higher value, or deciding not to pay if a certain benchmark isn’t met. Another strategy included lifting buprenorphine caps for waivered physicians. One panelist spoke about a large insurance carrier’s credentialing process, and policies related to whether to accept providers into the payer network if they are not providing evidence-based treatment.
Could a strategy using bundled payments be helpful in promoting cost-effective treatments, as it has for certain inpatient procedures? Participants emphasized the importance of determining who will receive the bundle and what providers can reasonably be responsible for. As noted by the panelists, one issue is that if there is a fixed amount of money going into the system, some treatment programs may gain from being paid by bundle instead of fee for service while other treatment programs may lose. Without controlling for case mix, there will be incentives to select patients who use fewer services than the bundled rate. Though there are ways to mitigate this risk, doing so can be challenging.
Finally, workshop participants noted that while patients could be steered towards choosing higher-value treatment, patients should have a choice in determining their specific treatment plan, including the option of no treatment at all. Participants suggested identifying policies that make medication treatment programs less punitive, and also recommended treatment centers offer therapeutic doses and same day admissions. It is also important to note that removing facilities that do not currently provide medication would leave many communities with no local treatment options or programs to engage people who use drugs.
Summary and Conclusions
The “Achieving Value in Substance Use Disorder Treatment: Paying for What Works (And Not Paying for What Doesn’t)” workshop examined evidence, ongoing efforts, and models that could improve the value of treatment for SUD. Panel discussions and interactive roundtable discussions engaged audience members and panelists across research, policy, and practice.
- Paying for value in OUD treatment is a promising path to improving care and reducing the impact of opioids on society. However, without meaningful ways to measure quality and outcomes, payers cannot drive this change alone.
- Improved access to treatment, training, and stakeholder buy-in is needed for successful de-adoption of low-value care over time. Research should focus on how we get to a place where medication is available and used, not if we should use medication. Existing models to improve care quality and value offer potential solutions and lessons learned.
- Regardless of the approach, public engagement and addressing stigma and bias is crucial to investing in and paying for the highest quality and most effective treatments.