Amity E. Quinn

The Role of Health Plans in Supporting Behavioral Health Integration

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.

Massachusetts Substance Use Disorder Treatment Organizations’ Perspectives on the Affordable Care Act: Changes in Payment, Services, and System Design

ABSTRACT The Affordable Care Act (ACA) expanded insurance benefits and coverage for substance use disorder (SUD) treatment and encouraged delivery and payment reforms. Massachusetts passed a similar reform in 2006. This study aims to assess Massachusetts SUD treatment organizations’ responses to the ACA. Organizational interviews addressing challenges of and responses to the ACA were conducted in person June–December 2014 with 31 leaders at 12 treatment organizations across Massachusetts. Many organizations were affiliated with medical or social services and offered a range of SUD services. Sampling was based on services offered (detoxification only, detoxification and outpatient, outpatient only). Framework analysis was used. Challenges identified were considered similar to ongoing challenges, not unique to the ACA. Organizations experienced insurance expansions in 2006 and faced new challenges, including insurance coverage, payment arrangements, expansion of services, and system design. System design efforts included care coordination/integration, workforce development, and health information technology. Differences in responses related to connections with medical and social service organizations. Many organizations engaged in efforts to respond to changing policies by expanding capacity and services. Offering a range of SUD treatment (e.g., detoxification and outpatient) and affiliating with a medical organization could enable organizations to respond to new insurance, delivery, and payment reforms.

Private Health Plans’ Contracts with Managed Behavioral Healthcare Organizations

Contracts between health plans and managed behavioral health care organizations (MBHOs) influence access and quality of behavioral health care. This report presents information on performance requirements, information sharing, and financial risk from a nationally representative survey of private health plans. Most contracts include geographic access to providers (93.3%) and NCQA’s performance standards (84.2%). Health plans and MBHOs share data (99.0%), generally by the MBHO sending information to the health plan (96.3%). About a quarter of contracts impose financial penalties (23.0%), but few include incentives related to performance standards (<1.0%). Contract terms can shape the provision of behavioral health services in response to changes such as parity legislation or health reform. If current trends continue towards increases in value-based purchasing in the privately financed behavioral health sector, the focus on quality in contracts between health plans and MBHOs will be critical to understand.

Availability of outpatient methadone maintenance

Background Multiple forms of effective treatment for opioid use disorders (OUDs) exist, but they have remained in short supply and have been underutilized where available. Simultaneously, OUDs persist as a large and growing public health problem across the United States, leading to epidemic levels of overdose death as well as many other damaging societal consequences. Our goal was to assess the current state of the U.S. substance abuse treatment system and measure its capacity for treating OUDs. Focusing on outpatient methadone maintenance therapy (OPMM), an effective but less frequently studied treatment in recent years, we investigated two primary questions about privately-run substance abuse treatment facilities: 1) What facility-level characteristics best predicted the provision of OPMM? 2) How much of the variation in OPMM availability was attributable to differences between states?

Translating the semi-structured assessment for drug dependence and alcoholism in the Western Pacific: rationale, study design and reliability of alcohol dependence.

AIMS The aims of this study were to develop a bilingual version of the Semi-Structured Assessment for Drug Dependence and Alcoholism (SSADDA) in English and Samoan and determine the reliability of assessments of alcohol dependence in American Samoa. METHODS The study consisted of development and reliability-testing phases. In the development phase, the SSADDA alcohol module was translated and the translation was evaluated through cognitive interviews. In the reliability-testing phase, the bilingual SSADDA was administered to 40 ethnic Samoans, including a sub-sample of 26 individuals who were retested. RESULTS Cognitive interviews indicated the initial translation was culturally and linguistically appropriate except items pertaining to alcohol tolerance, which were modified to reflect Samoan concepts. SSADDA reliability testing indicated diagnoses of DSM-III-R and DSM-IV alcohol dependence were reliable. Reliability varied by language of administration. CONCLUSION The English/Samoan version of the SSADDA is appropriate for the diagnosis of DSM-III-R alcohol dependence, which may be useful in advancing research and public health efforts to address alcohol problems in American Samoa and the Western Pacific. The translation methods may inform researchers translating diagnostic and assessment tools into different languages and cultures.

Provider payment approaches and incentives to implement screening

Screening in primary care is widely recommended (e.g. U.S. Preventive Services Task Force and UK National Institute for Health and Care Excellence), and is increasingly targeted for improvement. As health care payers try to influence the implementation and delivery of alcohol screening and brief intervention (SBI), some are using provider payment approaches. These include specific reimbursement for conducting screening, other financial incentives and linking payment with performance measures. We present 2010 data from a nationally representative survey of private US health plans and US health plan claims data (private health plans and Medicare), supplemented by literature review. Results indicate, among private health plan products in the US, 72.6% report allowing primary care physicians to bill for alcohol SBI, yet claims data analysis found only 0.01% of individuals in private plans or Medicare had an SBI procedure code on a medical claim in 2010. As of April 2013 the UK National Health Service requires that primary care practices conduct screening of individuals 16 and over and reimburses for SBI. In the US, although financial incentives for providers are becoming more common in private health plans (used by 31.6% for any condition), only 6% of health plans provided financial incentives for primary care screening for alcohol and drug use problems. Provider payment policies may be tied to performance measures to improve the quality of care. Alcohol screening is one of more than 300 performance measures selected for inclusion in the US Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System. Despite this recognition, CMS analyses indicate the alcohol screening measure was not among the top five measures chosen by primary care providers. Although alcohol SBI is beneficial, it is not as widely implemented as it could be. Favorable payment policies are necessary, but not sufficient to encourage implementation of SBI.

Behavioral Health Coverage Under the Affordable Care Act: What Can We Learn From Marketplace Products?

OBJECTIVE The 2008 federal parity law and the 2010 Affordable Care Act (ACA) sought to expand access to behavioral health services. There was concern that health plans might discourage enrollment by individuals with behavioral health conditions who tend to be higher cost. This study compared behavioral health benefits available in the group insurance market (nonmarketplace) to those sold through the ACA marketplaces to check for evidence of less generous behavioral health coverage in marketplace plans. METHODS Data were from a 2014 nationally representative survey of commercial health plans regarding behavioral health services (80% response rate). The sample included the most common silver marketplace product and, as a comparison, the most common nonmarketplace product of the same type (for example, health maintenance organization or preferred provider organization) from each health plan (N=106 marketplace and nonmarketplace pairs, or 212 products). RESULTS Marketplace and nonmarketplace products were similar in terms of coverage, prior authorization, and continuing review requirements. Marketplace products were more likely to employ narrow and tiered behavioral health provider networks. Narrow and tiered networks were more common in state than in federal marketplaces. CONCLUSIONS Provider network design is a tool that health plans may use to control cost and possibly discourage enrollment by high-cost users, including those with behavioral health conditions. The ACA was successful in ensuring robust behavioral health coverage in marketplace plans. As the marketplaces evolve or are replaced, these data provide an important baseline to which future systems can be compared.

Delivery and payment reform in Massachusetts: substance use disorder treatment organizations’ perspectives

Background The Affordable Care Act and many states’ health-care reforms present opportunities and challenges for the substance use disorder (SUD) treatment system. These reforms foster the implementation of new payment and delivery system models that emphasize care coordination and make providers more responsible for patients’ clinical management and costs. Bundled payments, a predetermined fee or budget that includes the prices of a group of services that would typically treat an episode of care in a defined period of time, are considered one of the most promising new payment models. Bundled payments for SUD treatment have the potential to improve care coordination, implementation of evidence-based practices, and engagement in outpatient treatment; reduce readmissions to detox; make care more patientcentered; and cover treatment services that are not traditionally reimbursed. The objective of this study was to obtain SUD treatment organizations’ perspectives on health-care reform and the design of bundled payments for SUD treatment.