Mary Brolin

Implementation of Client Incentives within a Recovery Navigation Program

OBJECTIVE Multiple detoxification admissions among clients with substance use disorders (SUD) are costly to the health care system. This study explored the impact on behavior and cost outcomes of recovery support navigator (RSN) services delivered with and without a contingent incentive intervention. METHODS New intakes at four detoxification programs were offered RSN-only (N=1116) or RSN plus incentive (RSN+I; N=1551) services. The study used a group-level cross-over design with the intervention in place at each clinic reversed halfway through the enrollment period. RSN+I clients could earn up to

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

240 in gift cards for accomplishing 12 different recovery-oriented target behaviors. All eligible clients entering the detoxification programs were included in the analyses, regardless of actual service use. RESULTS Among RSN+I clients, 35.5% accessed any RSN services compared to 22.3% in the RSN-only group (p<.01). Of RSN+I clients, 19% earned one, 12% earned two and 18% earned three or more incentives; 51% did not earn any incentives. The majority of incentives earned were for meeting with the RSN either during or after detoxification. Adjusted average monthly health care costs among clients in the RSN-only and RSN+I groups increased at a similar rate over 12 months post-detoxification. DISCUSSION Possible explanations for limited uptake of the incentive program discussed include features of the incentive program itself, navigator-client communication, organizational barriers and navigator bias. The findings provide lessons to consider for future design and implementation of multi-target contingency management interventions in real-world settings.

Provider payment approaches and incentives to implement screening

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.

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

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.

Financing of Behavioral Health Services within Federally Qualified Health Centers

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.