Victor Capoccia

Massachusetts’s Experience Suggests Coverage Alone Is Insufficient To Increase Addiction Disorders Treatment

The Affordable Care Act is aimed at extending health insurance to more than thirty million Americans, including many with untreated substance use disorders. Will those who need addiction treatment receive it once they have insurance? To answer that question, we examined the experience of Massachusetts, which implemented its own universal insurance law in 2007. As did the Affordable Care Act, the Massachusetts reform incorporated substance abuse services into the essential benefits to be provided all residents. Prior to the laws enactment, the state estimated that a half-million residents needed substance abuse treatment. Our mixed-methods exploratory study thus asked whether expanded coverage in Massachusetts led to increased addiction treatment, as indicated by admissions, services, or revenues. In fact, we observed relatively stable use of treatment services two years before and two years after the state enacted its universal health care law. Among other factors, our study noted that the percentage of uninsured patients with substance abuse issues remains relatively high--and that when patients did become insured, requirements for copayments on their care deterred treatment. Our analysis suggests that expanded coverage alone is insufficient to increase treatment use. Changes in eligibility, services, financing, system design, and policy may also be required.

Advancing performance measures for use of medications in substance abuse treatment

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.

The readiness of addiction treatment agencies for health care reform

The Patient Protection and Affordable Care Act (PPACA) aims to provide affordable health insurance and expanded health care coverage for some 32 million Americans. The PPACA makes provisions for using technology, evidence-based treatments, and integrated, patient-centered care to modernize the delivery of health care services. These changes are designed to ensure effectiveness, efficiency, and cost-savings within the health care system.To gauge the addiction treatment field’s readiness for health reform, the authors developed a Health Reform Readiness Index (HRRI) survey for addiction treatment agencies. Addiction treatment administrators and providers from around the United States completed the survey located on the http://www.niatx.net website. Respondents self-assessed their agencies based on 13 conditions pertinent to health reform readiness, and received a confidential score and instant feedback.On a scale of “Needs to Begin,” “Early Stages,” “On the Way,” and “Advanced,” the mean scores for respondents (n = 276) ranked in the Early Stages of health reform preparation for 11 of 13 conditions. Of greater concern was that organizations with budgets of < 

Specifying and Pilot Testing Quality Measures for the American Society of Addiction Medicine's Standards of Care.

5 million (n = 193) were less likely than those with budgets > 

Development of a Multilevel Framework to Increase Use of Targeted Evidence-Based Practices in Addiction Treatment Clinics.

5 million to have information technology (patient records, patient health technology, and administrative information technology), evidence-based treatments, quality management systems, a continuum of care, or a board of directors informed about PPACA.The findings of the HRRI indicate that the addiction field, and in particular smaller organizations, have much to do to prepare for a future environment that has greater expectations for information technology use, a credentialed workforce, accountability for patient care, and an integrated continuum of care.

Treating Alcohol And Drug Use Disorders

Objectives:In 2013, the American Society of Addiction Medicine (ASAM) approved its Standards of Care for the Addiction Specialist Physician. Subsequently, an ASAM Performance Measures Panel identified and prioritized the standards to be operationalized into performance measures. The goal of this study is to describe the process of operationalizing 3 of these standards into quality measures, and to present the initial measure specifications and results of pilot testing these measures in a large health care system. By presenting the process rather than just the end results, we hope to shed light on the measure development process to educate, and also to stimulate debate about the decisions that were made. Methods:Each measure was decomposed into major concepts. Then each concept was operationalized using commonly available administrative data sources. Alternative specifications examined and sensitivity analyses were conducted to inform decisions that balanced accuracy, clinical nuance, and simplicity. Using data from the US Veterans Health Administration (VHA), overall performance and variation in performance across 119 VHA facilities were calculated. Results:Three measures were operationalized and pilot tested: pharmacotherapy for alcohol use disorder, pharmacotherapy for opioid use disorder, and timely follow-up after medically managed withdrawal (aka detoxification). Each measure was calculable with available data, and showed ample room for improvement (no ceiling effects) and wide facility-level variability. Conclusions:Next steps include conducting feasibility and pilot testing in other health care systems and other contexts such as standalone addiction treatment programs, and also to study the specification and predictive validity of these measures.

Response to Dr Fiscella: Transparency and Debate are Essential to Improve Guidelines and Measures.

Implementing specific evidence-based practices (EBPs) across a set of addiction treatment providers have been a persistent challenge. In the Advancing Recovery(AR) demonstration project, single state agencies, the entities that distribute federal funds for substance use disorder prevention and treatment services, worked in partnership with providers to increase the use of EBPs in the treatment of addiction. The project supported two cohorts of six 2-year awards. Field observations from the first year of implementation guided development of a multilevel framework (the Advancing Recovery Framework). Government entities and other payers can use the framework as a guide for implementing evidence-based clinical practices within treatment networks. The Advancing Recover Framework calls for a combination of policy and organizational changes at both the payer (government agency) and provider levels. Using the Advancing Recovery Framework, 11 of the 12 AR payer/provider partnerships increased use of clinical EPBs. This article identifies key payer policy changes applied during different phases of EBP program implementation. The public health benefit of the demonstration project was broader use of medication-assisted therapy and continuing care in addiction treatment services.

The Network for the Improvement of Addiction Treatment (NIATx): Enhancing Access and Retention

Treating Alcohol And Drug Use Disorders Brendan Saloner and Benjamin Lê Cook (Jan 2013) provide an important analysis showing poor completion rates in contemporary treatment services for alcohol and drug use disorders. To address racial and ethnic discrepancies in treatment completion, they note the Affordable Care Act’s expansion of Medicaid and recommend that Medicaid cover residential treatment so residential care can increase. That expansion, unfortunately, would reinforce the stigma associated with treatment for alcohol and drug use disorders, further the segregation of addiction treatment from medical care, and fail to take advantage of emerging evidence-based treatments for these disorders. States should use the Affordable Care Act to build systems of care for the twenty-first century rather than relying on antiquated care models. States need to improve systems of care for everyone. Addiction is a chronic disorder that requires ongoing ambulatory care management. When fully implemented, the Affordable Care Act can promote integrated treatment for alcohol and drug use disorders within primary care medical homes. The act will increase access to therapists with graduate training and physicians trained in the use of pharmacotherapy. These changes are more complicated than simply expanding residential services and will have more positive long-term impacts on the quality of treatment for alcohol and drug use disorders, as well as reducing disparities in access to and use of care. Although residential care may facilitate recovery for the most severely dependent individuals, its role in twenty-first-century systems of care will be reduced. System change is not easy, but it is required for better, more effective treatment for alcohol and drug use disorders.

Making “Stone Soup”: Improvements in Clinic Access and Retention in Addiction Treatment

Author(s): Harris, Alex HS; Chen, Cheng; Weisner, Constance M; Chalk, Mady; Capoccia, Victor; Thomas, Cindy Parks