In a previous column, I wrote about the measures for value-based purchasing being developed together with the New York State Department of Health and the Center on Addictions, our partner on many projects. Our work to develop clear measures has set the foundation for insurance plans, providers and OASAS to assess how well substance use is being identified, how treatment is being initiated, and the effectiveness of how well people are engaged in treatment (see chart below for 2016 data on current measures) and cared for in New York through Medicaid and ultimately, all by all payers. As we move toward value-based purchasing, the next step for OASAS will be to help providers and payers understand the implication of these new measures.
Many providers are working together to form networks capable of looking at how people with SUD and mental health disorder are doing. They may aggregate and share the data they have and collectively identify practices and processes that can move the needle toward better performance on the measures. I am frequently asked why we chose these measures and how should programs be preparing to use them. The remainder of the article will focus on these two questions.
As measures were developed during the past two to three decades for physical health conditions to better track quality of care for health conditions, substance use disorder had only one Health Care Effectiveness Data and Information Set (HEDIS) endorsed measure to identify how well people were initiated into substance use disorder care (within 14 days of an initial diagnosis) and engaged (measured as a second visit within 30 days of initiation). This is an important measure of how well health care responds to diagnosed substance use disorder. This measure of quality is significant because, as we know, substance use, even when recognized is not always addressed and many people are not connected to care that can help, and even when they are, they may not be appropriately engaged. We will look at these rates for New York later in the article and I will pose the question, how would we react if these rates applied to individuals diagnosed with heart disease or diabetes?
OASAS recognized the need to go beyond these measures and was supported by the Department of Health to work toward additional measures for VBP pilots and quality performance measures for Medicaid Managed Care plans. During the past several decades, there have been many national conversations among substance use disorder experts. The Washington Circle developed the Initiation and Engagement measure and proposed and studied the feasibility of continuity and medication measures. The American Society of Addiction Medicine (ASAM) endorsed 9 potential measures of quality in a 2014 article*. However, none of these measures were endorsed or, at the time, moved toward endorsement.
OASAS and the Center on Addictions worked with a group of stakeholders to identify the measures that were most likely associated with outcomes in addition to those that were most feasible to develop quickly to identify a set that we could further develop and employ in New York. The measures include:
- continuity of care from withdrawal management (detox) to next level of care within 14 days of discharge;
- continuity of care from inpatient rehabilitation to next level of care within 14 days of discharge;
- initiation of medication for opioid use disorder within 30 days of diagnosis;
- utilization of medication for opioid use disorder – any medication prescribed during 12 months;
- initiation of medication for alcohol use disorder within 30 days of diagnosis;
- utilization of medication for alcohol use disorder – any prescription during 12 months; and a
- continuation of engagement in treatment – 6 consecutive months with at least one visit with primary diagnosis of SUD.
Each of these measures has significant evidence from research that show a correlation to better SUD outcomes for individuals. The evidence is very strong for the continuity, engagement and opioid medication measures (there is less evidence for alcohol medication measure). This means that while we need to continue to identify more direct measures of outcome in treatment, improving these measures will very likely have a positive impact on SUD outcomes.
The next question from providers was what to do about these measures. Some of the measures can be tracked at a program level like initiation and utilization of medications and continuing engagement in treatment. Programs should be aware of how well they compare to the statewide and regional performance on these measures. Others will require data from other sources for a group of Medicaid members who are served by a network of providers and many Behavioral Health Collaborative Care (BHCC) groups are working to identify ways of following more system level measures.
Finally, programs must be able to identify ways of improving the measures. In a VBP environment, the responsibility for how well members do is shared with providers of health and mental health care. However, program level practices can lead to movement on these measures. During the past year, OASAS has focused on access, quality and integration. As a leader in your program, I recommend that you focus on practices that will help to reduce the time from the initial phone call to access to services in addition to those that improve retention in care and better integrated care. OASAS is committed to continuing to work with providers, plans, state sister agencies and others to contribute to the development of a robust set of measures that support quality, transparency and promote consumer choice and excellence in addiction treatment.
American Society of Addiction Medicine. The ASAM Performance Measures for the Addiction Specialist Physician Available at: https://www.asam.org/docs/default-source/advocacy/performance-measuresfor-the-addiction-specialist-physician.pdf?sfvrsn=0