Financial Sustainability of Novel Delivery Models in Behavioral Health Treatment.

BACKGROUND: In the US, much of the research into new intervention and delivery models for behavioral health care is funded by research institutes and foundations, typically through grants to develop and test the new interventions. The original grant funding is typically time-limited. This implies that eventually communities, clinicians, and others must find resources to replace the grant funding -otherwise the innovation will not be adopted. Diffusion is challenged by the continued dominance in the US of fee-for-service reimbursement, especially for behavioral health care. AIMS: To understand the financial challenges to disseminating innovative behavioral health delivery models posed by fee-for-service reimbursement, and to explore alternative payment models that promise to accelerate adoption by better addressing need for flexibility and sustainability. METHODS: We review US experience with three specific novel delivery models that emerged in recent years. The models are: collaborative care model for depression (CoCM), outpatient based opioid treatment (OBOT), and the certified community behavioral health clinic (CCBHC) model. These examples were selected as illustrating some common themes and some different issues affecting diffusion. For each model, we discuss its core components; evidence on its effectiveness and cost-effectiveness; how its dissemination was funded; how providers are paid; and what has been the uptake so far. RESULTS: The collaborative care model has existed for longest, but has been slow to disseminate, due in part to a lack of billing codes for key components until recently. The OBOT model faced that problem, and also (until recently) a regulatory requirement requiring physicians to obtain federal waivers in order to prescribe buprenorphine. Similarly, the CCBHC model includes previously nonbillable services, but it appears to be diffusing more successfully than some other innovations, due in part to the approach taken by funders. DISCUSSION: A common challenge for all three models has been their inclusion of services that were not (initially) reimbursable in a fee-for-service system. However, even establishing new procedure codes may not be enough to give providers the flexibility needed to implement these models, unless payers also implement alternative payment models. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: For providers who receive time-limited grant funding to implement these novel delivery models, one key lesson is the need to start early on planning how services will be sustained after the grant ends. IMPLICATIONS FOR HEALTH POLICY: For research funders (e.g., federal agencies), it is clearly important to speed up the process of obtaining coverage for each novel delivery model, including the development of new billable service codes, and to plan for this as early as possible. Funders also need to collaborate with providers early in the grant period on sustainability planning for the post-grant environment. For payers, a key lesson is the need to fold novel models into stable existing funding streams such as Medicaid and commercial insurance coverage, rather than leaving them at the mercy of revolving time-limited grants, and to provide pathways for contracting for innovations under new payment models. IMPLICATIONS FOR FURTHER RESEARCH: For researchers, a key recommendation would be to pay greater attention to the payment environment when designing new delivery models and interventions.

Development of an addiction recovery patient-reported outcome measure: Response to Addiction Recovery (R2AR).

BACKGROUND: Recovery, a primary goal of addiction treatment, goes beyond abstinence. Incorporating broad domains with key elements that vary across individuals, recovery is a difficult concept to measure. Most addiction-related quality measurement has emphasized process measures, which limits evaluation of treatment quality and long-term outcomes, whereas patient-reported outcomes are richer and nuanced. To address these gaps, this study developed and tested a patient-reported outcome measure for addiction recovery, named Response to Addiction Recovery (R2AR). METHODS: A multi-stage mixed methods approach followed the Patient-Reported Outcomes Measurement Information System (PROMIS) measure development standard. People with lived experience (PWLE) of addiction, treatment providers, and other experts contributed to item distillation and iterative measure refinement. From an item bank of 356 unique items, 57 items were tested via survey and interviews, followed by focus groups and cognitive interviews. RESULTS: Face validity was demonstrated throughout. PWLE rated item importance higher and with greater variance than providers, yet both agreed that "There are more important things to me in my life than using substances" was the most important item. The final R2AR instrument has 19 items across 8 recovery domains, spanning early, active, and long-term recovery phases. Respondents assess agreement for each item as (1) a strength, and (2) importance to ongoing recovery. CONCLUSION: R2AR allows PWLE to define what is important to their recovery. It is designed to support treatment planning as part of clinical workflows and to track recovery progress. Inclusion of PWLE and providers in the development process enhances its face validity. Including PWLE in the development of R2AR and using the tool to guide recovery planning emphasizes the importance of patient-centeredness in designing clinical tools and involving patients in their own care.

Protocol for the implementation of a statewide mobile addiction program.

With overdose deaths increasing, improving access to harm reduction and low barrier substance use disorder treatment is more important than ever. The Community Care in Reach® model uses a mobile unit to bring both harm reduction and clinical care for addiction to people experiencing barriers to office-based care. These mobile units provide many resources and services to people who use drugs, including safer consumption supplies, naloxone, medication for substance use disorder treatment, and a wide range of primary and preventative care. This protocol outlines the evaluation plan for the Community in Care® model in MA, USA. Using the RE-AIM framework, this evaluation will assess how mobile services engage new and underserved communities in addiction services and primary and preventative care.

Payment and Financing for Substance Use Screening and Brief Intervention for Adolescents and Adults in Health, School, and Community Settings.

Screening and brief intervention (SBI) is an evidence-based, cost-effective practice to address unhealthy substance use. With SBI services expanding beyond healthcare settings (e.g., schools, community organizations) and reaching younger populations, sustainability efforts must consider payment and financing. This narrative review incorporated rapid scoping review methods and a search of the gray literature to determine payment and financing approaches for SBI with adolescents and to describe related barriers and facilitators for its sustainability. We sought information relevant to adolescents and settings in which they receive SBI, but also reviewed sources with an adult focus. Few peer-reviewed articles met inclusion criteria, and those mostly highlighted healthcare settings. School-based settings were better described in the gray literature; little was found about community settings. SBI is mostly paid through grant funding and public and commercial insurance; school-based settings use a range of approaches including grants, public insurance, and other public funding. We call upon researchers and providers to describe the payment and financing of SBI, to inform how the uptake of SBI may be practicable and sustainable. The increasing activation and use of insurance billing codes, and the expansion of SBI beyond healthcare, is encouraging to address unhealthy substance use by adolescents.

Use of Electronic Health Information Technology in a National Sample of Hospitals That Provide Specialty Substance Use Care.

OBJECTIVE: Most U.S. acute care hospitals have adopted basic electronic health record (EHR) functionality and health information exchange (HIE) (84% and 88%, respectively, in 2017). This study examined whether rates of EHR and HIE adoption by hospital-based substance use disorder programs are lower than rates by acute care hospitals. METHODS: Data from the 2017 National Survey on Substance Abuse Treatment Services were analyzed to examine adoption of basic EHR functionality (i.e., assessment, progress monitoring, discharge, labs, and prescription dispensing) and use of HIE by hospital-based programs. Analyses used weighted multivariable models of EHR and HIE outcomes, adjusted for nonresponse. RESULTS: Of 894 hospital-based substance use disorder programs with EHR information, two-thirds (N=606, 68%) reported use of basic EHR functionality. Psychiatric hospitals were less likely than acute care hospitals to have adopted EHR (odds ratio [OR]=0.49, 95% confidence interval [CI]=0.35-0.71). Compared with nonprofit hospitals, for-profit (OR=0.23, 95% CI=0.16-0.35) and government-owned (OR=0.52, 95% CI=0.33-0.83) hospitals were less likely to use basic EHR functionality. Hospital-based programs providing medications for alcohol or opioid use disorders were more likely than those not providing such medications to use basic EHR (OR=1.95, 95% CI=1.31-2.90). Of 839 hospitals with information on HIE use, 598 (71%) reported using electronic HIE. Adoption of basic EHR functionality was the strongest predictor of HIE use (OR=4.73, 95% CI=3.29-6.79). CONCLUSIONS: Hospital-based substance use disorder programs trail behind U.S. acute care hospitals in adoption of basic EHR and electronic HIE. Findings raise concerns about missed opportunities to improve hospital-based substance use disorder care quality and performance measurement.

Impact of recovery support navigators on continuity of care after detoxification.

Although evidence points to the benefits of continuity of care after detoxification (detox), especially when continuity of care occurs within a short time after discharge from a detox episode, the rate at which clients engage in continued treatment after detox remains low. The goal of the study was to develop and deploy a specially trained workforce, called recovery support navigators (RSNs), to increase the likelihood of clients continuing onto treatment after detox. Continuity of care is defined as receiving any substance use disorder (SUD) treatment service within 14 days of discharge from the index detox. We examined whether clients in the RSN Intervention group were more likely to meet the continuity of care after detox criteria than clients in the treatment-as-usual (TAU) group. A quasi-experimental intervention versus comparison group study was conducted. Data were from the Massachusetts Behavioral Health Partnership (MBHP), a Beacon Health Options company that manages behavioral health benefits for a subset of Medicaid beneficiaries in the state. Inclusion in the analytic sample (N = 4,236) required that the client's index admission to detox was between 3/29/13 and 3/31/15. RSN Intervention versus TAU status was assigned based on provider organization where the index detox occurred. Analyses were conducted on an intent-to-treat basis. Overall, the continuity of care rate across all study groups was 42%. The rate by study group was 38% for the TAU and 45% for the RSN group. Clients who were in the RSN group were significantly more likely to have continuity of care after discharge from detox than those in the TAU (OR = 1.233, p < .05, 95% CI = 1.044, 1.455). Clients who entered detox at a site that provided specialized training to RSN, which included motivational interviewing and educational sessions related to treatment issues, and allowing them to bill with a flexible daily case rate instead of the usual fee-for-service billing, were more likely to have continuity of care after discharge from detox compared to clients in the TAU group.

Rural Clients' Continuity Into Follow-Up Substance Use Disorder Treatment: Impacts of Travel Time, Incentives, and Alerts.

PURPOSE: Treatment after discharge from detoxification or residential treatment is associated with improved outcomes. We examined the influence of travel time on continuity into follow-up treatment and whether financial incentives and weekly alerts have a modifying effect. METHODS: For a research intervention during October 2013 to December 2015, detoxification and residential substance use disorder treatment programs in Washington State were randomized into 4 groups: potential financial incentives for meeting performance goals, weekly alerts to providers, both interventions, and control. Travel time was used as both a main effect and interacted with other variables to explore its modifying impact on continuity of care in conjunction with incentives or alerts. Continuity was defined as follow-up care occurring within 14 days of discharge from detoxification or residential treatment programs. Travel time was estimated as driving time from clients' home ZIP Code to treatment agency ZIP Code. FINDINGS: Travel times to the original treatment agency were in some cases significant with longer travel times predicting lower likelihood of continuity. For detoxification clients, those with longer travel times (over 91 minutes from their residence) are more likely to have timely continuity. Conversely, residential clients with travel times of more than 1 hour are less likely to have timely continuity. Interventions such as alerts or incentives for performance had some mitigating effects on these results. Travel times to the closest agency for potential further treatment were not significant. CONCLUSIONS: Among rural clients discharged from detoxification and residential treatment, travel time can be an important factor in predicting timely continuity.

Referral to Treatment After Positive Screens for Unhealthy Drug Use in an Outpatient Veterans Administration Setting.

OBJECTIVES: To measure the rates and predictors of clinician recommendation for follow-up after a positive screen for unhealthy drug use, in a context of mandatory routine screening. To measure response to clinician recommendations and identification of new drug use diagnoses. METHODS: Data are from a Veterans Health Administration (VHA) medical center that introduced mandatory routine screening for unhealthy drug use in outpatient primary care and mental health settings, using a validated single question. This study analyzed VHA electronic health records data for patients who screened positive for unhealthy drug use (n = 570) and estimated logistic regression models to identify the predictors of receiving a recommendation for any follow-up and for specialty substance use disorder (SUD) treatment. Bivariate tests were used for other analyses. RESULTS: Among patients who screened positive for unhealthy drug use, 66% received no recommendation to return to primary care or another setting from the screening clinician. Further, among the 23% of patients who received a recommendation to visit specialty SUD treatment, only 25% completed the visit within 60 days. Six percent of all positive screens both received a referral to specialty SUD treatment and acted upon it. CONCLUSIONS: In the context of mandatory drug use screening using a single item, rates of clinician action and patient receipt of care appeared low. Improved follow-up will require health systems to provide more supports for clinicians and patients at each of the stages from positive screen to attending the follow-up appointment.

Is it feasible to pay specialty substance use disorder treatment programs based on patient outcomes?

BACKGROUND: Some US payers are starting to vary payment to providers depending on patient outcomes, but this approach is rarely used in substance use disorder (SUD) treatment. PURPOSE: We examine the feasibility of applying a pay-for-outcomes approach to SUD treatment. METHODS: We reviewed several relevant literatures: (1) economic theory papers that describe the conditions under which pay-for-outcomes is feasible in principle; (2) description of the key outcomes expected from SUD treatment, and the measures of these outcomes that are available in administrative data systems; and (3) reports on actual experiences of paying SUD treatment providers based on patient outcomes. RESULTS: The economics literature notes that when patient outcomes are strongly influenced by factors beyond provider control and when risk adjustment performs poorly, pay-for-outcomes will increase provider financial risk. This is relevant to SUD treatment. The literature on SUD outcome measurement shows disagreement on whether to include broader outcomes beyond abstinence from substance use. Good measures are available for some of these broader constructs, but the need for risk adjustment still brings many challenges. Results from two past payment experiments in SUD treatment reinforce some of the concerns raised in the more conceptual literature. CONCLUSION: There are special challenges in applying pay-for-outcomes to SUD treatment, not all of which could be overcome by developing better measures. For SUD treatment it may be necessary to define outcomes more broadly than for general medical care, and to continue conditioning a sizeable portion of payment on process measures.

Cost Savings from a Navigator Intervention for Repeat Detoxification Clients.

BACKGROUND: Many clients with substance use disorders (SUD) have multiple admissions to a 24-hour level of care for detoxification without ever progressing to SUD treatment. In the US, health insurers have become concerned about the high costs and ineffective results of repeat detox admissions. For other diseases, health systems increasingly target high-risk, high-cost patients with individually tailored interventions delivered by `navigators' who help patients negotiate the complex health care system. Patient incentives are another increasingly common intervention. AIMS OF THE STUDY: (i) To examine how health care spending was affected by an intervention intended to improve entry to SUD treatment among clients who had multiple detox admissions. (ii) To see whether spending effects, overall and by type of service, differed by intervention arm. (iii) To assess whether the intervention resulted in net savings from the payer perspective, after subtracting implementation costs. METHODS: The intervention was implemented in a segment of the Massachusetts Medicaid population, and used Recovery Support Navigators (RSNs) who were trained to effectively engage and connect clients with SUD to follow-up care and community resources. Services were funded using a flat daily rate per client. Additionally, in one of the two intervention arms, clients were offered successive incentive payments for meeting pre-specified milestones to reinforce recovery-oriented behaviors. For this paper, multivariate analyses of claims and administrative data were used to measure the intervention's effect on health care spending, and to estimate net savings to the payer. RESULTS: Health care spending grew 1.6 percentage points more slowly for intervention-enrolled members than for others, implying gross savings of $68 per member per month. After subtracting intervention-related costs, net savings were estimated at $57 per member per month. The intervention was also associated with shifts in the health care service mix from more to less acute settings. DISCUSSION: While the results for total spending did not reach statistical significance, they suggest some potential for insurers to reduce the health care costs associated with repeat detox utilization by using a navigator-based intervention. Analyses reported elsewhere found that this intervention had favorable effects on rates of initiation of SUD treatment. Limitations of the study include the fact that neither subjects nor sites were randomized between study groups; lack of data on crime or productivity outcomes; low participant use of RSN services; and a policy change which altered the participant pool and truncated follow-up for some. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These results suggest some potential for payers to reduce the health care costs associated with repeat detox by using a navigator-based intervention. To the extent that this results in shifting resources from repeat detox to actual treatment, the result should provide longer term benefit to the population coping with SUD. IMPLICATIONS FOR HEALTH POLICY: These results may encourage Medicaid and other payers to further experiment with similar interventions using navigators to decrease health care costs and improved the lives of SUD patients. IMPLICATIONS FOR FURTHER RESEARCH: It could be informative to test similar navigator interventions for detox patients in other settings where enrollment periods are longer.

Incentives in a public addiction treatment system: Effects on waiting time and selection.

Program-level financial incentives are used by some payers as a tool to improve quality of substance use treatment. However, evidence of effectiveness is mixed and performance contracts may have unintended consequences such as creating barriers for more challenging clients who are less likely to meet benchmarks. This study investigates the impact of a performance contract on waiting time for substance use treatment and client selection. Admission and discharge data from publicly funded Maine outpatient (OP) and intensive outpatient (IOP) substance use treatment programs (N = 38,932 clients) were used. In a quasi-experimental pre-post design, pre-period (FY 2005-2007) admission data from incentivized (IC) and non-incentivized (non-IC) programs were compared to post-period (FY 2008-2012) using propensity score matching and multivariate difference-in-difference regression. Dependent variables were waiting time (incentivized) and client selection (severity: history of mental disorders and substance use severity, not incentivized). Despite financial incentives designed to reduce waiting time for substance use treatment among state-funded outpatient programs, average waiting time for treatment increased in the post period for both IC and non-IC groups, as did client severity. There were no significant differences in waiting time between IC and non-IC groups over time. Increases in client severity over time, with no group differences, indicate that programs did not restrict access for more challenging clients. Adequate funding and other approaches to improve quality may be beneficial.

Impact of Agency Receipt of Incentives and Reminders on Engagement and Continuity of Care for Clients With Co-Occurring Disorders.

OBJECTIVE: This study examined whether having co-occurring substance use and mental disorders influenced treatment engagement or continuity of care and whether offering financial incentives, client-specific electronic reminders, or a combination to treatment agencies improved treatment engagement and continuity of care among clients with co-occurring disorders. METHODS: The study used a randomized cluster design to assign agencies (N=196) providing publicly funded substance use disorder treatment in Washington State to a research arm: incentives only, reminders only, incentives and reminders, and a control condition. Data were analyzed for 76,044 outpatient, 32,797 residential, and 39,006 detoxification admissions from Washington's treatment data system. Multilevel logistic regressions were conducted, with clients nested within agencies, to examine the effect of the interventions on treatment engagement and continuity of care. RESULTS: Compared with clients with a substance use disorder only, clients with co-occurring disorders were less likely to engage in outpatient treatment or have continuity of care after discharge from residential treatment, but they were more likely to have continuity of care after discharge from detoxification. The interventions did not influence treatment engagement or continuity of care, except the reminders had a positive impact on continuity of care after residential treatment among clients with co-occurring disorders. CONCLUSIONS: In general, the interventions did not result in improved treatment engagement or continuity of care. The limited number of significant results supporting the influence of incentives and alerts on treatment engagement and continuity of care add to the mixed findings reported by previous research. Multiple interventions may be needed for performance improvement.

Implementing single-item screening for drug use in a Veterans Health Administration outpatient setting.

BACKGROUND: Unhealthy drug use is a concern in many settings, including military and veteran populations. In 2013, the Veterans Health Administration (VHA) medical center in Bedford, Massachusetts, started requiring routine screening for unhealthy drug use in outpatient primary care and mental health settings, using a validated single question. METHODS: This study used descriptive and multivariable analyses of VHA electronic records for patients eligible for the screening program (N = 16,118). The study assessed first-year rates and predictors of screening and of positive screens, both for drug use and for unhealthy alcohol use, for which screening was already required. RESULTS: During the first year, 70% of patients were screened for unhealthy drug use and 84% were screened for unhealthy alcohol use. In multivariable analyses, screening for drug use was more likely for patients who had 8 or more days with VHA visits or were aged 40 or over. Patients with a prior drug use disorder diagnosis were much less likely to be screened. Three percent of patients screened for unhealthy drug use had a positive screen, and 14% of those screened for unhealthy alcohol use had a positive screen. Strong predictors of a positive drug use screen included a prior-year diagnosis of drug use disorder, any mental health clinic visits, younger age, or being unmarried. CONCLUSIONS: The drug screening initiative was relatively successful in its first-year implementation, having screened 70% of eligible subjects. However, it failed to screen many of those most likely to screen positive, thereby missing many opportunities to address unhealthy drug use. Future refinements should include better training clinicians in how to ask sensitive questions and how to address positive screens.

Federal Parity and Access to Behavioral Health Care in Private Health Plans.

OBJECTIVE: The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) sought to improve access to behavioral health care by regulating health plans' coverage and management of services. Health plans have some discretion in how to achieve compliance with MHPAEA, leaving questions about its likely effects on health plan policies. In this study, the authors' objective was to determine how private health plans' coverage and management of behavioral health treatment changed after the federal parity law's full implementation. METHODS: A nationally representative survey of commercial health plans was conducted in 60 market areas across the continental United States, achieving response rates of 89% in 2010 (weighted N=8,431) and 80% in 2014 (weighted N=6,974). Senior executives at responding plans were interviewed regarding behavioral health services in each year and (in 2014) regarding changes. Student's t tests were used to examine changes in services covered, cost-sharing, and prior authorization requirements for both behavioral health and general medical care. RESULTS: In 2014, 68% of insurance products reported having expanded behavioral health coverage since 2010. Exclusion of eating disorder coverage was eliminated between 2010 (23%) and 2014 (0%). However, more products reported excluding autism treatment in 2014 (24%) than 2010 (8%). Most plans reported no change to prior-authorization requirements between 2010 and 2014. CONCLUSIONS: Implementation of federal parity legislation appears to have been accompanied by continuing improvement in behavioral health coverage. The authors did not find evidence of widespread noncompliance or of unintended effects, such as dropping coverage of behavioral health care altogether.

Agency-level financial incentives and electronic reminders to improve continuity of care after discharge from residential treatment and detoxification.

BACKGROUND: Despite the importance of continuity of care after detoxification and residential treatment, many clients do not receive further treatment services after discharged. This study examined whether offering financial incentives and providing client-specific electronic reminders to treatment agencies lead to improved continuity of care after detoxification or residential treatment. METHODS: Residential (N = 33) and detoxification agencies (N = 12) receiving public funding in Washington State were randomized into receiving one, both, or none (control group) of the interventions. Agencies assigned to incentives arms could earn financial rewards based on their continuity of care rates relative to a benchmark or based on improvement. Agencies assigned to electronic reminders arms received weekly information on recently discharged clients who had not yet received follow-up treatment. Difference-in-difference regressions controlling for client and agency characteristics tested the effectiveness of these interventions on continuity of care. RESULTS: During the intervention period, 24,347 clients received detoxification services and 20,685 received residential treatment. Overall, neither financial incentives nor electronic reminders had an effect on the likelihood of continuity of care. The interventions did have an effect among residential treatment agencies which had higher continuity of care rates at baseline. CONCLUSIONS: Implementation of agency-level financial incentives and electronic reminders did not result in improvements in continuity of care, except among higher performing agencies. Alternative strategies at the facility and systems levels should be explored to identify ways to increase continuity of care rates in specialty settings, especially for low performing agencies.

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.

Design and impact of bundled payment for detox and follow-up care.

INTRODUCTION: Recent payment reforms promote movement from fee-for-service to alternative payment models that shift financial risk from payers to providers, incentivizing providers to manage patients' utilization. Bundled payment, an episode-based fixed payment that includes the prices of a group of services that would typically treat an episode of care, is expanding in the United States. Bundled payment has been recommended as a way to pay for comprehensive SUD treatment and has the potential to improve treatment engagement after detox, which could reduce detox readmissions, improve health outcomes, and reduce medical care costs. However, if moving to bundled payment creates large losses for some providers, it may not be sustainable. The objective of this study was to design the first bundled payment for detox and follow-up care and to estimate its impact on provider revenues. METHODS: Massachusetts Medicaid beneficiaries' behavioral health, medical, and pharmacy claims from July 2010-April 2013 were used to build and test a detox bundled payment for continuously enrolled adults (N=5521). A risk adjustment model was developed using general linear modeling to predict beneficiaries' episode costs. The projected payments to each provider from the risk adjustment analysis were compared to the observed baseline costs to determine the potential impact of a detox bundled payment reform on organizational revenues. This was modeled in two ways: first assuming no change in behavior and then assuming a supply-side cost sharing behavioral response of a 10% reduction in detox readmissions and an increase of one individual counseling and one group counseling session. RESULTS: The mean total 90-day detox episode cost was $3743. Nearly 70% of the total mean cost consists of the index detox, psychiatric inpatient care, and short-term residential care. Risk mitigation, including risk adjustment, substantially reduced the variation of the mean episode cost. There are opportunities for organizations to gain revenue under this bundled payment design, but many providers will lose money under a bundled payment designed using historic payment and costs. CONCLUSIONS: Designing a bundled payment for detox and follow-up care is feasible, but low case volume and the adequacy of the payment are concerns. Thus, a detox episode-based payment will likely be more challenging for smaller, independent SUD treatment providers. These providers are experiencing many changes as financing shifts away from block grant funding toward Medicaid funding. A detox bundled payment in practice would need to consider different risk mitigation strategies, provider pooling, and costs based on episodes of care meeting quality standards, but could incentivize care coordination, which is important to reducing detox readmissions and engaging patients in care.

Influencing quality of outpatient SUD care: Implementation of alerts and incentives in Washington State.

Financial incentives for quality improvement and feedback on specific clients are two approaches to improving the quality of treatment for individuals with substance use disorders. We examined the impacts of these interventions in Washington State by randomizing outpatient substance use treatment agencies into intervention and control groups. From October 2013 through December 2015, agencies could earn financial incentives for meeting performance goals incorporating both achievement relative to a benchmark and improvement from agencies' own baselines. Weekly feedback was e-mailed to agencies in the alert or alert plus incentives arms. Difference-in difference regressions controlling for client and agency characteristics showed that none of the interventions significantly affected client engagement after outpatient admissions, overall or for sub-groups based on race/ethnicity, age, rural residence, or agency baseline performance. Treatment agencies offered insights related to several themes: delivery system context (e.g., agency time and resources needed during transition to a managed behavioral healthcare system), implementation (e.g., data lag), agency issues (e.g., staff turnover), and client factors (e.g., motivation). Interventions took place during a time of Medicaid expansion and planning for statewide integration of mental health and substance use disorder treatment into a managed care model, which may have resulted in agencies not responding to the interventions. Moreover, incentives and alerts at the agency-level may not be effective when factors are at play beyond the agency's control.

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.

How Do Private Health Plans Manage Specialty Behavioral Health Treatment Entry and Continuing Care?

OBJECTIVE: This study examined private health plans' arrangements for accessing and continuing specialty behavioral health treatment in 2010 as federal health reforms were being implemented. These management practices have historically been stricter in behavioral health care than in general medical care; however, the Mental Health Parity and Addiction Equity Act of 2010 required parity in management policies. METHODS: The data source was a nationally representative survey of private health plans' behavioral health treatment management approaches in 2010. Health plan executives were asked about activities for their plan's three products with highest enrollment (weighted N=8,427, 88% response rate). RESULTS: Prior authorization for outpatient behavioral health care was rarely required (4.7% of products), but 75% of products required authorization for ongoing care and over 90% required prior authorization for other levels of care. The most common medical necessity criteria were self-developed and American Society of Addiction Medicine criteria. Nearly all products had formal standards to limit waiting time for routine and urgent treatment, but almost 30% lacked such standards for detoxification services. A range of wait time-monitoring approaches was used. CONCLUSIONS: Health plans used a variety of methods to influence behavioral health treatment entry and continuing care. Few relied on prior authorization for outpatient care, but the use of other approaches to influence, manage, or facilitate access was common. Results provide a baseline for understanding the current management environment for specialty behavioral health care. Tracking health plans' approaches over time will be important to ensure that access to behavioral health care is not prohibitively restrictive.