Access to and Engagement in Substance Use Disorder Treatment Over Time.

OBJECTIVE: This study evaluated whether access to and engagement in substance use disorder treatment has improved from 2010 to 2016. METHODS: Data submitted by commercial and Medicaid health plans, representing over 163 million beneficiaries from 2010 to 2016, were analyzed. RESULTS: For commercial plans, identification increased (from 1.0% to 1.6%, p<0.001), the initiation rate declined (from 41.9% to 33.7%, p<0.001), and the engagement rate also declined (from 15.8% to 12.1%, p<0.001). The decline in the initiation and engagement rates could not be explained by the increasing identification rates. For Medicaid plans, the identification rate increased (from 3.3% to 6.7%, p<0.001), and the initiation and engagement rates were unchanged. CONCLUSIONS: Although an increasing proportion of health plan members are being identified with substance use disorders, the majority of these individuals are not engaging in treatment.

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.

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.

Applying American Society of Addiction Medicine Performance Measures in Commercial Health Insurance and Services Data.

OBJECTIVES: ASAM's Standards of Care for the Addiction Specialist established appropriate care for the treatment of substance use disorders. ASAM identified three high priority performance measures for specification and testing for feasibility in various systems using administrative claims: use of pharmacotherapy for alcohol use disorder (AUD); use of pharmacotherapy for opioid use disorder (OUD); and continuity of care after withdrawal management services. This study adds to the initial testing of these measures in the Veteran's Health Administration (VHA) by testing the feasibility of specifications in commercial insurance data (Cigna). METHODS: Using 2014 and 2015 administrative data, the proportion of individuals with an AUD or OUD diagnosis each year who filled prescriptions or were dispensed appropriate FDA-approved pharmacotherapy. For withdrawal management follow up, the proportion with an outpatient encounter within seven days was calculated. The sensitivity of specifications was also tested. RESULTS: Rates of pharmacotherapy for AUD ranged from 6.2% to 7.6% (depending on year and specification details), and rates for OUD pharmacotherapy were 25.0% to 29.7%. Seven-day follow up rate after withdrawal management in an outpatient setting was 20.5%, and an additional 39.7% in an inpatient or residential setting. CONCLUSIONS: Application of ASAM specifications is feasible in commercial administrative data. Because of varying system needs and payment practices across health systems, measures may require adjustment for different settings. Moving forward, important focus will be on the continued refinement of these measures with the new ICD-10 coding systems, new formulations of current medications, and new payment approaches such as bundled payment.

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.

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.

Reducing Behavioral Health Inpatient Readmissions for People With Substance Use Disorders: Do Follow-Up Services Matter?

OBJECTIVE: Individuals with substance use disorders are at high risk of hospital readmission. This study examined whether follow-up services received within 14 days of discharge from an inpatient hospital stay or residential detoxification reduced 90-day readmissions among Medicaid enrollees whose index admission included a substance use disorder diagnosis. METHODS: Claims data were analyzed for Medicaid enrollees ages 18-64 with a substance use disorder diagnosis coded in any position for an inpatient hospital stay or residential detoxification in 2008 (N=30,439). Follow-up behavioral health services included residential, intensive outpatient, outpatient, and medication-assisted treatment (MAT). Analyses included data from ten states or fewer, based on a minimum number of index admissions and the availability of follow-up services or MAT. Survival analyses with time-varying independent variables were used to test the association of receipt of follow-up services and MAT with behavioral health readmissions. RESULTS: Two-thirds (67.7%) of these enrollees received no follow-up services within 14 days. Twenty-nine percent were admitted with a primary behavioral health diagnosis within 90 days of discharge. Survival analyses showed that MAT and residential treatment were associated with reduced risk of 90-day behavioral health admission. Receipt of outpatient treatment was associated with increased readmission risk, and, in only one model, receipt of intensive outpatient services was also associated with increased risk. CONCLUSIONS: Provision of MAT or residential treatment for substance use disorders after an inpatient or detoxification stay may help prevent readmissions. Medicaid programs should be encouraged to reduce barriers to MAT and residential treatment in order to prevent behavioral health admissions.

Commercial Health Plan Coverage of Selected Treatments for Opioid Use Disorders from 2003 to 2014.

Opioid use disorders (OUDs) are receiving significant attention in the U.S. as a public health crisis. Access to treatment for OUDs is essential and was expected to improve following implementation of the federal parity law and the Affordable Care Act. This study examines changes in coverage and management of treatments for OUDs (opioid treatment programs (OTPs) as a covered service benefit, buprenorphine as a pharmacy benefit) before, during, and after parity and ACA implementation. Data are from three rounds of a nationally representative survey conducted with commercial health plans regarding behavioral health services in benefit years 2003, 2010, and 2014. Data were weighted to be representative of health plans' commercial products in the continental United States (2003 weighted N = 7,469, 83% response rate; 2010 N = 8,431, 89% response rate; and 2014 N = 6,974, 80% response rate). Results showed treatment for OUDs was covered by nearly all health plan products in each year of the survey, but the types and patterns varied by year. Prior authorization requirements for OTPs have decreased over time. Despite the promise of expanded access to OUD treatment suggested by parity and the ACA, improved health plan coverage for treatment of OUDs, while essential, is not sufficient to address the opioid crisis.

How health plans promote health IT to improve behavioral health care.

OBJECTIVES: Given the large numbers of providers and enrollees with which they interact, health plans can encourage the use of health information technology (IT) to advance behavioral health care. The manner and extent to which commercial health plans promote health IT to improve behavioral health care is unknown. This study aims to address that gap. STUDY DESIGN: Cross-sectional study. METHODS: Data are from a nationally representative survey of commercial health plans regarding administrative and clinical dimensions of behavioral health services in 2010. Data are weighted to be representative of commercial managed care products in the United States (n = 8427; 88% response rate). Approaches within the domains of provider support, access to care, and assessment and treatment were investigated as examples of how health plans can promote health IT to improve behavioral health care delivery. RESULTS: Health plans were using health IT approaches in each domain. About a quarter of products offered financial support for electronic health records, but technical assistance was rare. Primary care providers could bill for e-mail contact with patients for behavioral health in about a quarter of products. Few products offered member-provider e-mail, and none offered online appointment scheduling. However, online referral systems and online provider directories were common, and nearly all offered an online self-assessment tool; most offered online counseling and online personalized responses to questions or problems. CONCLUSIONS: In 2010, commercial health plans encouraged the use of health IT strategies for behavioral health care. Health plans have an important role to play for increasing health IT as a tool for behavioral health care.

Behavioral Health Services in the Changing Landscape of Private Health Plans.

OBJECTIVE: Health plans play a key role in facilitating improvements in population health and may engage in activities that have an impact on access, cost, and quality of behavioral health care. Although behavioral health care is becoming more integrated with general medical care, its delivery system has unique aspects. The study examined how health plans deliver and manage behavioral health care in the context of the Affordable Care Act (ACA) and the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA). This is a critical time to examine how health plans manage behavioral health care. METHODS: A nationally representative survey of private health plans (weighted N=8,431 products; 89% response rate) was conducted in 2010 during the first year of MHPAEA, when plans were subject to the law but before final regulations, and just before the ACA went into effect. The survey addressed behavioral health coverage, cost-sharing, contracting arrangements, medical home innovations, support for technology, and financial incentives to improve behavioral health care. RESULTS: Coverage for inpatient and outpatient behavioral health services was stable between 2003 and 2010. In 2010, health plans were more likely than in 2003 to manage behavioral health care through internal arrangements and to contract for other services. Medical home initiatives were common and almost always included behavioral health, but financial incentives did not. Some plans facilitated providers' use of technology to improve care delivery, but this was not the norm. CONCLUSIONS: Health plans are key to mainstreaming and supporting delivery of high-quality behavioral health services. Since 2003, plans have made changes to support delivery of behavioral health services in the context of a rapidly changing environment.

Health Plans' Early Response to Federal Parity Legislation for Mental Health and Addiction Services.

OBJECTIVE: In 2008, the federal Mental Health Parity and Addiction Equity Act (MHPAEA) passed, prohibiting U.S. health plans from subjecting mental health and substance use disorder (behavioral health) coverage to more restrictive limitations than those applied to general medical care. This require d some health plans to make changes in coverage and management of services. The aim of this study was to examine private health plans' early responses to MHPAEA (after its 2010 implementation), in terms of both intended and unintended effects. METHODS: Data were from a nationally representative survey of commercial health plans regarding the 2010 benefit year and the preparity 2009 benefit year (weighted N=8,431 products; 89% response rate). RESULTS: Annual limits specific to behavioral health care were virtually eliminated between 2009 and 2010. Prevalence of behavioral health coverage was unchanged, and copayments for both behavioral and general medical services increased slightly. Prior authorization requirements for specialty medical and behavioral health outpatient services continued to decline, and the proportion of products reporting strict continuing review requirements increased slightly. Contrary to expectations, plans did not make significant changes in contracting arrangements for behavioral health services, and 80% reported an increase in size of their behavioral health provider network. CONCLUSIONS: The law had the intended effect of eliminating quantitative limitations that applied only to behavioral health care without unintended consequences such as eliminating behavioral health coverage. Plan decisions may also reflect other factors, including anticipation of the 2010 regulations and a continuation of trends away from requiring prior authorization.

Racial/Ethnic disparities in patient experience with communication in hospitals: real differences or measurement errors?

BACKGROUND: An important aspect of medical care is clear and effective communication, which can be particularly challenging for individuals based on race/ethnicity. Quality of communication is measured systematically in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, and analyzed frequently such as in the National Healthcare Disparities Report. Caution is needed to discern differences in communication quality from racial/ethnic differences in perceptions about concepts or expectations about their fulfillment. OBJECTIVES: To examine assumptions about the degree of commonality across racial/ethnic groups in their perceptions and expectations, and to investigate the validity of conclusions regarding racial/ethnic differences in communication quality. METHODS: We used 2007 HCAHPS data from the National CAHPS Benchmarking Database to construct racial/ethnic samples that controlled for other patient characteristics (828 per group). Using multiple-groups confirmatory factor analyses, we tested whether the factor structure and model parameters (ie, factor loadings, intercepts) differed across groups. RESULTS: We identified support for basic tests of equivalence across 7 racial/ethnic groups in terms of equivalent factor structure and loadings. Even stronger support was found for Communication with Doctors and Nurses. However, potentially important nonequivalence was found for Communication about Medicines, including instances of statistically significant differences between non-Hispanic whites and non-Hispanic blacks, Asians, and Native Hawaiian/other Pacific Islanders. CONCLUSIONS: Our results provide strongest support for racial/ethnic comparisons on Communication with Nurses and Doctors, and reason to caution against comparisons on Communication about Medicines due to significant differences in model parameters across groups; that is, a lack of invariance in the intercept.

A performance measure for continuity of care after detoxification: relationship with outcomes.

Administrative data from five states were used to examine whether continuity of specialty substance abuse treatment after detoxification predicts outcomes. We examined the influence of a 14-day continuity of care process measure on readmissions. Across multiple states, there was support that clients who received treatment for substance use disorders within 14-days after discharge from detoxification were less likely to be readmitted to detoxification. This was particularly true for reducing readmissions to another detoxification that was not followed with treatment and when continuity of care was in residential treatment. Continuity of care in outpatient treatment was related to a reduction in readmissions in some states, but not as often as when continuity of care occurred in residential treatment. A performance measure for continuity of care after detoxification is a useful tool to help providers monitor quality of care delivered and to alert them when improvement is needed.

Drinking patterns of older adults with chronic medical conditions.

BACKGROUND: Understanding alcohol consumption patterns of older adults with chronic illness is important given the aging baby boomer generation, the increase in prevalence of chronic conditions and associated medication use, and the potential consequences of excessive drinking in this population. OBJECTIVES: To estimate the prevalence of alcohol consumption patterns, including at-risk drinking, in older adults with at least one of seven common chronic conditions. DESIGN/METHODS: This descriptive study used the nationally representative 2005 Medicare Current Beneficiary Survey linked with Medicare claims. The sample included community-dwelling, fee-for-service beneficiaries 65 years and older with one or more of seven chronic conditions (Alzheimer's disease and other senile dementia, chronic obstructive pulmonary disease, depression, diabetes, heart failure, hypertension, and stroke; n = 7,422). Based on self-reported alcohol consumption, individuals were categorized as nondrinkers, within-guidelines drinkers, or at-risk drinkers (exceeds guidelines). RESULTS: Overall, 30.9 % (CI 28.0-34.1 %) of older adults with at least one of seven chronic conditions reported alcohol consumption in a typical month in the past year, and 6.9 % (CI 6.0-7.8 %) reported at-risk drinking. Older adults with higher chronic disease burdens were less likely to report alcohol consumption and at-risk drinking. CONCLUSIONS: Nearly one-third of older adults with selected chronic illnesses report drinking alcohol and almost 7 % drink in excess of National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines. It is important for physicians and patients to discuss alcohol consumption as a component of chronic illness management. In cases of at-risk drinking, providers have an opportunity to provide brief intervention or to offer referrals if needed.

Performance contracting and quality improvement in outpatient treatment: effects on waiting time and length of stay.

We evaluate the effects of a performance contract (PC) implemented in Delaware in 2001 and participation in quality improvement (QI) programs on waiting time for treatment and length of stay (LOS) using client treatment episode level data from Delaware (n = 12,368) and Maryland (n = 147,151) for 1998-2006. Results of difference-in-difference analyses indicate that waiting time declined 13 days following the PC, after controlling for client characteristics and historical trends. Participation in the PC and a formal QI program was associated with a decrease of 20 days. LOS increased 22 days under the PC and 24 days under the PC and QI programs, after controlling for client characteristics. The PC and QI programs were associated with improvements in LOS and waiting time, although we cannot determine which aspects of the programs (incentives, training, and monitoring) resulted in these changes.

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.