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.

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.

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.

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.

Combat-Acquired Traumatic Brain Injury, Posttraumatic Stress Disorder, and Their Relative Associations With Postdeployment Binge Drinking.

OBJECTIVE: To examine whether experiencing a traumatic brain injury (TBI) on a recent combat deployment was associated with postdeployment binge drinking, independent of posttraumatic stress disorder (PTSD). METHODS: Using the 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Military Personnel, an anonymous survey completed by 28 546 personnel, the study sample included 6824 personnel who had a combat deployment in the past year. Path analysis was used to examine whether PTSD accounted for the total association between TBI and binge drinking. MAIN MEASURES: The dependent variable, binge drinking days, was an ordinal measure capturing the number of times personnel drank 5+ drinks on one occasion (4+ for women) in the past month. Traumatic brain injury level captured the severity of TBI after a combat injury event exposure: TBI-AC (altered consciousness only), TBI-LOC of 20 or less (loss of consciousness up to 20 minutes), and TBI-LOC of more than 20 (loss of consciousness >20 minutes). A PTSD-positive screen relied on the standard diagnostic cutoff of 50+ on the PTSD Checklist-Civilian. RESULTS: The final path model found that while the direct effect of TBI (0.097) on binge drinking was smaller than that of PTSD (0.156), both were significant. Almost 70% of the total effect of TBI on binge drinking was from the direct effect; only 30% represented the indirect effect through PTSD. CONCLUSION: Further research is needed to replicate these findings and to understand the underlying mechanisms that explain the relationship between TBI and increased postdeployment drinking.

Management of Newer Antidepressant Medications in U.S. Commercial Health Plans.

BACKGROUND: Private health insurance plays a large role in the U.S. health system, including for many individuals with depression. Private insurers have been actively trying to influence pharmaceutical utilization and costs, particularly for newer and costlier medications. The approaches that insurers use may have important effects on patients' access to antidepressant medications. AIMS OF THE STUDY: To report which approaches (e.g., tiered copayments, prior authorization, and step therapy) commercial health plans are employing to manage newer antidepressant medications, and how the use of these approaches has changed since 2003. METHODS: Data are from a nationally representative survey of commercial health plans in 60 market areas regarding alcohol, drug abuse and mental health services in 2010. Responses were obtained from 389 plans (89% response rate), reporting on 925 insurance products. For each of six branded antidepressant medications, respondents were asked whether the plan covered the medication and if so, on what copayment tier, and whether it was subject to prior authorization or step therapy. Measures of management approach were constructed for each medication and for the group of medications. Bivariate and multivariate analyses were used to test for association of the management approach with various health plan characteristics. RESULTS: Less than 1% of health plan products excluded any of the six antidepressants studied. Medications were more likely to be subjected to restrictions if they were newer, more expensive or were reformulations. 55% of products used placement on a high cost-sharing tier (3 or 4) as their only form of restriction for newer branded antidepressants. This proportion was lower than in 2003, when 71% of products took this approach. In addition, only 2% of products left all the newer branded medications unrestricted, down from 25% in 2003. Multivariate analysis indicated that preferred provider organizations were more likely than other product types to use tier 3 or 4 placement. DISCUSSION: We find that U.S. health plans are using a variety of strategies to manage cost and utilization of newer branded antidepressant medications. Plans appear to be finding that approaches other than exclusion are adequate to meet their cost-management goals for newer branded antidepressants, although they have increased their use of administrative restrictions since 2003. Limitations include lack of information about how administrative restrictions were applied in practice, information on only six medications, and some potential for endogeneity bias in the regression analyses. CONCLUSION: This study has documented substantial use of various restrictions on access to newer branded antidepressants in U.S. commercial health plans. Most of these medications had generic equivalents that offered at least some substitutability, reducing access concerns. At the same time, it is worth noting that high copayments and administrative requirements can nonetheless be burdensome for some patients. IMPLICATIONS FOR HEALTH POLICY: Health plans' pharmacy management approaches may concern policymakers less than in the early 2000s, due to the lesser distinctiveness of today's branded medications. This may change depending on future drug introductions. IMPLICATIONS FOR FURTHER RESEARCH: Future research should examine the impact of plans' pharmacy management approaches, using patient-level data.

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.

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.

Customization in prescribing for bipolar disorder.

For many disorders, patient heterogeneity requires physicians to customize their treatment to each patient's needs. We test for the existence of customization in physicians' prescribing for bipolar disorder, using data from a naturalistic clinical effectiveness trial of bipolar disorder treatment (STEP-BD), which did not constrain physician prescribing. Multinomial logit is used to model the physician's choice among five combinations of drug classes. We find that our observed measure of the patient's clinical status played only a limited role in the choice among drug class combinations, even for conditions such as mania that are expected to affect class choice. However, treatment of a patient with given characteristics differed widely depending on which physician was seen. The explanatory power of the model was low. There was variation within each physician's prescribing, but the results do not suggest a high degree of customization in physicians' prescribing, based on our measure of clinical status.

Frequent binge drinking after combat-acquired traumatic brain injury among active duty military personnel with a past year combat deployment.

OBJECTIVE: To determine whether combat-acquired traumatic brain injury (TBI) is associated with postdeployment frequent binge drinking among a random sample of active duty military personnel. PARTICIPANTS: Active duty military personnel who returned home within the past year from deployment to a combat theater of operations and completed a survey health assessment (N = 7155). METHODS: Cross-sectional observational study with multivariate analysis of responses to the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel, an anonymous, random, population-based assessment of the armed forces. MAIN MEASURES: Frequent binge drinking: 5 or more drinks on the same occasion, at least once per week, in the past 30 days. TBI-AC: self-reported altered consciousness only; loss of consciousness (LOC) of less than 1 minute (TBI-LOC <1); and LOC of 1 minute or greater (TBI-LOC 1+) after combat injury event exposure. RESULTS: Of active duty military personnel who had a past year combat deployment, 25.6% were frequent binge drinkers and 13.9% reported experiencing a TBI on the deployment, primarily TBI-AC (7.5%). In regression models adjusting for demographics and positive screen for posttraumatic stress disorder, active duty military personnel with TBI had increased odds of frequent binge drinking compared with those with no injury exposure or without TBI: TBI-AC (adjusted odds ratio, 1.48; 95% confidence interval, 1.18-1.84); TBI-LOC 1+ (adjusted odds ratio, 1.67; 95% confidence interval, 1.00-2.79). CONCLUSIONS: Traumatic brain injury was significantly associated with past month frequent binge drinking after controlling for posttraumatic stress disorder, combat exposure, and other covariates.

Characteristics of practitioners in a private managed behavioral health plan.

BACKGROUND: Little is known about the practitioners in managed behavioral healthcare organization (MBHO) networks who are treating mental and substance use disorders among privately insured patients in the United States. It is likely that the role of the private sector in treating behavioral health will increase due to the recent implementation of federal parity legislation and the inclusion of behavioral health as a required service in the insurance exchange plans created under healthcare reform. Further, the healthcare reform legislation has highlighted the need to ensure a qualified workforce in order to improve access to quality healthcare, and provides an additional focus on the behavioral health workforce. To expand understanding of treatment of mental and substance use disorders among privately insured patients, this study examines practitioner types, experience, specialized expertise, and demographics of in-network practitioners providing outpatient care in one large national MBHO. METHODS: Descriptive analyses used 2004 practitioner credentialing and other administrative data for one MBHO. The sample included 28,897 practitioners who submitted at least one outpatient claim in 2004. Chi-square and t-tests were used to compare findings across types of practitioners. RESULTS: About half of practitioners were female, 12% were bilingual, and mean age was 53, with significant variation by practitioner type. On average, practitioners report 15.3 years of experience (SD = 9.4), also with significant variation by practitioner type. Many practitioners reported specialized expertise, with about 40% reporting expertise for treating children and about 60% for treating adolescents. CONCLUSIONS: Overall, these results based on self-report indicate that the practitioner network in this large MBHO is experienced and has specialized training, but echo concerns about the aging of this workforce. These data should provide us with a baseline of practitioner characteristics as we enter an era that anticipates great change in the behavioral health workforce.

Racial and ethnic differences in substance abuse treatment initiation and engagement.

This study examined variations by race and ethnicity in initiation and engagement, two performance measures of treatment for substance use disorders that focus on the timely receipt of services during the early stage of substance abuse treatment. Administrative data from the Oklahoma Department of Mental Health and Substance Abuse Services were linked with facility-level information from the National Survey of Substance Abuse Treatment Services. We found that Black clients were least likely to initiate treatment, but no race or ethnic differences in treatment engagement were found when compared by race or ethnicity. Most client and facility characteristics' association with initiation or engagement did not differ across racial or ethnic groups. Increased attention is needed to understand what may contribute to the differences and how to address them. This study also offers an approach that state agencies may implement for monitoring treatment quality and examining racial and ethnic disparities in substance abuse treatment services.

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.

Systems-level smoking cessation activities by private health plans.

INTRODUCTION: The US Public Health Service urges providers to screen patients for smoking and advise smokers to quit. Yet, these practices are not widely implemented in clinical practice. This study provides national estimates of systems-level strategies used by private health insurance plans to influence provider delivery of smoking cessation activities. METHODS: Data are from a nationally representative survey of health plans for benefit year 2003, across product types offered by insurers, including health maintenance organizations (HMOs), preferred provider organizations, and point-of-service products, regarding alcohol, tobacco, drug, and mental health services. Executive directors of 368 health plans responded to the administrative module (83% response rate). Medical directors of 347 of those health plans, representing 771 products, completed the clinical module in which health plan respondents were asked about screening for smoking, guideline distribution, and incentives for guideline adherence. RESULTS: Only 9% of products require, and 12% verify, that primary care providers (PCPs) screen for smoking. HMOs are more likely than other product types to require screening. Only 17% of products distribute smoking cessation guidelines to PCPs, and HMOs are more likely to do this. Feedback to PCPs was most frequently used to encourage guideline adherence; financial incentives were rarely used. Furthermore, health plans that did require screening often conducted other cessation activities. CONCLUSION: Few private health plans have adopted techniques to encourage the use of smoking cessation activities by their providers. Increasing health plan involvement is necessary to reduce tobacco use and concomitant disease in the United States.

Treatment services: triangulation of methods when there is no gold standard.

Information about treatment services can be ascertained in several ways. We examine the level of agreement among data on substance user treatment services collected via multiple methods and respondents in the nationally representative Alcohol and Drug Services Study (ADSS, 1996-1999), and potential reasons for discrepancies. Data were obtained separately from facility director reports, treatment record abstracts, and client interviews. Concordance was generally acceptable across methods and respondents. Although any of these methods should be adequate, additional information is gleaned from multiple sources.

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.

The effect of employee assistance plan benefits on the use of outpatient behavioral health care.

BACKGROUND: Nearly half of all US workers have access to an employee assistance plan (EAP). At the same time, most large US employers also purchase health benefits for their employees, and these benefits packages typically include behavioral health services. There is some potential overlap in services covered by the EAP and the health plan, and some employers choose to purchase the two jointly as an 'integrated product'. It is not clear whether EAP services substitute for outpatient behavioral health care services covered by the health plan. AIM OF THE STUDY: To evaluate how the number of EAP visits covered affects the use of regular outpatient behavioral health care (number of visits, and total spending), in an integrated product setting. METHODS: Analysis of claims, eligibility and benefits data for 26,464 users of behavioral health care for the year 2005. For both EAP and regular behavioral health care, the individuals were enrolled with Managed Health Network (MHN), a large national specialty insurance plan. Multivariate regression analyses were performed to investigate the determinants of the number of regular outpatient visits, and spending for regular outpatient care. To address skewness in the dependent variables, the estimation used generalized linear models with a log link. A limited instrumental variable analysis was used to test for endogeneity of the number of EAP visits covered. RESULTS: Nearly half the enrollees in this sample were in employer plans that allowed 4-5 EAP visits per treatment episode, and 31% were allowed 3 EAP visits per year. Having an EAP visit allowance of 4-5 sessions per episode predicts fewer regular outpatient visits, compared with having an allowance of 3 sessions per year. More generous EAP allowances also reduce payments for outpatient care, with one exception. DISCUSSION: Greater availability of EAP benefits appears to reduce utilization of regular outpatient care, supporting the idea that the two types of care are to some extent perceived as substitutes. One limitation of this study is its cross-sectional nature, since the relationships observed could reflect the effect of other unmeasured variables. Also, the data are from a single managed behavioral health organization, limiting generalizability somewhat, although many employers are represented in the data. IMPLICATIONS FOR HEALTH POLICY: The results should discourage employers from either eliminating EAP benefits as duplicative, or replacing behavioral health benefits with an expanded EAP. Patients appear to perceive that EAP services offer something distinct from regular outpatient care. IMPLICATIONS FOR FURTHER RESEARCH: Future studies should see whether these results are reproduced, ideally by looking at employer plans with a wider range of EAP visit allowances.

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.

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.