The nation is responding to the opioid epidemic by pouring money and resources into increasing access to addiction treatment. But these critical expansion efforts must be accompanied by initiatives to improve accountability of addiction providers to deliver quality care. There are more than 14,000 specialty addiction treatment programs in the US. Although addiction can be treated with the same effectiveness as other chronic diseases, there is significant variability in the nature and quality of treatment services offered by these addiction providers. The major therapeutic component in virtually all these programs is group counseling, instead of a comprehensive set of treatment modalities that are consonant with evidence-based best practices. In fact, less than 20 percent of programs prescribe any of the four medications approved by the Food and Drug Administration (FDA) to treat opioid or alcohol use disorders. As a result, patients do not find available services helpful: On average, a third of patients discontinue treatment within two weeks of treatment initiation—far less than is recommended.
Why Report Cards Are Needed
Consumer report cards are a well-established approach to improving the accountability and quality of health care providers. The Leapfrog Group first created a publicly available hospital rating system in 2000, with the goal of promoting safety and overall health care value. Since, Leapfrog has expanded to produce a composite safety score, further driving accountability and quality within hospitals by publicly reporting this information, and has been joined by other private entities in the hospital rating space, such as Consumer Reports and US News and World Report.
Similar initiatives also exist in the public sector. The Centers for Medicare and Medicaid Services (CMS) first issued public report cards for nursing homes in 1998—known as Nursing Home Compare—followed by Hospital Compare in 2002. Since then, the CMS Compare Program has expanded to include physicians, home health, dialysis, hospice, inpatient rehabilitative facilities and long-term care hospitals.
Comprehensive reviews of public reporting conclude that, on balance, these initiatives provide immediate value to prospective patients in helping to select a care provider, as well as longer-term value by improving the quality of health care. Consumer report cards are complementary to regulations and accreditation, which tend to focus on the structural aspects of treatment and establish a minimal quality floor, instead of disseminating information on the relative quality of structure, process, and performance measures that can drive ongoing improvements.
Public-facing rating systems of mental health and addiction providers are already used in other parts of the world, such as in the UK; however, no such system exists to convey the quality of addiction treatment in the US.
What Should Consumers Expect From Addiction Treatment?
As described in the recent Surgeon General’s Report, which reviewed the past 30 years of research on treatment and health systems design, neurobiological research on alcohol and other drug addictions suggests that all addictions are best considered chronic illnesses affecting many organ systems but particularly the motivational, inhibitory, and reward circuits of the brain. In turn, the report suggested that it is reasonable to apply the same outcome expectations for addiction treatments as are commonly applied to the treatments of other chronic illnesses:
- Reduction of key symptoms (for example, substance use) to non-problematic levels
- Improvement in general patient health and function
- Training the patient and family to recognize and self-manage potential precipitants of future relapse
Consumers of addiction treatment can benefit from information that helps them identify which providers are most likely to help them progress across these three outcome domains. The core concepts of evidence-based treatment described in the report have been synthesized by an expert task force, organized by the nonprofit, advocacy organization Shatterproof, into the National Principles of Care for substance use disorder treatment. They are:
- Universal screening for substance use disorders (SUDs) across medical care settings
- Rapid access to appropriate SUD care
- Personalized diagnosis, assessment, and treatment planning
- Engagement in continuing long-term outpatient care with monitoring and adjustments to treatment
- Concurrent, coordinated care for physical and mental illness
- Access to fully trained and accredited behavioral health professionals
- Access to FDA-approved medications
- Access to non-medical recovery support services
These principles are consistent with the National Institute on Drug Abuse’s Principles of Drug Addiction Treatment and the National Institute on Alcohol Abuse and Alcoholism’s How to Spot Quality Treatment. Consumers should expect and be able to identify care that is consonant with these principles.
What Types Of Information Should Be Reported?
As with other areas of health care, an addiction provider report card should include reliable and validated quality indicators that capture the following domains:
- Provider characteristics and practices associated with effective treatment
- Patient satisfaction
- Risk-adjusted clinical outcomes
Below, we describe existing metrics that could be leveraged to capture these quality domains in an addiction provider report card as well as areas where additional National Quality Forum (NQF) quality measures should be developed.
Metrics To Identify Providers Following Evidence-Based Treatment Principles
Similar to care for other chronic diseases, screening is effective in preventing, reducing, treating and sustaining recovery from substance misuse and SUDs. Measures that capture screening and intervention for SUDs have been endorsed by the NQF and recommended in the Medicaid Innovation Accelerator Program.
When patients must wait for days to enter addiction treatment they are at increased risk of death. Many state public provider and health care contracts include wait-time standards, and many providers collect wait-time information. However, wait-time information is not easily accessible to consumers, who typically must call multiple programs to find which have immediate openings.
Personalized Diagnosis, Assessment, And Treatment Planning
No single program or treatment approach is right for every patient. Rather, a SUD diagnosis and treatment plan should include a personalized biopsychosocial assessment and should account for mental and general health problems and disease severity, all of which can affect the course of care and potential for relapse. The American Society of Addiction Medicine (ASAM) has developed performance measures that aim to capture appropriate diagnosis and treatment planning, but provider compliance with these practices is not readily available to consumers.
Engagement In Continuing Long-Term Outpatient Care With Monitoring And Adjustments To Treatment
A major deficit in the quality of addiction treatment has been the lack of continuity across time, treatment settings, and treatment modalities. On average, a third of patients treated at specialty addiction facilities discontinue treatment within two weeks of starting treatment. Individuals who receive acute medical interventions for the medical complications of addiction are rarely connected to addiction treatment. For example, individuals who are discharged following a drug-overdose hospitalization are more likely to fill a prescription for another prescription opioid than to fill a prescription for an FDA-approved opioid dependence medication. Studies conducted in the Veterans Health Administration system find that treatment engagement (defined as two or more outpatient visits for addiction treatment within 30 days of initiating treatment) is associated with a 34 percent reduction in the probability of death at 12 months and that receiving at least one visit each quarter over a one-year period following treatment initiation is associated with a 28 percent decrease in the probability of death.
There are already three NQF-endorsed quality measures specific to addiction treatment continuity of care: initiation and engagement measure, continuity of pharmacotherapy for opioid use disorder measure, and follow-up after substance use disorder-related emergency department visit measure. Other NQF-endorsed measures are needed. For example, a measure of receipt of post-discharge mental health treatment within seven and 30 days of a psychiatric hospitalization has been in use for many years as a quality measure in public and private programs; however, no parallel measure exists for follow-up treatment following a substance-use related hospitalization. Additional NQF-endorsed measures are also needed to track continuity after residential treatment.
In addition, addiction is now understood to require the type of monitoring and management that are hallmarks of good practice for management of other chronic diseases such as diabetes. Consumers will want to select providers that employ ongoing clinical assessment, such as through the appropriate use of biological tests of substance use (for example, breathalyzer and urine drug screens) and validated scales that track symptoms (for example, of withdrawal) and psychosocial functioning.
Concurrent, Coordinated Care For Physical And Mental Illness
Given the high rate of medical and psychiatric conditions among individuals with addictions, consumers will need information on whether their addiction providers are also paying attention to their medical and psychiatric health, particularly for those conditions that co-occur at high rates with addiction (for example, depression, anxiety, HIV). Many NQF-endorsed quality metrics exist for these commonly co-occurring conditions that could be applied to addiction treatment settings.
Access To Appropriately Trained And Accredited Providers
Addiction treatment can be provided by a range of professional and non-professional staff from physicians, to drug counselors, to peers. Professional organizations, such as the ASAM, have published staffing standards that align each type of addiction treatment setting and modality with appropriately credentialed medical, addiction and mental health professionals. Some states (such as California, Maryland, Massachusetts, Virginia, and West Virginia) are implementing stricter regulations under Medicaid to ensure that licensed facilities meet these staffing standards. For example, Virginia requires that intensive outpatient addiction providers are staffed with addiction-credentialed physicians. Consumers should be able to know what types of professional staff are available within an addiction treatment program, such as whether the program has professionals with prescribing privileges.
There are many effective medications and therapies available to treat addiction. Three medications—methadone, buprenorphine, and naltrexone—are effective medications for opioid addiction. Naltrexone, acamprosate, and disulfiram can improve outcomes for alcohol addiction. Consumers need to be able to identify providers that offer medications. Some of this information is already available through the federal government: specifically, the Substance Abuse and Mental Health Services Administration (SAMHSA) Behavioral Health Treatment Locator.
Non-Medical Recovery Support Services
Non-medical recovery support services include peer services (such as mutual aid groups) and community services (such as housing, education, employment and family support). Access to, and incorporation of, these services in an individual’s treatment plan is shown to improve outcomes. While many of these services fall outside of the traditional purview of the medical system, they are sometimes incorporated in discharge planning or within case management services and adoption of a formal measure may accelerate their widespread adoption. Presently, some aspects of recovery support services are being captured within the Treatment Episode Data Set (TEDS), collected by the SAMHSA, but defined measures would further quality improvement.
Patient Experience Of Care
Research has shown that addiction patients’ positive perceptions of care are associated with positive treatment outcomes. CMS Compare programs report the results of consumer surveys customized by provider type (for example, hospitals, nursing homes) developed under the stewardship of the Agency for Healthcare Research and Quality (AHRQ). The surveys are collectively known as Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys. To date, AHRQ has not developed a CAHPS survey for addiction providers; this could be done and could build on existing surveys. The SAMHSA developed an experience of care survey for patients receiving treatment from mental health providers that capture consumers’ general satisfaction, access to services, service quality and appropriateness, participation in treatment, treatment outcomes, cultural sensitivity, improved functioning, and social connectedness. In addition, some states have developed patient experience surveys, which they use with addiction providers; however, there is no national effort to link this information to the provider or to share it with consumers. Access to information on other patients’ experiences in addiction treatment, such as whether patients felt respected, is critical for the consumer.
Risk-Adjusted Outcome Measures
Finally, an addiction provider report card should include risk-adjusted measures of treatment outcomes, such as reduced drug use, improved functioning in major life domains, and mortality rates. Specialty addiction providers that receive any public funding routinely measure certain outcomes, including the frequency of use of drugs and alcohol, stable housing situation, criminal justice system involvement, and employment. States report these outcomes annually to the SAMHSA as part of the Substance Abuse Treatment Block Grant program. Connecticut is using these data to create quality dashboards for each behavioral health provider in the state. However, despite the availability of these data, and numerous other validated addiction outcome measures, neither states nor the federal government has yet created consumer-facing reports based on these data.
To our knowledge, no programs are reporting on mortality rates by addiction provider. However, premature mortality is a common consequence of addiction. Evidence-based addiction treatment has repeatedly been shown in rigorous studies to reduce the risk of death. Thus, mortality rates could be a useful metric for a report card system.
Who Should Lead These Efforts?
While there has been, and continues to be, both public and privately organized and funded health care rating systems, a well-constructed, comprehensive, and transparent addiction treatment rating system does not exist. One could argue that the addiction industry is today where the nursing home industry was in the 1980s. Concerns about the poor state of nursing home quality led to the passage of legislation requiring greater attention to quality monitoring and enforcement. The result was new data collection systems, public report cards and research to facilitate continuous improvements in the system. These efforts proved effective in improving nursing home quality and providing consumers better information to find high-quality nursing homes. With the opioid epidemic continuing to worsen, it is critical to develop a similar system for addiction providers, with involvement from both the public and private sectors. Government-sponsored report cards, such as the CMS Compare programs, typically have significant resources to devote to developing and evaluating metrics. Private-sector efforts may be more dynamic and more quickly adopted by consumers. Given the enormity of the problem, both the private and the public sector need to invest in and collaborate on the development of addiction treatment providers reporting systems.
---This blog post has been republished with permission from the Health Affairs blog. It was written by Tami Mark in collaboration with John O'Brien, Gary Mendell, A. Thomas McLellan, and Samantha Arsenault.---