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How Can Treatment Become More Accountable and Effective?. A series of briefings offered to state legislatures through a collaborative effort of the State Associations of Addiction Services, National Conference of State Legislatures, and the Treatment Research Institute. Funded by the Substance Ab

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2. How Can Treatment Become More Accountable and Effective? A series of briefings offered to state legislatures through a collaborative effort of the State Associations of Addiction Services, National Conference of State Legislatures, and the Treatment Research Institute. Funded by the Substance Abuse and Mental Health Services Association (SAMHSA) under the Partners for Recovery Initiative through a contract with Abt Associates Incorporated.

3. THE PRESENTATION Background Financing Comparisons with Other Chronic Illnesses Innovative State Practices V. Problems with the Current Addiction Treatment System VI. Using Outcome and Performance Measures for Quality Improvement and Accountability

4. What Are We Talking About? Failure to provide effective care has serious personal and societal consequences: crime, accidents, disability, death. Unidentified and untreated illness results in long-term high costs. There are rapid advances in neuroscience, evidence-based practices, and medications that need to be applied. We know that treatment pays dividends.

5. Why Are We Talking About It? The current state of the treatment system is such that care is seriously limited and much of it is outdated despite these advances.

6. Who is Paying for Treatment? At the national level, about 75% of treatment for substance use disorders is paid for by public sources (Mark et al., 2005). Over two-thirds of spending is on direct government grants and contracts. Only 1.5% of Medicaid expenditures is for treatment of substance use disorders. About one-third (33%) of treatment programs receive 90-100% of their revenues from public sources.

7. Who Is Paying for Treatment? The willingness by the public to pay for health care differs from that of treatment of substance use disorders. In private plans coverage for treatment of substance use disorders is substantially more limited than for other medical conditions (Barry et al., 2003). Seventy-five percent (75%) of covered employees have significant limits on outpatient visits and two-thirds (66%) have limits on inpatient days.

8. Private Expenditures Are a Tiny Portion of All Health Expenditures, 2001 in Billions

9. Public Expenditures Are Much Greater for Treatment of Substance Use Disorders Than for Health Care, 2001

10. Public Spending is a Growing Proportion of Expenditures Between 1991 and 2001, in billions

11. Spending Growth: Public Rapid, Private Curtailed, 1991-2001

12. What Are The Questions You Should Be Asking? What Should We Be Spending Public Dollars On? What Are the Lessons from Real-World Comparisons with Other Diseases? How Should We Hold Treatment Providers Accountable?

13. Treatment Comparisons and Proven Practices Comparisons with Other Chronic Illnesses Proven Practices

14. Chronic Illness and Continuing Care For many, if not most patients in the public sector, substance use disorders are chronic illnesses. As in other chronic illnesses there is no cure, but effective treatments are available. The effects of treatment do not last very long after treatment stops. Patients who are out of contact are at elevated risk for relapse; retention is essential.

15. How Does Treatment Look for Most Other Chronic Illnesses? Early, intensive stages of treatment prepare patients for later, less intensive care: the goal is self-management. Symptoms and function determine care intensity. Evaluation is a clinical duty done during treatment: Good function = continue care Bad function = change care

16. How Does Treatment Look for Substance Use Disorders? Some fixed amount or duration of treatment is believed to resolve the problem. Goal is to get patients to complete treatment. Evaluation is a research responsibility done following the conclusion of treatment. Poor function = poor outcome = failure.

17. What Do We Need to Do? Implement a Continuing Care Model: Primary Care – Identification, Brief Intervention, and Referral (if needed) Specialty Care – Initiation of Treatment Duration Determined by Symptoms and Function Primary Continuing Care – Concurrent Recovery Monitoring Recovery Management Support

18. What is Concurrent Recovery Monitoring? Monitoring care during outpatient treatment to: Identify and Reduce Threats to Progress Teach Self-Management Skills Monitoring following outpatient treatment during continuing care to: Support Abstinence Encourage Self-Monitoring Intervene Upon Threats to Relapse

19. What is Recovery Management Support? Providing follow-up by specialty and primary care providers. Assuring that patients receive check-ups with primary care clinicians and that clinicians intervene if threats to relapse are apparent. Requiring that treatment programs teach self-management skills. Providing access to continuing recovery support services.

20. What Are Some Promising Practices States Are Using? Braiding funding across state agencies; implementing cross-agency agreements. Purchasing networks or multiple levels of care, ensuring diversity in provider networks. Standardizing definitions, rates, and performance criteria across state purchasing units. Establishing priority funding for specific EBP implementation

21. What Are Some Promising Practices States Are Using? Identifying and removing unintended consequences of funding and regulatory practices that present barriers to implementation of EBPs by providers. Identifying performance measures that are connected to payment and monitoring systems. Monitoring systems that provide very accurate and timely reporting and feedback so that data can be counted on by providers and the State.

22. Two Problems with Addiction Treatment Treatment Infrastructure: The Current Treatment System The Government as Sole Purchaser: Public Responsibility for Treatment The Lack of Market Forces

23. The Treatment Infrastructure There are about 13,000 addiction specialty treatment programs in the US. About 80% of them are outpatient, and government funded. Of the outpatient programs, only 25% admit 300 or more patients per year.

24. The Public Treatment System Well-established nonprofit agencies with exclusive responsibility for providing treatment for low-income, uninsured groups. Public providers with fixed budgets, excess demand for services (as evidenced by waiting lists), and no competition. Political pressures reinforce an emphasis on maximizing people served and minimizing waiting lists, often at the expense of quality

25. The Government’s Role Improving Purchasing: Role of Market Forces on Quality Role of Incentives Improving the Use of Technology: Computers for Drug Courts

26. Moving Toward an Effective System of Care Implement performance-based contracting and other purchasing alternatives. Use performance measures to support change at the treatment program level. Implement screening and brief interventions in primary care clinics, emergency rooms, and trauma centers. Provide concurrent recovery monitoring and recovery management support services.

27. Moving Toward an Effective System of Care Unifying the authority of the separate entities that are responsible for planning, coordination, and implementation of treatment services. Direct involvement of treatment provider organizations to identify performance expectations, incentives, contract reimbursement models and reporting requirements.

28. Performance-Based Contracting Using incentives to improve treatment: Contract for reduced “time to treatment” and increased retention – the Delaware example Contract for public health value: eliminating “detox-only” services and contracting for continuity – the Philadelphia example Contract for post acute treatment recovery management and support – the Hazelton and Betty Ford examples

29. Performance-Based Contracting Increasing reimbursement rates for treating specific priority populations – the Iowa example. Using performance incentives to increase the use of motivational interviewing in outpatient treatment programs – the Massachusetts example.

30. Enhancing Performance by Using Technology Using Computers to Get Treatment Information to Drug Court Judges Provide Computers With Simple Client Information Systems: Attendance Urine Drug Screens Computer on Desk, One Chart for Each Drug Court Client, Web-Enabled and Simple, Displayed on Wall at Each Hearing

31. Early Results Judges Very Happy Takes 2-3 Minutes – Very Informative Clients View It as More Fair Clients in Gallery To Watch Counselors Have Clear Role Help Client Keep Good Court Record

32. Conclusions The Specialty Care System is in Trouble System Change is Necessary Purchasers CAN Change the System

33. Public Responsibility State and county public officials and legislatures who purchase care bear much of the responsibility for introducing change into public systems of care. The basic economics of the public system are at odds with shifts from well-established (entrenched) practices, yet shifts need to occur. Legislatures need to pay attention to the strategic location of their Substance Abuse State Agencies and to creating incentives for change.

34. Not Just Quality But Accountability The NOMS are public health and public safety outcome measures that reflect public expectations: Abstinence Increased employment/education Decreased crime/criminal justice involvement Increased stability of housing Social connectedness (under development) Client perception of care (consumer survey under development by the Forum on Performance Measurement) Increased access to services Increased retention in treatment

35. Legislators Can Change the Treatment System: This Means You Use performance incentives to leverage change. Increase the use of technology in service delivery and reporting, e.g. MIS Increase the focus on improving the workforce. Support collaborative planning and financing of treatment at the State level. Become smart purchasers by experimenting with purchasing alternatives and mechanisms in the public sector. Implement a continuing care model of treatment.

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