Quality definitions emerge for addiction treatment

Applying quality measures to addiction has traditionally been challenging because of a lack of research data and the anonymous nature of the treatment programs themselves. But as private payers and federal and state agencies shift to a pay-for-performance model of reimbursement, the industry has begun developing new quality measures and standards.

Many states, especially those that adopted Medicaid expansion, have seen significant demand for addiction treatment services over the past five years, and the ability for patients and payers to better gauge the efficacy of providers is critical. There are existing efforts, such as SAMHSA guidelines, but more formal standards are emerging.

“You have to have very good indicators of what quality is and a way to know when you are actually getting it,” says Sarah Duffy, associate director for economics research at the National Institute on Drug Abuse (NIDA). “There is not a lot of research on that aspect of treatment in the SUD field.”

For patients, the array of providers can be confusing and deciphering which services they need and from whom can be guesswork.

“The truth is, most of them look at whether their insurance will cover the service or how much it costs, rather than looking at the clinical components,” says interventionist Karen Rainer, founder and president of Circle of Care Consultants in Florida. “You want to look at the clinical staff, what their experience is and what services they can actually provide.”

If I hear someone say they’ve been to a treatment facility two or three times, it’s time to re-evaluate their needs

Integrated and evidence-based

Quality addiction treatment should be integrated, patient-centered, evidence-based and outcomes-informed. According to Siobhan Morse, director of research and fidelity at Foundations Recovery Network, in order to adequately and accurately judge the quality of a program or intervention, patients and payers need to know its impact. Is it effective in achieving a predetermined goal, such as remission or long term recovery? 

“This requires valid and reliable data collection processes, such as those that meet SAMHSA standards, use psychometrically sound data collection tools and methods, and represent a sufficient number in the treatment population as to be considered representative,” Morse says. “Outcome information is then used to support the quality management processes and to inform decisions at multiple levels: from programming decisions to management decisions.”

National efforts

In the past several years, there have been multiple efforts to adopt comprehensive measures that can better gauge the quality of care.

SAMHSA’s National Behavioral Health Quality Framework (NBHQF) was developed to help examine and prioritize quality prevention, treatment, and recovery elements, and was developed as a “guiding document” for implementing quality measures in agency or system funding decisions.

Last year, the agency also launched a pilot test to integrate a recovery measure into existing grantee programs’ data collection efforts using an eight-item recovery instrument originally developed by the World Health Organization.

NIDA earlier this year launched its “Innovations in Measuring and Managing Addiction Treatment Quality” challenge, asking for public input on ideas for ways to measure quality that go beyond the data available in provider and payer systems. According to Duffy, the NIDA challenge is a way to look at the next generation of measures and to inform ongoing data collection efforts.

“What other entities are doing right is looking at the data systems as they are now,” Duffy says. “What we’re trying to do is get ahead of the curve and come up with research, so that when we have an opportunity to enhance the data system, we can have really innovative ways to measure quality that might be better at capturing the clinical effect.”

NIDA also hopes to find ways to make data collection easier for providers.

“We hope as we receive submissions for the challenge that people have thought through these issues,” Duffy says. “The criteria are comprehensive, and they have to think about the effects on workflow and how burdensome these processes are.”

Addiction specialists

Last November, the American Society of Addiction Medicine’s (ASAM) board approved a new set of performance measures for addiction specialist physicians developed through the organization’s Practice Improvement and Performance Measures Action Group (PIPMAG). With input from a wide array of stakeholders, ASAM released nine initial measures and recommendations on research that would help improve their use.

In March, ASAM released a full report on those performance measures. According to PIPMAG Chair Corey Waller, the group focused on measures related to treatment effectiveness.

“The truth of any measure is whether it equates with an outcome,” Waller says. “If it doesn’t help you to understand how it improves patient care, then it is a useless measure. We spent time making sure the measures we put in place, if those activities are followed, then health is improved and outcomes are improved.”

ASAM believes all of the standards and benchmarks are achievable, although reaching them will take time.

“As a practitioner looking at these standards, all of these are things I know we can do,” Waller says. “They are hard things to do, and expensive things to do, but someone has to be held accountable for that outcome.”

Among the developing measures, Rainer sees readmission rates as critical for evaluating performance. And the trend rings true within the overall healthcare landscape as well. For example, in physical acute care, Medicare is now financially penalizing hospitals that readmit too many seniors with preventable complications, and commercial payers are looking to follow suit.

“If I hear someone say they’ve been to a treatment facility two or three times, it’s time to re-evaluate their needs,” Rainer says. “If you aren’t successful in trying to help them, you should help them find the therapist they need. It’s not a failure. This disease is too complicated for finger pointing.”

Importance of non-clinical measures

While non-clinical measures are not expressly included in current standards being developed, there is opportunity to measure such factors that might help patients evaluate care choices while also helping payers differentiate providers within a community.

 “Non-clinical measures include patient satisfaction, financial data, process data such as efficiency measures, and length of stay data.” Morse says.

Others include client-to-staff ratios, amenities, cleanliness, comfort factors, relationships with other providers and access. However, the clinical measures themselves can also provide insight into non-clinical aspects of the provider system.

“If the system isn’t built properly, then they can’t meet the standard because there is no way to get the patient from point A to point B in the right timeframe,” Waller says. “We’re trying to raise the standard of care within the practice, but also indirectly change the systems that funnel patients to those practices, and that surround those practices.”

Data collection challenges

Having quality measures is just one part of the puzzle. The industry also needs enough data to establish benchmarks, so that providers can be measured against them. Even in the ASAM report, the association noted that in several categories there is little information available to set good benchmarks.

“We have not yet developed consensus on how best to measure outcomes,” Duffy says. “What are we trying to achieve in a given treatment episode? There are a lot of possible positive effects, but there’s no consensus on what the best measures are. Without that, it’s difficult to develop performance or quality measures because there has to be science available to link those measures to improvements in outcomes.”

Gathering the data needed to establish benchmarks is an ongoing challenge, both because there is little research available in some of the pertinent areas of measurement, and because of the nature of addiction treatment. Much of what happens in the course of addiction treatment is private and confidential per 42 CFR Part 2 requirements. Administrative data can help track readmissions, for example, but it’s use is limited. Patient/enrollee surveys are another source of quality data, although that information can be skewed by the fact that the surveys are more likely to be filled out by the most successful patients.

“When you look at outcomes data, typically the major facilities have the best data, and it’s very speculative,” Rainer says. “The only people reporting back are the patients that are doing well. We don’t have numbers and data that tell us about where and when somebody relapsed, and what caused the relapse so we can better prepare for new patients.”

It is also difficult to track specific interventions, according to Waller. Medication utilization, for example, is easy to track, but group or behavioral therapies still don’t have enough performance to create measures around them.

Compounding the issue, electronic medical records, where they exist, are held in such a wide array of formats that compiling useful aggregate data across providers is challenging. And addiction treatment providers are behind the curve on electronic medical records, in comparison to primary care, although that is slowly changing.

“As more providers adopt EMR systems, we will see better statistics and data,” Rainer says. “Even though we may lack some detail, we can generalize that in ways that will help clinicians formulate new modalities and treatments.”

Next steps

The industry is in the early phase of rolling out formalized quality measures. There is still a significant amount of work yet to be done to create measures for different therapeutic approaches, to determine what elements of those practices are mandatory versus optional, and to find ways to easily document performance.

ASAM is actively working to further specify each of the nine measures it has identified and is testing them in existing systems nationwide. Next up is the more practical, how-to manual.

“Once we’ve specified and tested the measures, we’ll put out secondary work that will show providers how to do this,” Waller says.

ASAM is also working closely with NIDA, SAMHSA, and other organizations to make sure all of the efforts are moving in the same direction.

“We want to connect the dots and make sure we don’t create measures that are different than what is being funded,” Waller says.

Now that ASAM has released its recommendations, Waller says the hope is that several of those measures can become National Quality Forum (NQF) endorsed, and can then be rolled over to organizations like the Joint Commission. Consequently, there will be more pressure on providers to meet those standards. For example, one of the measure calls for a seven-day follow up after being released from a detox facility because after seven days, mortality rates tend to skyrocket.

Waller says seven days might seem untenable for some organizations that are hard pressed to achieve that kind of outreach even within 30 days after release.

 “But it’s not okay that it takes that long,” he says. “If this is something that Joint Commission monitors or another oversight body monitors, then it will just happen. Hospitals will move mountains to make these things happen if they are being monitored and graded based on those benchmarks.”

Increasingly, the same type of demands will come from payers, too, as providers are pressured all the more to prove their value.

“Ultimately, demonstrating that you provide a service is no longer sufficient,” Morse says. “Organizations will need to demonstrate that the interventions provided have achieved the goals of treatment in a cost-conscious environment.”

Brian Albright is a freelance writer based in Columbus, Ohio.

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Siobhan Morse, director of research and fidelity at Foundations Recovery Network, will present “Improving Patient Retention and Length of Stay” at the Behavioral Healthcare Executive Summit on Tuesday, August 4, 2015. Register here.

More Online

Read the ASAM report here

See the NIDA Challenge here