The Affordable Care Act: An Opportunity for Improving Care for Substance Use Disorders?

Abstract

The Patient Protection and Affordable Care Act (ACA) will greatly increase coverage for treatment of substance use disorders. To realize the benefits of this opportunity, it is critical to invest in the development of reliable, valid and feasible measures of quality to ensure that treatment is accessible and of high-quality. The authors review the availability of current quality measures for substance use disorder treatment and conclude there is a pressing need for additional measure development, validation and use. While there are unique challenges to developing and using quality measures for substance use disorders, the authors provide specific recommendations for research and policy changes which will increase the likelihood that patients, families and society will benefit from the increased coverage provided by the ACA.

The opportunity

The Patient Protection and Affordable Care Act (hereafter ACA) represents the most ambitious expansion and regulatory overhaul of the US health care system since the introduction of Medicare and Medicaid. In addition to the principal goal of increased insurance coverage, the ACA includes multiple reforms aimed at improving quality of care by holding clinicians and treatment programs financially accountable for providing high quality services (1). Provisions within the ACA to improve quality include the development of new performance measures for primary care and chronic diseases and the establishment of an Interagency Working Group on Healthcare Quality, designed to coordinate quality activities across 24 Federal departments and agencies (2).

The need for investment in quality measures

The success of reforms to improve quality depends on the availability of reliable, valid and feasible quality measures. Quality measures, which indicate the capacity of the system to deliver care as well as the proportion of patients who are able to access and receive recommended care and the outcomes of such care, are used to assess provider and system performance and provide essential information to support identifying areas of improvement and monitoring changes in the quality of care delivered. Quality measurement plays an important role in identifying and tracking progress against organizational goals, identifying problems and opportunities for improvement, and comparing performance against both internal and external standards. Within the ACA, measurement is an essential component of several strategies to improve performance (3, 4), including creating and implementing innovative payment and delivery models, value-based purchasing and public reporting so that consumers and purchasers can make informed decisions when selecting health care providers and insurers (1).

The ACA will also bring significant changes in coverage for publicly-funded substance use disorder treatment services, whether provided in primary care or specialty care settings (5, 6). The full implementation of the law will significantly expand the Medicaid population, making more individuals eligible for substance use evaluation and treatment if there is sufficient capacity. Coverage for substance use disorder treatment will be included in Medicaid benchmark and benchmark equivalent plans, which Medicaid expansion states must provide to the newly enrolled population. Market plans are also required to cover substance use disorders at parity with medical and surgical benefits, due to an expansion of the Mental Health Parity and Addiction Equity Act of 2008. Screening, brief interventions and referral to treatment (SBIRT) for risky alcohol use will be a covered benefit in most states, and medical providers offered training in this modality. Those with chronic substance use disorders will be eligible to receive care through ‘health homes,’ which will integrate and coordinate all primary, acute, behavioral health and long term care (7).

Despite this focus on quality measurement and increased coverage, currently the ACA directs little attention to the development and validation of quality measures for substance use disorders. For example, in the core list of measures developed for Medicaid under the ACA, only one is directly related to substance use disorder treatment (8). This runs the risk of increasing coverage for substance use treatment without ensuring that the treatment is of high quality, and of increasing potential access without ensuring that there is sufficient capacity to meet the additional need. If the potential benefits of increased coverage are to be realized, quality measures for substance use disorders must be developed, validated and implemented.

Limited attention to the quality of substance use treatment is not particular to the ACA. Over the past decade, as the development and implementation of quality measurement has expanded, apart from efforts by the Washington Circle (9), few national efforts have included measurement activities related to substance use disorders. Of the 651 measures endorsed by National Quality Forum (NQF), other than tobacco, only five are related to substance use disorders. Similarly, the National Center for Quality Assurance (NCQA) has endorsed only two measures related to substance use. The measures endorsed by NQF and NCQA focus on screening for substance use problems (NQF), substance use treatment initiation (NQF, NCQA) and engagement (NQF), receipt of counseling (NQF), patient experience with care (NQF), and receipt of substance use treatment in different settings (NCQA). Notably, none of the endorsed measures have been found to have a strong relationship with clinical outcomes. For example, the treatment initiation and engagement measures, originally developed by the Washington Circle, have only shown a modest association with clinical outcomes (10, 11). While measures should and can cover the entire continuum of care—including prevention, screening, assessment, treatment and continuing care—and include different types of measures—for example, the availability of the resources at the system or organizational level necessary to deliver recommended care, process of care, outcomes of care and patient experience—endorsed substance use measures focus only on limited aspects of the process of care. Despite the existence of effective pharmacotherapy and psychotherapies, no endorsed measures assess whether a patient received an evidence-based treatment or showed an improvement in outcomes, although several measures related to alcohol pharmacotherapy are in development (12). There are no measures of the physical or organizational infrastructure necessary to improve or sustain access and quality, or of workforce capacity. Thus the available substance abuse measures are small in number, limited in scope and do not reflect current knowledge of treatment effectiveness.

Challenges and recommendations

There are many challenges to developing performance measures for substance use disorders (13). Capacity is an important determinant of how well a system performs, but it’s unclear how capacity influences outcomes or which elements of capacity are most important. Many commonly-used treatments have not been prospectively linked to outcomes, and there are major gaps in what constitutes an evidence-based approach to prevention, screening, assessment and continuing care. Because substance use affects many aspects of a person’s life, and because treatment often includes providers outside the medical system, documenting and measuring care coordination and referrals will be challenging , in part because of the specific requirements for confidentiality (14). When assessing the delivery of psychotherapy for substance use disorders, it is essential to move beyond simple counts of service utilization and also assess whether providers document using techniques associated with an evidence-based psychotherapy. Finally, apart from toxicology screens, there are few objective outcome measures, and routine assessment of standardized self-reported outcomes is not widely used.

Furthermore, once available there are specific difficulties associated with implementing quality measures. Stigma may prevent both patients and providers from identifying problematic substance use. There is no diagnosis code for risky drinking—drinking that puts one at risk of adverse consequences-- the most prevalent condition related to substance use and the one primary care providers are most likely to encounter. The lack of universal screening means that detection and treatment is fragmented and inconsistent across primary and specialty care settings. This is important because several of the available measures use the number of patients with positive alcohol screens as the denominator for the measure, which has been shown to bias measurement and interpretation (15). In primary care settings, the number of patients identified through screening is relatively small (16). Given the many measures already required, including additional measures for less prevalent conditions may not be feasible. Assessment and treatment practices are not yet standardized and classified for use in administrative datasets. The Health Information Technology for Economic and Clinical Health Act excluded substance use facilities from obtaining resources to acquire and implement health information technology; in general behavioral health care providers are behind primary care in implementing and using electronic health records. Eligibility criteria for treatment (including off-label use of medications) may vary across systems of care, making comparisons problematic.

Numerous studies suggest that most individuals with substance use disorders do not receive any treatment (17)—and when they do, it is not evidence-based (18). For patients, families and society to benefit from the increased access provided by the ACA, new measures must be developed and tested, while existing measures are refined. We need to develop measures of treatment capacity and availability, and study how capacity influences performance and outcomes. The predictive validity of different care processes at the level of the individual as well as the program or organization (19) needs to be established; this should be done by conducting prospective observational studies as well as effectiveness and implementation research, rather than relying purely on data from efficacy studies. Data elements within the electronic health record should be standardized and guidelines updated with emerging evidence; new measures should reflect the growth in knowledge about treatment effectiveness. We need to develop a methodology to test the validity of measures when randomization is not possible for ethical reasons, and agree upon what level of evidence is sufficient.

If performance measurement is going to be feasible, we need to improve our ability to get data to populate measures and to interpret the data we have. Structured templates to facilitate documentation in the electronic health record may be helpful, as are recent advances in natural language processing. Clinical registries that systematize data collection, data extraction and patient care could also be useful. While there is an ICD-10 code for harmful alcohol use—use that is already causing damage to health—we should consider establishing a code for risky drinking, use at a level that confers the risk of harmful consequences. Establishing this code would allow providers to be reimbursed for ongoing counselling if the initial brief intervention at the time of identification of risk was unsuccessful.

With the landscape of health care in the United States now shifting rapidly under the ACA and more Americans gaining coverage for substance use disorders, there is an unparalleled opportunity to reduce the harms associated with untreated or ineffectively treated substance use. To realize this opportunity we need to invest in the development and application of reliable, valid and feasible performance measures. As coverage expands under the ACA, performance measures can help ensure that treatment is accessible and high-quality.