Expecting Value: Monitoring Medicaid Provision of Substance Use Treatment
A quick check of the numbers will show how well your Medicaid health insurance plan is identifying and treating individuals with substance use disorders. Many Medicaid health plans use a standard report card, the National Committee on Quality Assurance (NCQA) Health Plan Employer Data and Information Set. There are three required alcohol and drug treatment measures: rates of identifying substance use problems; rates of starting treatment; and rates of engaging patients in continuing care. Your health plans should be at least average, and many states are setting stretch goals for their Medicaid plans such as the following:
|Identification of alcohol and other drug problems||at least 3 percent of all covered beneficiaries|
|Initiation into treatment||at least 66 percent of all patients identified|
|Engagement in treatment||at least 50 percent of all patients who start alcohol treatment|
Unfortunately, average HEDIS results for Medicaid plans remain significantly below these goals. Listed below are the mean 2008 HEDIS scores results Medicaid HMOs reporting results to the National Committee on Quality Assurance. If your health insurance plan is below average, your health plan design or the way it is being managed needs improvement.
|Identification of alcohol and other drug problems||2.3%|
|Initiation into treatment||45.6%|
|Engagement in treatment||14.4%|
These results only refer to Medicaid HMOs that report HEDIS results to the National Committee on Quality Assurance. Many individuals receiving Medicaid services are enrolled in plans that do not currently report to NCQA. While 66 percent of Medicaid beneficiaries were enrolled in a private health plan, only 25% of them were covered by a plan that reported HEDIS data to NCQA in 2008. In contrast, over 44 percent of individuals with private, commercial health insurance were enrolled in plans that report to NCQA.
National Quality Forum Evidence-Based Practices
In 2004, the National Quality Forum convened a workshop attended by payers, policymakers, researchers and substance abuse treatment providers to begin to outline a set of treatment standards that are well-established in the research literature. The results of this workshop were used as a basis for the development of detailed consensus statements that outline evidence-based practices for the treatment of substance use conditions.
In 2007, the National Quality Forum announced the release of a set of eleven consensus statements outlining evidence-based practices, organized into four domains:
- Identification of substance use conditions
- Initiation and engagement into treatment
- Therapeutic interventions to treat substance use illnesses
- Continuing care management for substance use illnesses.
The eleven endorsed evidence-based practices are:
Identification of Substance Use Conditions
Screening and Case Finding
- During new patient encounters and at least annually, patients in general and mental health care settings should be screened for at-risk drinking, alcohol use problems and illnesses, and any tobacco use.
- Health care providers should employ a systematic method to identify patients who use drugs that considers epidemiologic and community factors and the potential health consequences of drug use for their specific population.
Diagnosis and Assessment
- Patients who have a positive screen for—or an indication of—a substance use problem or illness should receive further assessment to confirm that a problem exists and determine a diagnosis. Patients diagnosed with a substance use illness should receive a multidimensional, biopsychosocial assessment to guide patient-centered treatment planning for substance use illness and any coexisting conditions.
Initiation and Engagement in Treatment
- All patients identified with alcohol use in excess of National Institute on Alcohol Abuse and Alcoholism guidelines and/or any tobacco use should receive a brief motivational counseling intervention by a health care worker trained in this technique.
Promoting Engagement in Treatment for Substance Use Illness
- Health care providers should systematically promote patient initiation of care and engagement in ongoing treatment for substance use illness. Patients with substance use illness should receive supportive services to facilitate their participation in ongoing treatment.
- Supportive pharmacotherapy should be available and provided to manage the symptoms and adverse consequences of withdrawal, based on a systematic assessment of the symptoms and risk of serious adverse consequences related to the withdrawal process. Withdrawal management alone does not constitute treatment for dependence and should be linked with ongoing treatment for substance use illness.
Therapeutic Interventions to Treat Substance Use Illness:
- Empirically validated psychosocial treatment interventions should be initiated for all patients with substance use illnesses.
- Pharmacotherapy should be recommended and available to all adult patients diagnosed with opioid dependence and without medical contraindications. Pharmacotherapy, if prescribed, should be provided in addition to and directly linked with psychosocial treatment/support.
- Pharmacotherapy should be offered and available to all adult patients diagnosed with alcohol dependence and without medical contraindications. Pharmacotherapy, if prescribed, should be provided in addition to and directly linked with psychosocial treatment/support.
- Pharmacotherapy should be recommended and available to all adult patients diagnosed with nicotine dependence (including those with other substance use conditions) and without medical contraindications. Pharmacotherapy, if prescribed, should be provided in addition to and directly linked with brief motivational counseling.
Continuing Care Management of Substance Use Illness
- Patients with substance use illness should be offered long-term, coordinated management of their care for substance use illness and any coexisting conditions, and this care management should be adapted based on ongoing monitoring of their progress.
The NQF workshop also identified six practices that have been shown to be ineffective treatments for substance use disorders, and which should not be routinely covered as part of treatment. They include:
- The use of acupuncture, relaxation therapy, didactic group education, or biological monitoring of substance use as a stand-alone treatment
- Detoxification as a stand-alone treatment for dependence
- Individual psychodynamic therapy
- Unstructured group therapy
- Confrontation as a principal approach to treatment
- Discharge from treatment in response to relapse.
The full NQF report “National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices“can be found here: http://www.rwjf.org/pr/product.jsp?id=20611
For more information on the NQF and its work, see their website: www.qualityforum.org
Closing the Addiction Treatment Gap
Closing the Addiction Treatment Gap is a national program funded by The Open Society Institute that aims to address the treatment gap that exists for addiction services. Research suggests that only one out of five individuals who need treatment for a substance use problem are able to get it. Closing the Addiction Treatment Gap attempts to increase public support for improved access to addiction treatment services by addressing the following three key issues:
- Insurance: Addiction diagnoses and treatment should be recognized as a health/medical condition covered by specific benefits in all existing and future public, semi-public, and private health plans
- Appropriations: The expansion of public and private appropriations to pay for treatment at all levels until universal health plan coverage reduces the need for special categorical funding
- Efficiency: The engagement, integration, and retention of individuals into treatment more quickly as a critical means of using existing resources more effectively
Closing the Addiction Treatment Gap attempts to mobilize public support for increased addiction services through the use of a comprehensive communications strategy that includes education and advocacy on a variety of substance abuse issues. This strategy also includes the dissemination of information on best practices and model programs deigned to address the treatment gaps from their current eight grant sites.
For more information on Closing the Addiction Gap, and their current grantees, see the Closing the Addiction Treatment Gap website at: http://www.soros.org/initiatives/treatmentgap