Experts: Substance Abuse Must Be Matched to Value-Based Payment

Can value-based care delivery change the equation around helping Americans living with substance abuse to recover, where fee-for-service and discounted fee-for-service healthcare could not? That’s precisely what a team of policy experts are contending, in a new op-ed in the Forefront section of Health Affairs.

In “Value-Based Care Can Transform The Treatment Of Patients With Substance Use Disorder,” published online on Jan. 19, Robert S. Kaplan, Ph.D., and Sarah E. Wakeman, M.D., look at the issues facing health system leaders who are working to help patients overcome their substance abuse issues. Kaplan is a senior fellow and Marvin Bower Professor of Leadership Development (Emeritus) at the Harvard Business School. He is the co-developer of activity-based costing methods and the Balanced Scorecard.  Wakeman is medical director for the Mass General Hospital Substance Use Disorder Initiative, program director of the Mass General Addiction Medicine fellowship, and an assistant professor of medicine at Harvard Medical School.

Kaplan and Wakeman note that “US overdose deaths currently exceed 100,000 per year. New facilities, known as bridge clinics, are broadening access to high-quality care by offering outpatient substance use disorder (SUD) treatment with few access barriers. But many of the critical services offered by bridge clinics, such as recovery coaching and resource navigation,” they note, “are not consistently reimbursable under a fee-for-service payment model. Even for billable services, the existing billing codes fail to capture the intensity of bridge clinics’ full scope of work, such as post-emergency department (ED) ambulatory alcohol withdrawal management and medication for opioid use disorder (MOUD) initiation. These services, like ambulatory withdrawal management, often involve hours of direct nursing care and provider treatments whose costs far exceed current reimbursements under outpatient Current Procedural Terminology (CPT) codes. The payment failures can be addressed and solved, but not with ad hoc patches to the current fee-for-service system.”

So what’s the solution? The article’s authors believe that “four necessary steps” must be taken in order to achieve “breakthrough performance in patient outcomes and cost reduction:

Organize care around the medical condition.

Measure and improve outcomes that matter to patients.

Measure and lower the cost of treating patients for the medical condition.

Use value-based payments to reimburse providers.”

Essentially, Kaplan and Wakeman argue, research and case studies have shown that it is highly effective for patient-centered care to be structured around patients and their needs, and delivered via multidisciplinary teams in which physicians and nurses “work alongside specialists in other disciplines such as nutrition, behavioral modification, social services, physiotherapy, pharmacy, and postacute care. The multidisciplinary team, which we refer to as an integrated practice unit (IPU), offers comprehensive and integrated care across the condition’s treatment cycle. From the patient’s perspective, the IPU offers more convenient and holistic treatments that address social and behavioral determinants of health as well as their clinical needs.”

The authors write that the bridge clinic established at Massachusetts General Hospital in 2016 exemplifies a model that they believe can “bridge” the many gaps that have long existed in the substance abuse treatment system, including “long waiting lists, rigid treatment models, and limited insurance coverage. The model has now expanded to several institutions across the nation across a range of settings including academic medical centers and community sites,” they note. A key element in value-based contracting, they argue, is that VBC requires accurate measurement of all the costs of all the resources used to treat an individual patient over the full cycle of care, and that fact will make value-based care delivery successful for substance abuse patients and their clinician caregivers. In that regard, they insist that payment for substance abuse care delivery must shift from the prevailing fee-for-service-based payment model to a value-based one. And they add, referring to patient-reported outcome measures (PROMs), that “Payers, both governmental and commercial, can begin to demand that clinics providing SUD treatments develop and collect PROMs, even if limited scope, from the patients they treat. We believe analyses of these data will confirm that widespread adoption of the bridge clinic models will lead to greater access, superior outcomes, and lower total costs. This evidence will facilitate the transition from fee-for-service to value-based payment models that incentivize the sustainability and expansion of bridge clinics’ treatment model.”