The Affordable Care Act (ACA) will significantly increase coverage for the publicly funded treatment of substance use disorders. Medicaid expansion will make more individuals eligible for substance use evaluation and treatment, and health plans purchased through the new health insurance exchanges (also called “marketplaces”) must cover substance use disorders just as they do medical and surgical benefits.
But in order to maximize the benefit to patients, families, and society, it's critical to invest in the development, validation, and use of performance measures. These objective measures of provider and system performance indicate the proportion of patients who receive recommended care. As coverage expands under the ACA, performance measures can help ensure that treatment is accessible and high-quality.
Currently, the ACA directs little attention to the development and validation of performance measures for substance use disorders. For example, in the core set of measures developed for Medicaid under the ACA, only one is directly related to substance use disorder treatment.
This is not unique to the ACA. While the development and implementation of performance measurement has grown over the past decade, few national efforts have included measurement activities related to substance use disorders. For example, of the 651 measures endorsed by the National Quality Forum, only five are related to non-tobacco substance use disorders. There are no measures of capacity, patient outcomes, or receipt of evidence-based treatment.
There are unique challenges to developing performance measures for substance use disorders. Capacity is an important determinant of how well a system performs, but it's unclear how it influences outcomes or which elements of capacity are most important. There are also major gaps in what constitutes an evidence-based approach to prevention, screening, assessment, and continuing care. Finally, because substance use often 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.
There are also unique challenges to implementing performance measures for substance use disorders. Stigma may prevent both patients and providers from identifying and documenting problematic substance use. There's also no diagnosis code for the most prevalent substance use condition, risky drinking (drinking that puts a person at risk of adverse consequences). The lack of universal screening means that detection and treatment is fragmented and inconsistent across primary and specialty care settings, creating significant complications for interpreting results.
Numerous studies suggest that most people with substance use disorders don't receive any treatment—and when they do, it's not evidence-based. For patients, families, and society to benefit from the increased access provided by the ACA, new performance measures must be developed and tested, while existing measures are refined.
New measures should gauge treatment capacity and availability, and study how capacity influences performance and outcomes. Electronic health records could also be better leveraged; these should be standardized and updated in real time with emerging evidence. Structured templates could help electronic health records document information, which would generate data to populate performance measures. These are just some of the many ways to infuse substance use services with performance measurement.
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, stakeholders should seize the opportunity to reduce the harms associated with untreated substance use by investing in performance measures.
Katherine Watkins is a senior natural scientist at the nonprofit, nonpartisan RAND Corporation and a board-certified practicing psychiatrist.
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