The Affordable Care Act
Dec 8, 2014
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The Affordable Care Act (ACA) significantly increases coverage for substance use treatment in both the public sector (under Medicaid expansion) and the private sector for plans offered on the insurance exchanges in compliance with expanded parity legislation. Increased coverage is an opportunity to improve the health and well-being of many individuals who need but do not currently have access to treatment for substance use — but if this care is ineffective, increasing access will not generate benefits. Reliable ways to measure the quality of treatment are needed to ensure that the opportunity is not lost. Unfortunately, existing measures are sparse, are of limited scope, and do not adequately reflect the current science about treatment effectiveness.
Quality measures are essential because what cannot be measured cannot be monitored or improved. Measuring quality makes it possible to target areas for improvement, assess progress toward quality goals, and compare performance against standards both within an organization and externally. Quality measurement plays a key role in several ACA strategies intended to improve health system performance, including value-based purchasing and public reporting. But the ACA is nearly silent on the topic of measures for substance use treatment. For example, a list of measures for evaluating Medicaid treatment includes only one directly relevant to substance use. As a result, the ACA could expand coverage for substance use treatment without providing measures to assess either the quality of treatment or the system's capacity to provide it.
The ACA is not alone in giving short shrift to measuring the quality of substance use treatment. Appropriate measures are conspicuously meager in the repertoire of quality measures issued by the National Quality Forum and the National Center for Quality Assurance.
Most notably, none of the measures these organizations endorse has been strongly linked to clinical outcomes. In addition, the measures focus on fragmented parts of the continuum of care — e.g., only on prevention, screening, or continuing care. Clinically proven psychotherapies and pharmacotherapies exist, but there are no validated measures to ascertain whether a patient has received them.
Reaping the benefits of expanded coverage under the ACA will require developing quality measures for substance use treatment. This will not be easy. For example, measures will be needed to assess treatment capacity and availability, although it is unclear which aspects of capacity are the most important. It will be challenging to measure coordination of care across the multiple settings in which treatment may be provided. It is unclear what constitutes an evidence-based approach to various dimensions of the care process, including prevention, screening, and continuing care. The field also lacks objective measures of the clinical outcomes of care. Implementing measures brings its own challenges, stemming in part from the stigma attached to problematic substance use.
Expanded coverage under the ACA could provide evidence-based substance use care for many individuals whose condition now goes untreated. The potential for reducing the harms associated with substance abuse is enormous. But increased coverage will not translate into better outcomes unless we ensure that the care provided is of high quality. New measures need to be developed and tested, and existing measures must be refined.
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