Why would programs continue to provide services that are low or no value? Why would regulatory agencies continue to certify these programs? And why would payers continue to reimburse them? After people receive non-evidence based interventions such as 72-hour detox or 28-day rehabilitation without medication, a panelist noted, “They’re in exactly the same place they were in before they went to the program, if not in a more dangerous position.”
Panelists discussed the urgency of the issue while audience members discussed the possibility, feasibility, and political viability of using existing economic levers to reduce the use of therapies that simply don’t work. The discussion highlighted several model programs that have helped de-adopt low-value care, as well as promising new strategies to be tried.
Innovative Programs and Demonstrations
One exemplary program described was Virginia’s Addiction Recovery Treatment Services (ARTS) program, which transformed benefits under Medicaid to include an integrated continuum of SUD treatment services. With increased funding (and a federal waiver), Virginia implemented standards around opioid prescribing, provider trainings, and a new treatment system that covers a full range of evidence-based care. Results from the first year show increases in medication treatment, increases in outpatient SUD providers and networks, and decreases in emergency department (ED) visits.
Participants emphasized that new strategies could be used in demonstration projects as a way to improve and expand access to SUD treatment, with the potential for scaling up if successful. For example, projects could test the effectiveness of blended payment model that includes care management fees, and an incentive based on quality measures (ones that may capture retention and treatment).
Recovery Support Navigators
An intervention implemented in a segment of the Massachusetts Medicaid population involved recovery support navigators and incentives to address revolving door issues where patients go in and out of detox but never connect to treatment. Recovery support navigators meet patients in the ED or in detox and set up appointments in primary care settings where medications can be initiated. Navigators are paid on a case rate instead of fee for service to give them more flexibility to spend time organizing services for the client, and the clients receive gift cards contingent on receiving primary care and for reaching other milestones.
Screening and Treatment in Prisons
A program in Rhode Island’s jails and prison includes SUD screening upon entry, options to initiate one of three medications for opioid use disorder, and for those already taking medication, maintenance at the proper dose for up to a year. The discussion highlighted how programs like this require political will, strong leadership, provider training, and education to secure buy-in from policymakers and elected leaders.
High-touch Outpatient Support
In CleanSlate’s high-touch outpatient model patients are seen with some intensity (once or twice a week), especially at the beginning of their treatment. They receive short prescriptions that reinforce compliance with provider visits for prescription renewals. Psychosocial support is built into the program with care coordination that connects patients with services such as Supplemental Nutrition Program (SNAP) for Women, Infants and Children, and other social services, mental health care, and dental care. Though this model is primarily – and intentionally – insurance-based, it does include a cash-based program that uses a sliding scale fee.
Clinical Redesign in Primary Care
Clinical redesign is a system used at the Camden Coalition of Healthcare Providers, in which redesign teams work in primary care offices to help with patient flow and understand how to take on a new treatment area. In Camden, they helped primary offices figure out how they could commit to seeing any Medicaid patient within seven days of discharge from a local hospital. The results showed that getting providers to a point at which they felt comfortable with the process was key to success.